Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Denver Sunset Home during CMS and state inspections, most recent first.
Failure to inform a resident representative of the risks and benefits and treatment alternatives before starting sertraline for a resident with dementia, depression, and severely impaired cognition. The EHR lacked documentation of advance notification or consent, the MAR showed daily administration of the SSRI, and both the Administrator and family representative confirmed no prior family consent or notification occurred.
A resident with intact cognition, a stroke history, and Dupuytren’s contracture had a severe left hand contracture noted on observation, with the hand unusable. The resident said therapy had tried to work with him but it was painful and uncomfortable, so he stopped. The care plan did not include the hand contracture or any interventions, and the DON stated it should have been included.
The facility failed to create and implement adequate Baseline Care Plans for several residents upon admission, as required. A resident's Baseline Care Plan was missing entirely, while others lacked essential information such as goals, medication summaries, and monitoring for symptoms and side effects. Observations revealed that necessary safety measures, like the use of a gait belt, were not documented. The facility's policy required Baseline Care Plans to be posted at admission and involved the interdisciplinary team, but the current documents were found lacking in essential information and signatures.
A facility failed to provide a resident with the Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of a Medicare-covered Part A stay. The NOMNC indicated services would end on a specific date, but the form was signed two days later, missing the required notice period. The Administrator confirmed the lack of documentation for family notification, and the DON admitted to not documenting a conversation with the resident's family.
A facility failed to accurately code a resident's PASRR on their annual MDS. The MDS incorrectly documented that the resident did not need a Level II PASRR, despite a previous PASRR indicating the requirement. The DON was unsure why the coding was inaccurate, although aware of the Level II PASRR requirement.
An LPN failed to follow proper insulin administration procedures by not keeping the needle under the skin for a full count of 10 seconds after injecting insulin. The LPN was unaware of this requirement but later confirmed the correct procedure with administration. The DON confirmed the facility's expectation, and the facility's caregiver education materials also stated this requirement.
The facility failed to obtain specific parameters for oxygen administration for a resident, leading to inadequate documentation and unclear orders for oxygen therapy. The DON acknowledged the issues and confirmed that future orders would be clarified.
The facility failed to issue the bed hold policy to two residents who were recently hospitalized. The ADON confirmed that the required written bed hold policy was not provided to the residents or their representatives during their most recent hospitalizations, despite the facility's policy mandating this information be given prior to hospital transfers.
Failure to Inform Resident Representative Before Psychotropic Medication Use
Penalty
Summary
The facility failed to notify a resident representative of the risks and benefits of psychotropic medication use and failed to inform the representative of treatment alternatives before administering sertraline to Resident #5. Resident #5 had a BIMS score of 6 out of 15 on the MDS, indicating severely impaired cognition, and the MDS documented diagnoses of dementia, depression, and peripheral vascular disease. A physician order dated 8/25/25 prescribed sertraline 25 mg by mouth daily for dementia with anxiety and major depressive disorder. The resident's EHR did not contain documentation that the resident's representative was notified in advance of the medication's risks and benefits, treatment alternatives, or other options, or that the representative was allowed to choose the preferred option before administration. The MAR showed the resident received sertraline daily from August 2025 through March 2026, and on 3/26/26 the Administrator reported the facility did not do a consent with the family before giving the medication, while the family representative reported she was not notified of the risks and benefits or treatment alternatives.
Care Plan Missing Hand Contracture
Penalty
Summary
The facility failed to ensure that a resident’s left hand contracture was addressed on the care plan for one resident reviewed for contractures. Resident #18’s MDS assessment showed intact cognition with a BIMS score of 15 out of 15, impairment to both upper and lower extremities on one side, and a diagnosis of stroke. Observation on 3/23/26 noted a severe contracture of the resident’s left hand, and the resident was unable to use the left hand. The resident stated the hand had not worsened, and reported therapy had been trying to work with him but it hurt and was uncomfortable, so he made them stop. Physician progress notes dated 2/9/26 and 6/6/24 documented Dupuytren’s contracture. Review of the care plan showed no documentation of the hand contracture or related interventions, and the DON stated on 3/26/2026 that the contracture should have been on the care plan.
Deficiencies in Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to create and implement a Baseline Care Plan for Resident #11 upon admission, as required. The Director of Nursing was unable to locate the Baseline Care Plan in either the resident's paper chart or electronic health record. This oversight was identified during a review of the resident's records, which indicated diagnoses of coronary artery disease, renal failure, and depression, and included medications such as Escitalopram, Acetaminophen, and Hydrocodone. For Resident #126, the Baseline Care Plan was incomplete, lacking goals based on admission orders, a summary of medications and diagnoses, and monitoring for symptoms and side effects of medications such as diuretics and anticoagulants. The resident's diagnoses included pulmonary fibrosis, chronic systolic heart failure, and type 2 diabetes mellitus, with medications like Acetaminophen, Eliquis, and Lasix prescribed. Similarly, Resident #127's Baseline Care Plan did not address fall history, goals, or interventions, despite the resident experiencing multiple falls. The resident's conditions included acute respiratory failure with hypoxia and major depressive disorder, with medications such as Metformin and Warfarin. Resident #128's Baseline Care Plan failed to address the need for a gait belt, which was observed as necessary for the resident's safety. The resident had diagnoses of dementia and peripheral vascular disease. Additionally, Resident #12's Baseline Care Plan did not include mental health diagnoses, medications, or behavior concerns, despite the resident's history of depression and anxiety. The facility's policy required Baseline Care Plans to be posted at admission and involved the interdisciplinary team, but the current documents were found lacking in essential information and signatures, indicating a systemic issue in care planning upon admission.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) Form CMS-10123 at least two days before the end of a Medicare-covered Part A stay for one resident. The record review indicated that the NOMNC for the resident stated services would end on 10/28/2024, but the form was not signed until 10/30/2024, indicating that the required notice period was not met. During an interview, the Administrator confirmed the absence of documentation of family notification prior to the 10/30/2024 date. Additionally, the Director of Nursing acknowledged having spoken to the resident's family but admitted to not documenting the conversation.
Inaccurate PASRR Coding on MDS
Penalty
Summary
The facility failed to accurately code a resident's Preadmission Screening and Resident Review (PASRR) on their annual Minimum Data Set (MDS). The MDS for the resident, dated June 13, 2024, incorrectly documented that the resident was not considered by the state as needing a Level II PASRR. However, a record review of the resident's PASRR dated June 13, 2021, indicated that the resident required a Level II PASRR. During an interview, the Director of Nursing (DON) admitted uncertainty about why the resident's PASRR was inaccurately coded, despite being aware of the requirement for a Level II PASRR.
Failure to Follow Proper Insulin Administration Procedure
Penalty
Summary
The facility failed to provide services that met professional standards regarding medication administration for a resident observed for insulin administration. During a medication pass, an LPN administered insulin using a Humalog flex pen and a Lantus flex pen but did not keep the needle under the skin for a full count of 10 seconds to ensure the full dose was injected before removing the needle. The LPN was unaware of this requirement at the time of administration but later confirmed the correct procedure after checking with administration. The Director of Nursing confirmed that it was the facility's expectation for licensed staff to leave the insulin pen needle under the skin for a full count of 10 seconds after injecting insulin to ensure the complete dose is administered. The facility's caregiver education materials also stated this requirement. The LPN acknowledged learning this information and committed to implementing the practice moving forward.
Failure to Obtain Specific Parameters for Oxygen Administration
Penalty
Summary
The facility failed to obtain specific parameters for oxygen administration for a resident who was receiving oxygen therapy. On multiple occasions, the resident was observed with and without oxygen, but the treatment administration record lacked documentation of the oxygen flow rate and the specific instances when oxygen was administered. The doctor's order only specified oxygen as needed for comfort without detailing the liter flow or criteria for its application. The Director of Nursing (DON) acknowledged the absence of specific parameters and documentation issues when informed of the concerns. The DON later clarified that the provider had intended the oxygen order for a situation where the resident was actively dying, but this was not clearly documented in the order. The facility's policy on oxygen administration directed staff to administer oxygen based on specific medical needs, such as relieving hypoxemia, hypoxia, congestion, respiratory distress, pain, and discomfort. However, the lack of detailed orders and proper documentation led to a deficiency in providing safe and appropriate respiratory care for the resident. The DON confirmed that the provider would clarify all future oxygen orders to prevent similar issues. The facility reported a census of 28 residents at the time of the survey.
Failure to Issue Bed Hold Policy
Penalty
Summary
The facility failed to issue the bed hold policy to two residents who were recently hospitalized. Resident #9 had a hospital paid leave starting on 10/28/23 and returned to the facility on an unspecified date. Similarly, Resident #21 had a hospital paid leave on 7/13/23 and also returned on an unspecified date. The Assistant Director of Nursing confirmed that the facility did not provide the required written bed hold policy to either resident or their representatives during their most recent hospitalizations. The facility's policy, dated 1/2017, mandates that staff provide written information regarding bed hold to residents or their representatives prior to hospital transfers, specifying the duration of the bed hold.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Denver
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pillar Of Cedar Valley | 7.3 mi | ★★★★★ | 13 | 0 |
| Woodland Terrace | 8.9 mi | ★★★★★ | 2 | 0 |
| Tripoli Nursing & Rehab | 9.7 mi | ★★★★★ | 0 | 0 |
| Northcrest Specialty Care | 11 mi | ★★★★★ | 7 | 0 |
| Martin Health Center, Inc | 11.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.