Sunterra Springs Riverview
Sunterra Springs Riverview in Boise, ID — inspection on January 9, 2026.
Found 11 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
ensure the interdisciplinary team had determined it was safe for a resident to self-administer
medications.
This failure created the potential for adverse outcome if Resident #29 was to take her medications inappropriately.
Findings include:The facility's Resident Self-Administration of Medication policy, revised 7/2024, documented residents had the right to self-administer medication and may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Resident #29 was admitted to the facility on [DATE], with multiple diagnoses including hypertension, and GERD (a chronic digestive disorder where stomach acid frequently flows back into the esophagus). Resident #29's care plan revised 12/15/25, documented she had impaired vision secondary to being legally blind. A physician order dated 12/12/25, documented the following:calcium carbonate (Tums) tablet chewable 500 mg: Give 1 tablet by mouth every 6 hours as neededacetaminophen (Tylenol) tablet 325 mg: Give 2 tablets by mouth every 6 hours as needed A Self-Administration Evaluation dated 12/12/25, documented Resident #29 did not want to self-administer medication while in the facility. On 1/5/26 at 2:06 PM and 1/6/26 at 8:49 AM, a bottle labeled antacids was observed on top of Resident #29's bedside table.
Inside the bottle were several white oblong shaped pills mixed with round colored tablets.
When asked about the white oblong shaped pills, Resident #29 stated the white pills were Tylenol.
When asked how often she takes the antacids and Tylenol, Resident #29 stated she took the antacids and Tylenol whenever she needed them. On 1/6/26 at 10:02 AM, the DON accompanied the surveyor to Resident #29's room and verified the antacid bottle at Resident #29's bedside was Tums, and the white pills were Tylenol.
The Self-Administration Evaluation was reviewed with the DON who confirmed the assessment documented Resident #29 did not want to self-administer medications.
The DON stated Resident #29 should not be self-administering medications.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
135139 01/09/2026
Sunterra Springs Riverview 3550 West Americana Terrace Boise, ID 83706
abnormal.
When asked if Resident #48's vitals were rechecked, the DON stated, not that I can see in
135139 01/09/2026
Sunterra Springs Riverview 3550 West Americana Terrace Boise, ID 83706
misappropriation of property reported after this date.At the time of the survey, the facility was in
135139 01/09/2026
Sunterra Springs Riverview 3550 West Americana Terrace Boise, ID 83706
bed-hold policies.
record review and interview, it was determined the facility failed to ensure resident specific
(Resident #47) whose records were reviewed.
This deficient practice had the potential for harm if resident required health information not provided to the hospital.
Findings include:The State Operations Manual Appendix PP issued 7/23/25, documented when the facility discharged a resident under any circumstances, the facility must ensure that the transfer or discharge was documented in the resident's medical record.Resident #47 was admitted to the facility on [DATE] with multiple diagnoses including aftercare following a surgical procedure.Resident #47's Nursing Notes documented the following:On 11/6/25 at 9:47 AM - Resident #47 had scattered scabs on his hands and arms.On 11/6/25 at 2:41 PM - Resident #47 at the hospital.Resident #47's record did not include documentation why he was at the hospital.On 1/6/26 at 3:13 PM, the DON stated on 11/6/25 Resident #47 was driven to his appointment at the Infectious disease clinic.
The DON stated Resident #47 refused to get out of the transport vehicle due to severe pain and was diaphoretic.
The PA at the clinic assessed him and was sent to the emergency room.
When asked why the Nursing Notes did not include documentation of the Resident #47's reason for hospitalization, the DON stated, I guess the best practice is to document the resident went to the hospital.
135139 01/09/2026
Sunterra Springs Riverview 3550 West Americana Terrace Boise, ID 83706
reviewed, and revised by a team of health professionals.
observation, record review, and staff interview, it was determined the facility failed to ensure
(Resident #54) whose care plan was reviewed.
This created the potential for adverse outcomes if resident #54's care and services provided were not ordered by the physician.
Findings include:Resident #54 was admitted to the facility on [DATE], with multiple diagnoses including repeated falls, major depressive disorder, and anxiety.Resident #54's care plan initiated 12/29/25, documented Resident #54 was at risk for falls secondary to left sided weakness and directed staff to encourage the use of the call light and to keep resident's room free of clutter and tripping hazards.On 1/5/26 at 11:38 AM, Resident #54's bed was observed against the wall by the window.
When asked about the location of her bed, Resident #54 stated staff moved her bed against the wall after she fell out of bed.On 1/8/26 at 10:50 AM, When asked if the resident's bed against the wall was in the care plan, the DON stated, I do not see it in the care plan. On 1/8/26 at 10:55 AM, the DON and the RNC accompanied the surveyor to Resident #54's room and confirmed the bed against the wall and stated the bed should have been care planned for fall intervention.
135139 01/09/2026
Sunterra Springs Riverview 3550 West Americana Terrace Boise, ID 83706
following a surgical procedure on the digestive system, and heart failure.
to receive Therapeutic Activities 5 times per week.
On 1/6/26 at 9:40 AM, Resident #55 stated she was supposed to have physical therapy five times a week, but did not have therapy the week before. Resident #55 stated she did not know if she was done with her physical therapy since she was told she could walk in her room and go to the bathroom without assistance.
A COTA progress note dated 12/24/25, documented Resident #55 missed her occupational therapy session due to NSG [nursing] completing care/colostomy care in afternoon, unable to see despite several attempts.
The progress note did not document how many attempts were attempted or if Resident #55 refused the therapy.
There was no documentation on why Resident #55 missed her physical therapy on 12/24/25 and occupational therapy on 12/26/25.
On 1/6/26 at 2:19 PM, the Physical Therapist stated he evaluated Resident #55 and recommended for her to have PT/OT five times a week.
The Physical Therapist stated they were working on her transfer and ambulation.
When asked if Resident #55 had completed her PT/OT program, the Physical Therapist stated he works part-time in the facility and did not know if Resident #55 had completed her physical and occupational therapy program.
On 1/7/26 at 9:19 AM, the OTA stated when a resident missed their physical or occupational therapy during the weekdays, generally they would provide an extra session during the weekend to cover the missed therapy.
The OTA stated there was no progress notes for the missed PT session on 12/24/25 and OT session on 12/26/25. Resident #55's PT/OT record did not have documentation she had PT/OT on the following weekend to cover her missed PT/OT session.
On 1/7/26 at 2:51 AM, the DON with the Administrator present reviewed Resident #55 PT and OT progress notes and stated, from the notes there was an issue on wound care.
When asked if colostomy wound care would last that long, the DON stated she would look for the documentation for the missed OT session.
On 1/7/26 at 3:07 PM, the DON provided a Physical Therapy progress note dated 1/7/26, which documented Per nursing, extended time would be needed today for wound changes 3 attempts at therapy were made, unable to see pnt [patient] d/t [due to] nursing needs such as wound changes and pain management timing issues.
This progress note was made 14 days after the missed session.
135139 01/09/2026
Sunterra Springs Riverview 3550 West Americana Terrace Boise, ID 83706
Review of her personnel file did not document she had completed her onboarding training. LPN #1 completed 3 out of 24 of the assigned modules.On 1/9/26 at 12:00 PM, the Administrator confirmed LPN #1 had not completed her required training beyond the three she completed on 1/7/26 and stated she should not have been working with residents without completing all her training.On 1/9/26 at 12:15 PM, the DON stated all newly hired staff must complete their assigned training by the due date prior to working with residents.
When questioned about LPN #1's training, the DON stated she was not aware the training had not been completed and had not addressed it with LPN #1.
135139 01/09/2026
Sunterra Springs Riverview 3550 West Americana Terrace Boise, ID 83706
following irregularity reporting guidelines in developed policies and procedures.
record review and staff interview, it was determined the facility failed to ensure pharmacist
whose pharmacy recommendations were reviewed.
This failure created the potential for Resident #31 to receive medications that were ineffective.
Findings include:Resident #31 was admitted to the facility on [DATE], with multiple diagnoses including aftercare for fracture of right femur, bipolar disorder, and major depressive disorder.Resident #31's record documented the following physician's orders:lurasidone (an antipsychotic medication) oral tablet 20 mg, give 20 mg by mouth one time a day: take with 80 mg for 100 mg total.
Start 12/18/25.An Interim Medication Regimen Review form included a section for the pharmacist to write his/her detailed description of irregularity and recommendations and a section for the physician to make a comment regarding the pharmacist recommendation.Resident #31's Interim Medication Regimen Review form dated 12/23/25, documented the Pharmacist wrote, Lurasidone: Per manufacturer's recommendation: Administer lurasidone with a meal.
Medication is dependent on food for absorption.Resident #31's Interim Medication Regimen Review form dated 12/23/25, was signed by the physician's but did not indicate accept or decline of the pharmacist's recommendation for lurasidone to be taken with food.On 1/7/26 at 11:30 AM, RN #1 reviewed Resident #31's MAR and stated the medication was scheduled to be administered between 1400 (2:00 PM) and 1600 (4:00 PM), but no indication it was to be administered with a food.On 1/7/26 at 10:24 AM, the ADON with the DON present, reviewed Resident #31's Interim Medication Regimen form and stated the physician should have marked that they acknowledged the recommendation one way or the other and they did not.
135139 01/09/2026
Sunterra Springs Riverview 3550 West Americana Terrace Boise, ID 83706
regimen was free from unnecessary drugs when a psychoactive medication was administered without
unnecessary medications.
This deficient practice created the potential for harm if residents received medications that may result in negative outcomes without clear indication of need.
Findings include:Resident #39 was admitted to the facility on [DATE] with multiple diagnoses including depressive disorder, hypertension, and osteoporosis.Resident #39's physician's order for lorazepam (anti-anxiety medication) oral tablet 0.5 mg, give one by mouth every 24 hours as needed for anxiety.Resident #39's MAR documented she was administered lorazepam 0.5 mg oral tablet on 1/3/26 and again on 1/6/26.Resident #39's Monitor For Anxiolytic Use did not indicate she had anxiety symptoms or behaviors on 1/3/26 and 1/6/26.On 1/7/26 at 9:35 AM, the DON reviewed Resident #39's records and confirmed she was administered an anti-anxiety medication on 1/3/26 and on 1/6/26 with no documentation of symptoms or behaviors.
The DON stated her expectation was for her staff to document anxiety symptoms or behaviors present when administering anti-anxiety medications prescribed to be given as needed.
135139 01/09/2026
Sunterra Springs Riverview 3550 West Americana Terrace Boise, ID 83706
protected from significant medication errors.
This was true for 2 of 12 residents (#31 and #56)
the wrong dosage of medications.
Findings include: The online Nursing 2025 Drug Handbook accessed on 1/12/26, stated the eight rights of medication administration were:Right drugRight patientRight doseRight timeRight routeRight reasonRight responseRight documentation 1. Resident #31 was admitted to the facility on [DATE], with multiple diagnoses including aftercare for fracture of right femur, bipolar disorder, and major depressive disorder.Resident #31's record documented the following physician's orders:Lurasidone oral tablet 20 mg, give 20 mg by mouth one time a day for antipsychotic: take with 80 mg for 100 mg total.
Start 12/18/25.Resident #31's MAR dated 12/18/25 through 12/27/25 documented she received lurasidone as follows:At 6:00 AM lurasidone oral tablet 20 mg by mouth one time a dayAt 2:00 PM lurasidone oral tablet 80 mg by mouth one time a [NAME] Nursing Progress Note dated 12/27/25, documented Resident #31requested her lurasidone 20 mg and 80 mg oral tablets to be administered together in the evening medication pass. On 1/7/26 at 2:15 PM, the DON reviewed Resident #31's physician's order and December 2025 MAR and stated she did not know why the dose was divided from 12/18/25 through 12/27/25. 2) Resident #56 was admitted to the facility on [DATE] with multiple diagnoses including aftercare following joint replacement surgery, osteoarthritis of left knee, and dementia.A Medication error report dated 10/3/25, documented LPN #3 administered Resident #56 Lyrica 75 mg (a controlled medication) and auvelity 45-105 mg (an antipsychotic medication) in error.
The report documented the medication was intended for a resident in a different room.
Per the report, both the resident and her husband were upset about the error, but no physical harm noted.On 1/7/26 at 2:30 PM, the DON reviewed the medication error report and confirmed LPN #3 reported the medication error to her and took full responsibility for the mistake.
135139 01/09/2026
Sunterra Springs Riverview 3550 West Americana Terrace Boise, ID 83706
professional principles; and all drugs and biologicals must be stored in locked compartments,
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on
pharmacy labels matched the physician's order.
This was true for 1 of 5 residents (Resident #40) whose medication administration was observed.
This failed practice created the potential for harm if Resident #40's Prazosin (blood pressure medication) was administered at the wrong dose.
Findings include: The State Operations Manual, Appendix PP revised 7/23/25 documented . labeling of the medication or device pursuant to a prescription/order.Resident #40 was admitted to the facility on [DATE] and re-admitted on [DATE], with multiple diagnoses including hypertensive heart disease with heart failure (when long-standing high blood pressure strains the heart, resulting in heart failure).A physician's order, dated 1/2/26 documented Resident #40 was to receive the following:Prazosin HCl 1 mg capsule: 2 capsules by mouth two times a day for hypertension for systolic blood pressure less than 110 and heart rate less than 60.On 1/7/26 at 7:54 AM, LPN #2 prepared Resident #40's medication which included the Prazosin and administered the oral medication at 8:11 AM.
The Prazosin pharmacy label documented Give 1 capsule by mouth twice daily.On 1/7/26 at 10:57 AM, when asked to confirm the Prazosin pharmacy card label, LPN #2 stated the label read to give 1 capsule by mouth twice daily, but the physician order changed to 2 capsules by mouth twice daily. On 1/8/26 at 11:28 AM, when the DON was asked if the physician order and the pharmacy card label were to match, the DON confirmed the label should match the physician order.