Inspection Reports for Denver Sunset Home
235 North Mill Street, IA, 506220383
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 15, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective April 1, 2025.
Inspection Report
Annual Inspection
Census: 27
Deficiencies: 4
Mar 27, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey from March 24, 2025 to March 27, 2025.
Findings
The facility was found deficient in multiple areas including failure to provide timely Notice of Medicare Non-Coverage to residents, inadequate notice and documentation of bed hold policies upon resident transfer, inaccurate coding of resident assessments, and failure to develop and implement comprehensive baseline care plans for residents. The facility reported a census of 27 residents during the survey.
Severity Breakdown
SS=B: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide Notice of Medicare Non-Coverage (NOMNC) Form CMS-10123 at least two days before the end of a Medicare covered Part A stay for 1 of 3 residents reviewed. | SS=B |
| Failure to provide written notice of bed hold policy and rates before transfer for 1 of 1 residents reviewed. | SS=B |
| Failure to accurately code 1 of 2 residents' Preadmission Screening and Resident Review (PASRR) on the Minimum Data Set (MDS). | SS=B |
| Failure to develop and implement a comprehensive baseline care plan for 1 of 6 residents reviewed, including missing goals, medication summaries, and monitoring for side effects. | SS=E |
Report Facts
Census: 27
Deficiencies cited: 4
Correction date: Apr 1, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding notification and care plan deficiencies. |
| Administrator | Administrator | Interviewed regarding notification and bed hold policy deficiencies. |
| Staff A | Licensed Practical Nurse (LPN) | Interviewed regarding bed hold form submission. |
| Staff B | Certified Nurse Aide (CNA) | Interviewed regarding resident care and observations. |
Inspection Report
Plan of Correction
Deficiencies: 0
May 22, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance and will be certified effective May 15, 2024. No specific deficiencies or severity levels are detailed in this document.
Inspection Report
Annual Inspection
Census: 28
Deficiencies: 3
May 9, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from May 6, 2024 to May 9, 2024.
Findings
The facility was found deficient in issuing bed hold policies for residents during hospitalizations, medication administration standards related to insulin injections, and oxygen administration orders. The facility reported a census of 28 residents during the inspection.
Severity Breakdown
Level B: 1
Level D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to issue bed hold policy to 2 out of 2 residents reviewed for recent hospitalizations. | Level B |
| Failed to provide services that met professional standards regarding medication administration for insulin injections. | Level D |
| Failed to obtain parameters for oxygen administration for 1 resident; oxygen order lacked specification of liter flow. | Level D |
Report Facts
Census: 28
Residents reviewed for bed hold policy: 2
Residents reviewed for medication administration: 1
Residents reviewed for oxygen administration: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in medication administration deficiency related to insulin injections |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding insulin administration and oxygen order deficiencies |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Stated facility did not issue bed hold policy for residents #9 and #21 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 13, 2024
Visit Reason
An investigation of complaints #116250-C and #118853-C and a facility self-reported incident #116767-I was conducted from March 12, 2024 through March 13, 2024.
Findings
The facility was found in substantial compliance at the time of the investigation.
Complaint Details
Investigation involved complaints #116250-C and #118853-C and a self-reported incident #116767-I; facility found in substantial compliance.
Report Facts
Complaint numbers: 3
Inspection Report
Routine
Census: 28
Deficiencies: 0
Sep 19, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey and investigation of facility reported incident #112946-I was conducted by the Department of Inspection and Appeals on 9/18/23-9/19/23.
Findings
The facility was found to be in substantial compliance with CMS and CDC recommended practices to prepare for COVID-19. Incident #112946-I was not substantiated.
Complaint Details
Incident #112946-I was not substantiated.
Report Facts
Total Residents: 28
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 26, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of a credible allegation of compliance and plan of correction, effective January 20, 2023.
Inspection Report
Annual Inspection
Census: 25
Deficiencies: 1
Jan 19, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey from January 17, 2023 to January 19, 2023.
Findings
The facility failed to issue the Center for Medicare and Medicaid Skilled Nursing Facility Advanced Beneficiary Notice (ABN) form 10055 for 2 of 3 residents discharged from skilled services in the last 6 months. The Administrator confirmed the forms were not available during the survey.
Severity Breakdown
Level B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to issue Center for Medicare and Medicaid Skilled Nursing Facility Advanced Beneficiary Notice (ABN) form 10055 for 2 of 3 residents discharged from skilled services in the last 6 months. | Level B |
Report Facts
Residents discharged without ABN form: 2
Census: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed and confirmed forms were not available |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 13, 2022
Visit Reason
A revisit of the survey ending August 29, 2022 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility was found to be in substantial compliance effective September 15, 2022.
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 1
Aug 29, 2022
Visit Reason
The inspection resulted from investigation of complaints #102745-C and a facility reported incident #102756-I conducted from August 25 to August 29, 2022.
Findings
The facility failed to provide appropriate supervision, training, safety, and follow facility policy for use of a standing lift for 2 of 3 residents sampled, resulting in a resident fall and fracture. The complaints and incident were substantiated.
Complaint Details
Complaint #102745-C was substantiated. Facility reported incident #102756-I was substantiated.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide appropriate supervision, training, safety, and follow facility policy and manufacturer's instructions for use of a standing lift for 2 of 3 residents sampled. |
Report Facts
Resident census: 26
Complaint numbers: 2
Dates of incident: Feb 22, 2022
Fall risk score: 30
BIMS score: 10
BIMS score: 99
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (C.N.A.) | Involved in fall incident and transfer of Resident #1; suspended pending investigation |
| Staff B | Certified Nursing Assistant (C.N.A.) | Witnessed fall incident and assisted with Resident #1 |
| Staff C | Registered Nurse (RN) | Completed Fall Scene Investigation Report and interviewed regarding incident |
| Staff D | Certified Nursing Assistant (C.N.A.) | Involved in standing lift sling placement and transfer of Resident #2 |
| Staff E | Certified Nursing Assistant (C.N.A.) | Involved in standing lift sling placement and transfer of Resident #2 |
| Staff F | Certified Nursing Assistant (C.N.A.) | Current employee; involved in standing lift training |
| Staff G | Certified Nursing Assistant (C.N.A.) | Current employee; involved in standing lift training |
| Staff I | Certified Nursing Assistant (C.N.A.) | Current employee; involved in standing lift training |
| Staff J | Certified Nursing Assistant (C.N.A.) | Current employee; involved in standing lift training |
| Staff K | Certified Nursing Assistant (C.N.A.) | Current employee; involved in standing lift training |
| Staff L | Certified Nursing Assistant (C.N.A.) | Current employee; involved in standing lift training |
| Staff M | Licensed Practical Nurse (LPN) | Reported facility policy requiring two staff assist with mechanical lifts |
| Staff N | Maintenance Assistant | Performed monthly maintenance checks on standing lifts |
| Director of Nursing | Director of Nursing (DON) | Provided self-identification and correction form; implemented corrective actions; interviewed regarding incident |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 7
Sep 21, 2021
Visit Reason
The inspection was a Recertification Survey and Investigation of Complaint #89796 conducted from 09/14/21 through 09/21/21. The complaint was not substantiated.
Findings
The facility was found deficient in multiple areas including resident rights, accuracy of assessments, quality of care, food safety, infection control, and immunization policies. Specific issues included failure to ensure residents' dignity, incomplete shaving of male residents, inaccurate vaccination records, improper food handling, and catheter care deficiencies.
Complaint Details
Complaint #89796 was investigated during the recertification survey and was not substantiated.
Severity Breakdown
SS=D: 6
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure residents' dignity by not completing shaving of 2 male residents. | SS=D |
| Failure to ensure code status matched in all locations for 1 of 16 residents reviewed. | SS=D |
| Failure to ensure accurate assessment of influenza and pneumococcal vaccination status for 1 of 5 residents sampled. | SS=D |
| Failure to assess 1 of 3 residents for bruises and serve physician ordered diet for 1 of 2 residents sampled. | SS=D |
| Failure to cover desserts served to residents in their rooms. | SS=E |
| Failure to maintain an infection prevention and control program including proper catheter care and hand hygiene. | SS=D |
| Failure to develop and implement policies for influenza and pneumococcal immunizations. | SS=D |
Report Facts
Census: 28
Residents reviewed: 16
Residents sampled: 5
Residents assessed for bruises: 3
Residents sampled for nutritional services: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding shaving expectations, code status, vaccination status, and plan of correction monitoring. |
| Assistant Director of Nursing | Assistant Director of Nursing | Audited resident records for vaccination status and immunization records. |
| Staff B | Certified Medication Assistant (CMA) | Observed providing care to Resident #17. |
| Staff C | Certified Nursing Assistant (CNA) | Observed providing care and interviewed regarding meal service and catheter care. |
| Staff F | Certified Nursing Assistant (CNA) | Observed catheter care and interviewed regarding catheter bag handling. |
| Staff H | Licensed Practical Nurse (LPN) | Reported catheter care practices. |
| Dietary Supervisor | Food Services Supervisor (FSS) | Interviewed regarding meal service and dessert coverage. |
| Consulting Dietician | Licensed Consulting Dietician | Interviewed regarding resident diet and fluid intake. |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 1
Sep 16, 2020
Visit Reason
The inspection was conducted as a Focused Infection Control Survey and Facility Reported Incident #91921, which was substantiated.
Findings
The facility failed to complete post-fall assessments for 3 of 3 sampled residents (#3, #4, and #5) following unwitnessed falls, contrary to their policy requiring neurological checks and follow-up assessments within 72 hours.
Complaint Details
Facility Reported Incident #91921 was substantiated.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to complete post-fall assessments for 3 of 3 sampled residents following unwitnessed falls. | D |
Report Facts
Residents with incomplete post-fall assessments: 3
Census: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Interviewed regarding post-fall assessment procedures |
| Staff B | Licensed Practical Nurse | Interviewed regarding routine neurological assessments |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for post-fall assessments and facility procedures |
Inspection Report
Routine
Census: 26
Deficiencies: 0
Jul 14, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted onsite by the Department of Inspection and Appeals on 7/13-14/20 to assess compliance with CMS and CDC recommended practices.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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