Inspection Report Summary
The most recent inspection on May 1, 2025, found no deficiencies during complaint investigations. Earlier inspections showed a mixed history with several citations related mainly to resident care, including inadequate personal care assistance, delayed abuse reporting, and failure to follow elopement policies. Complaint investigations were mostly unsubstantiated, though some substantiated complaints involved care documentation and safety procedures. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s recent inspections indicate improvement, with no deficiencies noted in the last three complaint investigations.
Deficiencies (last 13 years)
Deficiencies (over 13 years)
1.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
47 residents
Based on a May 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Date: May 1, 2025
Visit Reason
The inspection was conducted as part of investigations of Complaint #124959 and Incident #125805-I at the assisted living facility.
Complaint Details
Investigations of Complaint #124959 and Incident #125805-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigations of the complaint and incident.
Report Facts
Number of tenants without cognitive impairment: 42
Number of tenants with cognitive impairment: 5
Total census: 47
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Date: Sep 26, 2024
Visit Reason
Investigation of Incident #122409-C at the assisted living program for people with dementia.
Complaint Details
Investigation of Incident #122409-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation.
Report Facts
Number of tenants without cognitive impairment: 44
Number of tenants with cognitive impairment: 2
Total census: 46
Inspection Report
Census: 52
Deficiencies: 0
Date: Jun 12, 2024
Visit Reason
The visit was conducted as a recertification survey to determine compliance with certification of an Assisted Living Program for People with Dementia, including investigation of two incidents and one complaint.
Complaint Details
Complaint #119858-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #121109-I, Incident #121108-I, Complaint #119858-C, and the recertification visit.
Report Facts
Number of tenants without cognitive impairment: 45
Number of tenants with cognitive impairment: 7
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 0
Date: Apr 1, 2024
Visit Reason
The inspection was conducted to investigate multiple incidents and complaints reported at the facility.
Complaint Details
Investigation covered Incident #119578-I, Complaint #118824-C, Incident #117249-I, Complaint #117206-C, Complaint #117251-C, and Incident #119665-I with no deficiencies found.
Findings
No regulatory insufficiencies were cited during the investigation of the listed incidents and complaints.
Report Facts
Number of tenants without cognitive impairment: 46
Number of tenants with cognitive impairment: 6
Total census: 52
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Date: Sep 5, 2023
Visit Reason
The inspection was conducted following the investigation of multiple complaints and a mandatory report concerning potential abuse and neglect at the facility.
Complaint Details
The visit was complaint-related, triggered by multiple complaints and a mandatory report. The allegations involved suspected abuse of Tenant #5 by staff, delayed reporting of the incident by staff members, and failure to follow abuse reporting policies. The Administrator confirmed the findings and reported the allegations to the Department.
Findings
The facility failed to follow its written policy regarding the identification and reporting of dependent adult abuse for one tenant. Staff delayed reporting suspected abuse, and improper care was observed during a shower incident causing distress to the tenant.
Deficiencies (2)
Failure to follow the written policy regarding identification and reporting of dependent adult abuse for Tenant #5.
Failure to immediately notify the Administrator of suspected dependent adult abuse regarding Tenant #5.
Report Facts
Number of tenants without cognitive impairment: 46
Number of tenants with cognitive impairment: 7
Total census: 53
Number of tenants reviewed: 5
Number of shifts worked by Staff I between incident and report: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Observed and reported abuse incident involving Tenant #5 | |
| Staff C | New hire trainee | Observed and reported abuse incident involving Tenant #5 |
| Staff I | Staff member alleged to have mistreated Tenant #5 and placed on suspension | |
| Administrator | Administrator | Confirmed findings, reported allegations to Department, and managed investigation |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Date: Jan 18, 2023
Visit Reason
The inspection was conducted as an investigation of Incident #110009-I and Complaint #112069-C related to an elopement event involving Tenant #1 at the assisted living program.
Complaint Details
The investigation was triggered by a complaint and incident involving Tenant #1 eloping from the facility on 12/28/22. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The program failed to follow its policies and procedures related to elopement, door alarm response, visual checks, and keys/door codes for one tenant who eloped. Staff did not adequately check the perimeter of the building when the alarm was triggered, and visual checks were not completed as scheduled. The tenant was found outside in cold weather with frostbite on her feet.
Deficiencies (1)
Failure to follow policies and procedures related to elopement, door alarm response, visual checks, and keys/door codes for one tenant who eloped.
Report Facts
Number of tenants without cognitive impairment: 42
Number of tenants with cognitive impairment: 10
Total census: 52
Date survey completed: Jan 18, 2023
Inspection Report
Renewal
Census: 58
Deficiencies: 0
Date: Jun 9, 2022
Visit Reason
The recertification visit was conducted to determine compliance with certification for a Dementia-Specific Assisted Living Program and to investigate Complaint #98727-C.
Complaint Details
Investigation of Complaint #98727-C was conducted with no regulatory insufficiencies found.
Findings
No regulatory insufficiencies were cited during the recertification visit for the Dementia-Specific Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder in General Population: 48
Number of tenants with cognitive disorder in General Population: 2
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 8
Total Census of Assisted Living Program for People with Dementia: 58
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Date: Nov 4, 2021
Visit Reason
The inspection was conducted as an investigation of Complaint #96754-C and included an onsite infection control survey.
Complaint Details
Investigation of Complaint #96754-C. The complaint was substantiated as evidenced by the cited regulatory insufficiencies.
Findings
The program failed to provide adequate and appropriate care for 1 of 3 tenants reviewed, specifically Tenant #2, with issues including inadequate shower assistance, lack of task documentation for personal care, and failure to implement task sheets for routine personal care assistance.
Deficiencies (2)
Program failed to provide adequate and appropriate care for Tenant #2, including failure to provide shower assistance and proper documentation of personal care tasks.
Program failed to implement task sheets for completion of routine personal care assistance for Tenant #2.
Report Facts
Census of Assisted Living Program for People with Dementia: 56
Number of tenants without cognitive disorder in General Population: 43
Number of tenants with cognitive disorder in General Population: 4
Total Census of General Population: 47
Number of tenants without cognitive disorder in Memory Care Unit: 9
Number of tenants with cognitive disorder in Memory Care Unit: 9
Total Census of Memory Care Unit: 18
Score on Global Deterioration Scale (GDS) for Tenant #2: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jerry Bell | Community Director | Signed the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 4
Date: Aug 26, 2021
Visit Reason
The inspection was conducted as a result of the investigation of Incidents #97317-I, #97631-I and Complaint #97858-C, focusing on regulatory insufficiencies related to tenant evaluations, service plans, and respite care services.
Complaint Details
Investigation of Incidents #97317-I, #97631-I and Complaint #97858-C. The complaint was substantiated as evidenced by multiple regulatory insufficiencies found during the investigation.
Findings
The program failed to complete initial evaluations and service plans prior to tenant occupancy and did not ensure service plans reflected tenant needs. There were multiple incidents involving tenants with cognitive impairments, including safety concerns and behavioral issues. The program also failed to ensure documented care needs were followed for respite care individuals.
Deficiencies (4)
Failed to complete an initial evaluation prior to signing the occupancy agreement for 1 of 1 tenants reviewed.
Failed to develop a service plan prior to signing the occupancy agreement for 1 of 1 tenants reviewed.
Failed to ensure service plans reflected the identified needs of 2 of 5 tenants reviewed.
Failed to ensure documented care needs were followed by staff for 1 of 1 respite care individuals reviewed.
Report Facts
Total Census: 63
Tenants without cognitive disorder (General Population): 51
Tenants with cognitive disorder (General Population): 3
Tenants without cognitive disorder (Memory Care Unit): 0
Tenants with cognitive disorder (Memory Care Unit): 9
Tenants reviewed for service plans: 5
Respite care individuals reviewed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jerry Bell | Community Director | Signed the Plan of Correction and named in corrective actions. |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Date: Jan 20, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to tenant rights and care concerns at Sunset Park Place, specifically Complaint #95128-C.
Complaint Details
Complaint #95128-C was investigated from 1/12/21 through 1/20/21. The complaint was substantiated based on findings of inadequate care and documentation for Tenant #1.
Findings
The investigation found that Tenant #1 experienced inadequate care related to shoulder pain and bruising, with documentation and communication deficiencies noted in nursing records and medication administration. The tenant was hospitalized with a fractured rib and clavicle after a fall.
Deficiencies (1)
Failure to provide adequate care and treatment for Tenant #1, including lack of documentation of shoulder pain and no pain medications given on 1/5/21.
Report Facts
Total Population: 57
General Population without cognitive disorder: 45
General Population with cognitive disorder: 3
Memory Care Unit with cognitive disorder: 9
Memory Care Unit without cognitive disorder: 0
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Date: Sep 2, 2020
Visit Reason
The inspection was conducted as an investigation of Complaint #90770-C and included an onsite infection control survey.
Complaint Details
Complaint #90770-C was investigated and found to have no insufficiencies.
Findings
No insufficiencies were cited during the complaint investigation or the onsite infection control survey.
Report Facts
Number of tenants without cognitive disorder: 49
Number of tenants with cognitive disorder: 7
Inspection Report
Renewal
Census: 57
Deficiencies: 0
Date: Oct 31, 2019
Visit Reason
Recertification visit conducted to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Findings
There were no regulatory insufficiencies cited during the recertification visit for the Dedicated Dementia Specific Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder in general population: 48
Number of tenants with cognitive disorder in general population: 0
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 9
Total Census: 57
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 0
Date: Jan 8, 2019
Visit Reason
The inspection was conducted as an investigation of Complaint #79883 at the assisted living facility.
Complaint Details
Complaint #79883 was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder in general population: 47
Number of tenants with cognitive disorder in general population: 2
Number of tenants without cognitive disorder in memory care unit: 4
Number of tenants with cognitive disorder in memory care unit: 5
Total Census of Assisted Living Program for People with Dementia: 58
Inspection Report
Renewal
Census: 53
Deficiencies: 0
Date: Oct 26, 2017
Visit Reason
Recertification visit conducted to determine compliance with certification for a dedicated dementia specific assisted living program.
Findings
No regulatory insufficiencies were cited during the recertification visit for the dedicated dementia specific assisted living program.
Report Facts
Number of tenants without cognitive disorder: 43
Number of tenants with cognitive disorder: 10
Total Population of Program at time of on-site: 53
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Date: Aug 11, 2016
Visit Reason
The inspection was conducted as an onsite investigation of Complaint #60138-C at the assisted living facility Sunset Park Place Company LLC.
Complaint Details
Complaint #60138-C was investigated onsite with no regulatory insufficiencies found.
Findings
No regulatory insufficiencies were cited during the onsite complaint investigation. The census included 59 residents across general and dementia-specific programs.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 48
Number of tenants with cognitive disorder in General Population Program: 2
Total Population of General Population Program: 50
Number of tenants without cognitive disorder in Dementia-Specific Program: 1
Number of tenants with cognitive disorder in Dementia-Specific Program: 8
Total Population of Dementia-Specific Program: 9
Total census of Assisted Living Program: 59
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Date: Feb 11, 2016
Visit Reason
The inspection was conducted as a complaint/incident investigation related to medication management at Sunset Park Place, Dubuque, IA.
Complaint Details
Allegation: Medication Management. Findings: Unsubstantiated. Review of tenant files, staff interviews, and program documents did not reveal any regulatory insufficiency related to medication management.
Findings
The investigation found the allegation of medication management to be unsubstantiated with no regulatory insufficiencies cited during the investigation.
Report Facts
Census: 54
Population without cognitive disorder: 44
Population with cognitive disorder: 1
Population without cognitive disorder: 5
Population with cognitive disorder: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator, Adult Services Bureau | Author of the complaint/incident investigation report |
Inspection Report
Monitoring
Census: 52
Deficiencies: 0
Date: Oct 28, 2015
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to assess compliance with certification requirements for the Assisted Living Program at Sunset Park Place.
Findings
No regulatory insufficiencies were found during the evaluation. The review of recertification documents was completed and accepted, including the State Fire Marshal's inspection and Facility Engineer's approval of evacuation plans.
Report Facts
Number of tenants without cognitive disorder: 44
Number of tenants with cognitive disorder: 0
Total population of General Population Program: 44
Number of tenants without cognitive disorder: 4
Number of tenants with cognitive disorder: 4
Total population of Dementia-Specific Program: 8
Total census of Assisted Living Program: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Signed letter regarding the Final Recertification Monitoring Evaluation Report |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Date: May 11, 2015
Visit Reason
The inspection was conducted as a complaint/incident investigation related to medication management at Sunset Park Place Company, LLC, following a complaint intake #51823-C.
Complaint Details
Allegation: Medication Management. Findings: Unsubstantiated. No regulatory insufficiencies were identified during the investigation.
Findings
The investigation found the medication management allegation to be unsubstantiated. Reviews of tenant files, staff interviews, and observations revealed no regulatory insufficiencies or forced medication administration.
Report Facts
Number of tenants without cognitive disorder: 49
Number of tenants with cognitive disorder: 5
Total Population of Program at time of on-site: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Author of the report and contact person for questions |
Inspection Report
Monitoring
Census: 52
Deficiencies: 4
Date: Sep 4, 2013
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review the Plan of Correction and regulatory compliance of Sunset Park Place Assisted Living Program, including tenant documents, service plans, and life safety.
Findings
The report found regulatory insufficiencies in tenant documents, service plans, and life safety (specifically exit door alarms). The Plan of Correction was accepted, and the facility was recertified. Tenant satisfaction was generally positive, with some minor issues noted in documentation and service plan reviews.
Deficiencies (4)
Incident reports were not completed related to bruising of unknown origin on Tenant #1 and an unresponsive episode of Tenant #2.
Documentation for each tenant was insufficient as incident reports involving tenants were not maintained as required.
Service plans were updated with minor discretionary changes without completion of nurse reviews as required.
An exit door from a tenant apartment in the dementia unit did not have any operating door alarm.
Report Facts
Tenant census: 52
General Population Program tenants without cognitive disorder: 42
General Population Program tenants with cognitive disorder: 1
Dementia-Specific Program tenants without cognitive disorder: 6
Dementia-Specific Program tenants with cognitive disorder: 3
Total tenants in Dementia-Specific Program: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the monitoring visit |
Inspection Report
Monitoring
Census: 53
Deficiencies: 0
Date: Aug 18, 2011
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to assess compliance with Iowa Code and Administrative Code for the assisted living program at Sunset Park Place.
Findings
No regulatory insufficiencies were found during the evaluation. The program met all requirements, and the State Fire Marshal's inspection and evacuation plans were approved.
Report Facts
Current number of tenants without cognitive disorder: 44
Current number of tenants with cognitive disorder: 2
Total Population of General Population Program: 46
Total Population of Dementia Specific Program: 7
Total Census of Assisted Living Program: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Kaltefleiter | RN MS | Monitor conducting the evaluation |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Date: May 3, 2011
Visit Reason
The inspection was conducted as a final incident investigation following a report that a tenant was found on the floor and sustained a hip fracture.
Complaint Details
The complaint involved a tenant who fell and sustained a hip fracture. The investigation included review of incident reports, staff observations, and resident checks. The tenant received hospice care and was transferred to a skilled nursing facility after surgical repair. No regulatory insufficiencies were substantiated.
Findings
The investigation found no regulatory insufficiencies. The tenant was found to have received appropriate care, with staff responding promptly and adequately to the incident. There were no substantiated deficiencies related to the incident.
Report Facts
Current number of tenants without cognitive disorder: 47
Current number of tenants with cognitive disorder: 1
Total Population of General Population Program: 48
Total Population of Dementia Specific Program: 6
Total Census of Assisted Living Program: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | MA | Monitor for the incident investigation |
| Margaret Kaltefleiter | RN MS | Monitor for the incident investigation |
| Jim Berkley | Program Coordinator | Author of cover letter for the incident investigation report |
Inspection Report
Monitoring
Census: 57
Deficiencies: 0
Date: Dec 15, 2009
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review the assisted living program's compliance with regulatory requirements and to evaluate the program's status as part of the recertification process.
Findings
No regulatory insufficiencies were found during this evaluation. Tenant satisfaction was positive with no complaints, and the program was deemed compliant with no substantiated regulatory insufficiencies during the certification period.
Report Facts
Current number of tenants without cognitive disorder: 49
Current number of tenants with cognitive disorder: 2
Total Population of General Population Program: 51
Total Population of Dementia Specific Program: 7
Total Census of Assisted Living Program: 57
Tenants attending community meeting: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the evaluation |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Date: Jul 7, 2009
Visit Reason
The visit was conducted as a final incident investigation regarding a tenant fall incident at Sunset Park Place, an assisted living program, to monitor compliance and investigate complaints related to the incident.
Complaint Details
The complaint involved a tenant fall on 5-16-09 resulting in injuries including a laceration requiring five sutures, fractured humerus, and fractured femur. The investigation substantiated that staff responded properly and no regulatory insufficiencies were found.
Findings
The investigation found that a tenant fell while ambulating with a walker, resulting in multiple injuries requiring hospital care. Staff responded appropriately by calling emergency services and notifying family and healthcare coordinators. No regulatory insufficiencies were identified related to the incident.
Report Facts
Current number of tenants without cognitive disorder: 47
Current number of tenants with cognitive disorder: 2
Total Population of General Population Program: 49
Total Population of Dementia Specific Program: 7
Total Census of Assisted Living Program: 56
Date of tenant fall incident: May 16, 2009
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Named as monitor of the incident investigation |
| Chris Nothaft | Certification Coordinator – Eastern Iowa | Signed cover letter for the report |
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