Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunterra Springs Riverview during CMS and state inspections, most recent first.
A resident with impaired vision and multiple diagnoses was found to be self-administering antacids and Tylenol from a bedside bottle, despite documentation that she did not wish to self-administer medications and without interdisciplinary team approval, as required by facility policy.
The facility did not notify the physician of significant changes in condition for three residents, including substantial weight loss and abnormal vital signs. Two residents experienced notable weight loss without physician notification, despite care plans indicating risk for nutritional deficits. Another resident had abnormal vital signs prior to death, with no evidence that the physician or DON were informed or that appropriate monitoring was documented.
An LPN diverted multiple doses of controlled medications, including oxycodone, that were prescribed for three residents with serious medical conditions such as fractures, dementia, and post-surgical care. The LPN removed the medications, failed to administer them as ordered, provided inconsistent explanations about their whereabouts, and refused a search of personal belongings. The facility's investigation confirmed the misappropriation and exploitation of resident property.
A resident with multiple diagnoses was transferred to a hospital after experiencing severe pain and diaphoresis during a clinic visit, but the facility failed to provide discharge paperwork or document the reason for hospitalization in the medical record. The DON confirmed that documentation of the transfer and hospitalization reason was not completed as required.
A resident with a history of falls and left-sided weakness had their bed moved against the wall by staff after a fall, but this intervention was not added to the care plan. The DON and RNC confirmed the omission when reviewing the care plan and observing the resident's room.
Three residents experienced deficiencies in care, including unclarified medication orders for Parkinson's and antifungal treatment, and missed or undocumented physical and occupational therapy sessions. The facility did not ensure medication orders were clarified with providers or that therapy was delivered and documented as scheduled.
An LPN was found to have worked with residents without completing the required onboarding training, having finished only a small portion of the assigned modules. The Administrator confirmed the incomplete training, and the DON was unaware of the deficiency and had not addressed it.
A pharmacist recommended that an antipsychotic medication be administered with food for a resident, but the physician did not indicate acceptance or rejection of this recommendation on the review form. The medication was scheduled without instructions to give it with food, and nursing leadership confirmed the lack of physician acknowledgment.
A resident with multiple medical conditions was given lorazepam, an anti-anxiety medication, on two occasions without any documented symptoms or behaviors of anxiety. The DON confirmed that the medication was administered without the necessary documentation to support its use as required.
Two residents experienced significant medication errors when one received divided doses of lurasidone against physician orders, and another was given Lyrica and auvelity intended for a different resident. The DON confirmed both incidents after reviewing records and staff reports.
A resident with hypertensive heart disease and heart failure was prescribed Prazosin HCl 1 mg, 2 capsules twice daily, but the pharmacy label instructed administration of only 1 capsule twice daily. An LPN administered the medication according to the incorrect label, and the DON confirmed that the label should have matched the physician's order.
Three residents experienced discomfort due to improper temperature control in their rooms. One resident's room was consistently cold, another's bathroom was particularly cold, and a third faced fluctuating temperatures. Despite thermostat settings indicating compliance, ambient temperature readings showed discrepancies, leading to discomfort and potential health risks. The Maintenance Director acknowledged issues with thermostat accuracy, and the Administrator noted that while regulatory temperature ranges were met, the facility's policy required resident comfort.
The facility did not ensure pharmacy recommendations were addressed by the attending physician for two residents, potentially leading to harm. One resident was prescribed alprazolam without a stop date, and another was prescribed vancomycin without a specified duration. The DON received the recommendations but could not show they were reviewed by the physician due to a rescheduled QAPI meeting.
A resident with a documented allergy to opioid analgesics was administered oxycodone due to an error in transcribing allergy information from hospital documents. The allergy was not listed in the transferring hospital's records, leading to the administration of the medication without complication. The error was confirmed by the DON and went unnoticed during order verification and medication administration.
Failure to Ensure Interdisciplinary Team Approval for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team determined it was safe for a resident to self-administer medications, as required by facility policy. The policy stated that residents may only self-administer medications after the interdisciplinary team has determined which medications may be self-administered safely. In this case, a resident with multiple diagnoses, including hypertension and GERD, and who was legally blind, had a care plan and a self-administration evaluation indicating she did not want to self-administer medications while in the facility. Despite this, surveyors observed a bottle labeled antacids on the resident's bedside table containing both antacids and Tylenol. The resident stated she took the antacids and Tylenol whenever she needed them. The DON confirmed the medications at the bedside and acknowledged that the resident should not be self-administering medications, as documented in the assessment.
Failure to Notify Physician of Significant Changes in Condition
Penalty
Summary
The facility failed to ensure timely physician notification of significant changes in condition for three residents. For one resident with multiple diagnoses including a femur fracture, diabetes, and Crohn's Disease, a 14.9% weight loss occurred over 27 days, but there was no documentation that the physician was informed of this significant change. Another resident with a femur fracture, B-12 deficiency anemia, and hyperlipidemia experienced an 11.66% weight loss over 84 days, again without evidence of physician notification. Both residents were identified as being at risk for nutritional deficits and had care plans indicating that untreated weight variances should not occur. A third resident with mild cognitive impairment, sepsis, and Parkinson's disease exhibited a notable decrease in blood pressure and increases in temperature and heart rate, but there was no documentation that the physician or DON were notified of these changes. The resident was later found pulseless and passed away, with conflicting documentation regarding the frequency and nature of monitoring prior to death. Interviews with facility staff confirmed the lack of physician notification and absence of required documentation regarding these significant changes in condition.
Diversion of Controlled Substances by LPN Resulting in Misappropriation and Exploitation
Penalty
Summary
The facility failed to protect residents from misappropriation of property and exploitation, as evidenced by the diversion of controlled medications intended for three residents. The incident involved an LPN who was observed by the DON to mishandle and ultimately divert multiple pills, including oxycodone, which were prescribed for residents with significant medical needs such as fractures, dementia, post-surgical care, and congestive heart failure. The LPN removed several controlled substances into a single medicine cup, signed them out in the controlled medication logbook, and then failed to administer them to the residents as ordered. When questioned, the LPN provided inconsistent explanations regarding the disposal of the medications and refused to allow a search of her personal belongings before leaving the facility. A review of the controlled drug logbook, medication administration records, and resident interviews confirmed that five doses of oxycodone, belonging to three residents, were signed out but not administered. The facility's investigation substantiated that the LPN diverted these medications, constituting misappropriation of resident property and exploitation. The incident was documented in a Facility Reported Incident and confirmed by the Administrator, with evidence showing that the medications were not located and the LPN was responsible for their diversion.
Failure to Provide Resident-Specific Discharge Documentation During Hospital Transfer
Penalty
Summary
The facility failed to provide resident-specific discharge paperwork to the hospital during the transfer of a resident. Record review showed that the resident, who had multiple diagnoses including aftercare following a surgical procedure, was transported to an infectious disease clinic but refused to get out of the vehicle due to severe pain and diaphoresis. The clinic's physician assistant assessed the resident and sent him to the emergency room. However, the nursing notes did not document the reason for the resident's hospitalization, and there was no documentation in the record explaining why the resident was at the hospital. The Director of Nursing confirmed that the best practice would have been to document the resident's transfer and the reason for hospitalization, but this was not done.
Failure to Update Care Plan After Fall Intervention
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised and updated as needed following a significant change in the resident's condition. The resident, who had a history of repeated falls, major depressive disorder, and anxiety, was admitted with left-sided weakness and was identified as being at risk for falls. The initial care plan directed staff to encourage the use of the call light and to keep the resident's room free of clutter and tripping hazards. However, after the resident fell out of bed and staff moved the bed against the wall as a fall intervention, this change was not documented or incorporated into the resident's care plan. The Director of Nursing and Registered Nurse Coordinator confirmed that the intervention of placing the bed against the wall was not included in the care plan, despite being implemented after the fall.
Failure to Clarify Medication Orders and Provide Scheduled Therapy
Penalty
Summary
The facility failed to ensure professional standards of care were followed for three residents reviewed for quality of care. For one resident with mild cognitive impairment, dysphagia, sepsis, and Parkinson's disease, there was a lack of clarification regarding the frequency of Carbidopa/Levodopa ODT dosing after the resident's spouse brought in medication and requested a change due to swallowing difficulties. Documentation showed conflicting orders and a possible transcription error, but there was no evidence that the provider clarified the correct dosing frequency. For another resident with chronic lymphocytic leukemia, the medication order for Voriconazole was unclear and inconsistent with the hospital discharge summary, and the DON acknowledged the order should have been clarified with the physician. A third resident, admitted for aftercare following digestive surgery and heart failure, did not receive scheduled physical and occupational therapy sessions as ordered. Progress notes lacked documentation on the number of therapy attempts, whether the resident refused therapy, or reasons for missed sessions. There was also no evidence that missed therapy sessions were made up on the weekend, and a progress note explaining a missed session was entered 14 days after the fact. These deficiencies demonstrate failures in medication order clarification and therapy service delivery according to professional standards and resident care plans.
LPN Provided Care Without Completing Required Training
Penalty
Summary
The facility failed to ensure that a licensed nurse had completed the required onboarding training and demonstrated the necessary competencies before providing care to residents. Personnel record review showed that one LPN, hired on 9/26/25, had only completed 3 out of 24 assigned training modules, with no documentation of full onboarding training in her file. The Administrator confirmed that the LPN had not completed the required training and acknowledged that she should not have been working with residents. The DON stated that all newly hired staff are required to complete assigned training before working with residents but was unaware that this LPN had not fulfilled the requirement and had not addressed the issue.
Physician Failed to Address Pharmacist Medication Recommendation
Penalty
Summary
The facility failed to ensure that pharmacist recommendations regarding medication administration were addressed by the physician for one resident. Specifically, a pharmacist reviewed a resident's medication regimen and recommended that lurasidone, an antipsychotic medication, be administered with food as per the manufacturer's instructions for proper absorption. This recommendation was documented on the Interim Medication Regimen Review form, which included a section for the physician to indicate acceptance or rejection of the pharmacist's recommendation. Despite the pharmacist's documented recommendation, the physician signed the form without indicating whether the recommendation was accepted or declined. Further review of the resident's Medication Administration Record (MAR) showed that the medication was scheduled for administration in the afternoon, but there was no indication that it should be given with food. Facility nursing leadership confirmed that the physician should have acknowledged the pharmacist's recommendation, but this was not done.
Psychoactive Medication Administered Without Documented Indication
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs when a psychoactive medication was administered without adequate indication for its use. A resident with multiple diagnoses, including depressive disorder, hypertension, and osteoporosis, had a physician's order for lorazepam to be given as needed for anxiety. The medication administration record showed that lorazepam was administered on two occasions, but there was no documentation of anxiety symptoms or behaviors at those times. The Director of Nursing confirmed that the medication was given without documentation of the required symptoms or behaviors, contrary to facility expectations.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure residents were protected from significant medication errors, as evidenced by two documented incidents involving medication administration. For one resident with multiple diagnoses, including aftercare for a right femur fracture and psychiatric conditions, the physician's order specified lurasidone 100 mg daily, to be given as 20 mg and 80 mg together. However, the Medication Administration Record (MAR) showed the doses were administered separately at different times over a ten-day period, contrary to the order. The Director of Nursing (DON) reviewed the records and could not explain why the doses were divided during that period. In another case, an LPN administered Lyrica 75 mg and auvelity 45-105 mg, both controlled and antipsychotic medications, to the wrong resident. The medication was intended for a different resident in another room. The error was documented in a medication error report, and both the affected resident and her husband were upset, though no physical harm was noted. The DON confirmed the LPN reported the error and accepted responsibility.
Medication Labeling Discrepancy for Antihypertensive Drug
Penalty
Summary
The facility failed to ensure that the pharmacy label for a resident's medication matched the physician's order. Specifically, a resident with hypertensive heart disease and heart failure had a physician's order for Prazosin HCl 1 mg capsules, instructing administration of 2 capsules by mouth twice daily. However, the pharmacy label on the medication card directed staff to give only 1 capsule by mouth twice daily. During medication administration, an LPN prepared and administered the medication according to the label, not the updated physician's order. Upon review, the LPN confirmed the discrepancy between the label and the order, and the Director of Nursing acknowledged that the pharmacy label should match the physician's order.
Temperature Control Issues in Resident Rooms
Penalty
Summary
The facility failed to maintain comfortable bedroom temperatures for three residents, leading to discomfort and potential health risks. Resident #10 reported his room was consistently too cold, despite the thermostat being set to 78 degrees Fahrenheit. Observations confirmed the room felt drafty and cold, with the ambient temperature measured at 71 degrees Fahrenheit, indicating a discrepancy with the thermostat reading. The Maintenance Director acknowledged the issue, suggesting the thermostat might need repair. Resident #127 also experienced discomfort due to cold temperatures, particularly in her bathroom, which she described as feeling like the North Pole. Despite the thermostat being set to 76 degrees Fahrenheit, the ambient temperature in her bedroom was 70 degrees Fahrenheit, and the bathroom was even colder at 68 degrees Fahrenheit. The Maintenance Director was unaware of her complaints, and the discrepancy between the thermostat and ambient temperature readings was noted. Resident #144 faced fluctuating temperatures, with her room being too cold in the mornings and too hot in the evenings. The thermostat settings and readings varied, with the ambient temperature measured at 71 degrees Fahrenheit, despite the thermostat reading 77 degrees Fahrenheit. The Maintenance Director attributed the temperature fluctuations to the large windows in her room. The Administrator noted that the Maintenance Director's computer showed all rooms within the regulatory temperature range, but the facility's policy required temperatures to be comfortable for residents.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were followed or addressed by the attending physician for two residents, which could potentially lead to harm if medications were administered without a clinical rationale. The facility's policy required the pharmacist to send monthly medication reviews to the Director of Nursing (DON) or designee, who would then print the recommendations and provide them to the medical provider for review and signature. However, this process was not completed for two residents, as the physician did not sign off on the pharmacy consultation reports. One resident was prescribed alprazolam for depression without a stop date, and the pharmacy recommended re-evaluation after 14 days, as per regulations for PRN psychotropic medications. Another resident was prescribed vancomycin for osteomyelitis, but the order lacked a specified duration of therapy, with the pharmacy recommending a duration of at least six weeks. The DON acknowledged receiving the pharmacy recommendations but could not provide evidence that the physician had addressed them, as the review was delayed due to a rescheduled Quality Assurance and Performance Improvement (QAPI) meeting.
Medication Error Due to Inaccurate Allergy Documentation
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record, which led to the administration of a medication listed on the resident's allergy list. The resident, admitted for care following a lumbar fracture, had an allergy to opioid analgesics documented in his medical record. Despite this, the resident was prescribed and received oxycodone, an opioid analgesic, since mid-December. The Director of Nursing (DON) confirmed that the allergy was incorrectly transcribed from the transferring hospital's documents, which did not list an opioid allergy. This error went unnoticed during the verification of physician orders and each administration of the opioid medication.
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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 Boise
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Idaho State Veterans Home - Boise | 1.5 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Boise | 1.5 mi | ★★★★★ | 0 | 0 |
| Shaw Mountain Of Cascadia | 2 mi | ★★★★★ | 18 | 0 |
| Skyline Transitional Care Center | 2 mi | ★★★★★ | 9 | 0 |
| Cascadia Of Boise | 2 mi | ★★★★★ | 11 | 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 August 2026) and official state health department websites.