Sunterra Springs Riverview

In the surveyor’s words

From the most serious findings on record at Sunterra Springs Riverview, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Feb 23, 2024

  Based on record review, review of the State Agency's Long-Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for Resident #171 and placed this resident in immediate jeopardy of serious harm, impairment, or death when LPN #1 and RN #2 failed to administer a high-risk medication. Findings include: Resident #171 was admitted to the facility on [DATE], with multiple diagnoses including pneumonia caused by influenza, hypertension, and longstanding persistent atrial fibrillation (an irregular and often very rapid heart rate which can lead to blood clots and stroke). […]

• No harm, potential for more than minimal, isolatedF554Jan 9, 2026

  Based on observation, record review, policy review, and interviews, it was determined the facility failed to ensure the interdisciplinary team had determined it was safe for a resident to self-administer medications. This was true for 1 of 1 resident (Resident #29) reviewed for self-administration of 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. […]

• No harm, potential for more than minimal, isolatedF580Jan 9, 2026

  Based on policy review, record review, and interviews, it was determined the facility failed to ensure the physician was notified of a change in condition. This was true for 3 of 3 residents (#19, #37, and #48) reviewed for physician notification. This failure had the potential for harm if the physician was not provided with information necessary to make decisions to initiate and/or alter interventions to meet a resident's changing needs. Findings include: The facility's policy and procedure for Weight Monitoring revised on 7/2024, documented the physician was to be notified of significant weight variances, which included gain or loss if any of the following occurred: 5% weight change in 30 days 7.5% weight change in 90 days 10% weight change in 180 days 1. […]

• No harm, potential for more than minimal, isolatedF602Jan 9, 2026

  Based on policy review, staff interview, record review, and review of the State Long Term Care Reporting System, it was determined that facility failed to ensure residents were free from misappropriation of property and exploitation. This was true for 3 of 3 residents (#57, #58, and #59) reviewed for abuse, neglect, misappropriation of resident property, and exploitation. This failed practice created the potential for all facility residents to experience exploitation and misappropriation of property. Findings include:The facility's Abuse, Neglect and Exploitation policy revised 4/2025, stated the facility would prevent all types of abuse, neglect, exploitation and misappropriation of residents' property. […]

• No harm, potential for more than minimal, isolatedF628Jan 9, 2026

  Based on record review and interview, it was determined the facility failed to ensure resident specific discharge paperwork was provided to the hospital during transfer. This was true for 1 of 2 residents (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… […]