Denver Sunset Home

In the surveyor’s words

From the most serious findings on record at Denver Sunset Home, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 29, 2022

  Based on clinical record review, observation and staff interviews, the facility failed to provide appropriate supervision, training, safety and follow the facility policy and manufacturer's instructions for use of a standing lift for 2 of 3 residents sampled, (Resident's #1 and #2). The facility identified a census of 26 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #1 dated 1/06/22 showed a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive loss. The Resident required extensive assistance of two staff for transfers and toileting; extensive assistance of one staff for dressing and personal hygiene. […]

• No harm, potential for more than minimal, patternF655Mar 27, 2025

  Based on record review, staff interview, and policy review the facility failed to create and implement upon admission a Baseline Care Plan for 1 of 6 residents reviewed (Resident #11). The facility also failed to implement Baseline Care Plans that included goals residents wanted to archive while living at the facility, significant diagnoses, and symptoms to monitor for, medications and significant medication side effects to monitor, and signatures that the resident and/or Power of Attorney (POA) were aware and agreed for 5 of 6 residents reviewed. The facility reported a census of 27 residents. Findings include: 48452 1. […]

• No harm, potential for more than minimal, patternF812Sep 21, 2021

  Based on observation, policy review and staff interview, the facility failed to cover desserts served to all residents being served in their rooms. The facility reported a census of 28. Findings include: During an interview on 9/14/21 at 12:17 PM, the Food Service Supervisor (FSS) stated all residents were eating in their rooms at this time. During an observation of the meal trays being delivered to residents 9/14/21 at 12:17 PM, the cake noted to be in bowls covered with a plastic lid. The lid rested on top of the cake and did not cover the sides of the cake as it was being transported through the halls. During an observation of meal service on 9/15/21 at 11:38 AM, chocolate cream pie was placed on trays going out to residents being served in their room covered with plastic lids. […]

• No harm, potential for more than minimal, isolatedF552Mar 26, 2026

  Based on record review, staff interview, and family interview, the facility failed to notify a resident representative of the risks and benefits of psychotropic medication use prior to administration of psychotropic medication, and failed to inform a resident representative of treatment alternatives to the medication prior to administration for 1 of 5 residents reviewed (Resident #5). The facility reported a census of 24 residents.Findings include: 1. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 6 out of 15, indicating severely impaired cognition. The MDS included diagnoses of dementia, depression, and peripheral vascular disease. Per this assessment, the resident took antidepressant medication. […]

• No harm, potential for more than minimal, isolatedF656Mar 26, 2026

  Based on observation, record review, and staff and resident interview, the facility failed to ensure a contracture of a resident's hand was addressed on the care plan for 1 of 1 resident reviewed for contractures (Resident #18). The facility reported a census of 24 residents. Findings include:Resident #18's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The MDS documented he had an impairment to both upper and lower extremities on one side. The MDS included the diagnosis of a stroke. On 3/23/26 at 1:35 PM, observation of the resident's left hand noted severe contracture to left hand. The resident was unable to use the left hand. […]