Sunset Drive - a Prospera Community

In the surveyor’s words

From the most serious findings on record at Sunset Drive - a Prospera Community, in the surveyor’s own words.

• Immediate jeopardy, widespreadF812Jul 9, 2026

  Based on observations, review of facility policy, and staff interviews, the facility failed to ensure sanitization of dishware (utensils, dishes, pots/pans) used to serve residents, staff, and visitors for 2 of 5 dishwashers (main kitchen and Edgewater). Failure to ensure the mechanical dishwashing machine maintains the correct hot water temperature to destroy pathogens may result in the spread of illness and/or foodborne illness to residents, staff, or visitors. During the on-site recertification survey, the team determined a potential Immediate Jeopardy (IJ) situation existed on 07/08/26 at 12:55 p.m. when the dishwasher rinse cycle failed to reach 160 degrees Fahrenheit (F) at plate level. […]

• Immediate jeopardy, widespreadF689Jul 28, 2025

  Based on review of facility policy and resident and staff interviews, the facility failed to ensure residents remained free from accident hazards during 2 of 2 severe weather events (06/20/25 and 06/27/25). Failure to ensure facility staff took appropriate action/precautions to protect residents during severe weather events placed all residents at risk for physical and emotional harm. During an on-site complaint survey, the survey team consulted with the State Survey Agency (SSA) on 07/24/25 and determined an Immediate Jeopardy (IJ) situation existed on 06/20/25. […]

• Actual harm, isolatedF692Jul 9, 2026

  Based on record review, review of facility policy, and staff interview, the facility failed to maintain acceptable parameters of nutritional status for 1 of 8 sampled resident (Resident #81) with weight loss. Failure to document post-dialyzed weights, complete a dietary assessment, and identify/implement nutritional interventions for a resident at nutritional risk, resulted in a significant weight loss.Findings include: Review of facility policy titled Nutrition and Hydration - Food and Nutrition occurred on 07/09/26. This policy, dated 04/27/26, stated, . Accurately and consistently assess a resident's nutritional status on admission and as needed. Identify a resident at nutritional risk . Provide nutritional care . […]

• Actual harm, isolatedF689May 15, 2025

  Based on record review, review of the facility reported incident (FRI) and investigation, and resident and staff interviews, the facility failed to provide appropriate supervision and/or assistance to prevent an accident for 1 of 1 sampled resident (Resident #55) injured during a facility van transport. Failure to ensure the power control to the motorized scooter (wheelchair) is turned off during transport resulted in an injury to Resident #55's foot and placed all residents with motorized wheelchairs at risk for injury during transports. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 02/28/25. […]

• Actual harm, isolatedF684Feb 3, 2022

  1. Based on observation, record review, review of facility policy, review of professional literature, and staff interview, the facility failed to ensure 2 of 2 sampled residents (Resident #36 and #90) observed in an inclined/reclined position during meals received the care and services necessary to attain the highest degree of safety possible. Failure to ensure staff properly positioned and/or supervised residents with dysphagia (difficulty swallowing food and/or liquids) (Resident #36 and #90) or known aspiration (breathing food and/or liquids into the airway) (Resident #90) during meals resulted in Resident #90 aspirating and placed Resident #36 at risk of aspiration. Findings include: The facility policy titled Resident-Assisted Dining-Rehab/Skilled, revised 04/16/21, stated, . […]