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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Three Rivers Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found multiple unclean kitchen and food service areas, including meal carts with white residue, a deep fryer with cloudy oil and food crumbs, a tray line cooler with brown and white buildup, and a dishwasher with yellow and white flaky deposits. Walls behind cooking equipment were covered with drip marks, a plastic bin and steamer pans on the clean rack had black residue, and a white liquid spill remained on the walk-in refrigerator floor despite being seen by a dietary aide. Review of cleaning logs showed inconsistent documentation and indicated that key equipment such as the deep fryer, steamer, and dishwasher had not been cleaned as scheduled. Staff interviews revealed that heavy workloads, incomplete shift cleaning, and lack of consistent oversight by the Dietary Manager led to missed weekly cleaning tasks and failure to follow the established cleaning checklist.
A resident with a suprapubic catheter and severe cognitive impairment was observed twice with the urinary drainage bag lying on the floor, wedged between the floor and bedframe, despite a care plan directing proper catheter bag positioning. The assigned NA reported the bag was secured to the bedframe and suggested it may have fallen when the bed was lowered for feeding, while a nurse stated she had earlier found the bag on the floor and repositioned it but did not reassess it later. The DON/Infection Preventionist noted staff likely did not recognize that lowering the bed could cause the bag to rest on the floor, and the Administrator stated staff should know the catheter bag must not touch the floor.
Surveyors found an opened, undated multi-dose 70/30 insulin pen assigned to a resident in the 200-hall medication cart, despite manufacturer instructions requiring tracking of the 31-day room-temperature use period. An RN working from that cart acknowledged that insulin pens should be dated when opened and that nurses are expected to check their carts daily, but she had not checked the cart that day. The pharmacist reported she periodically reviews carts for proper labeling and open dates on insulin and expects monthly cart inspections, while the DON and Administrator stated that nurses, nurse managers, and the pharmacy consultant all share responsibility for ensuring insulin pens are labeled with an open date and that medication carts are routinely checked.
A long-term care facility failed to properly account for and reconcile controlled medications, leading to potential drug diversion. Several residents had discrepancies between the medications delivered and those accounted for after administration, with significant quantities unaccounted for. The process was solely managed by one DON, lacking adequate tracking and oversight, contributing to the misappropriation of medications.
A medication cart on the 200 hall was left unlocked and unattended, with a resident sitting nearby. The cart was not visible from the nurses' station, and the push lock was not engaged. Medication Aide #1 admitted to leaving the cart unlocked, and both the Administrator and DON confirmed that the cart should be locked when not in use.
A resident was prescribed Seroquel for schizophrenia without a proper diagnosis due to a miscommunication between a nurse and the DON during the admission process. The resident's hospital discharge summary did not indicate schizophrenia, and the medication was intended for short-term use for a brief psychotic episode. The error was identified after clarification from the resident's responsible party and physician.
Failure to Maintain Clean Kitchen Equipment and Food Service Areas
Penalty
Summary
The deficiency involves the facility’s failure to properly clean and maintain multiple pieces of kitchen equipment and surfaces in accordance with professional standards. During a continuous observation of the kitchen, surveyors noted white residue on the tops and bottom inner surfaces of two meal carts, while the Dietary Manager stated the carts were cleaned weekly. Cloudy white oil and food crumbs were observed inside and around the deep fryer, despite the Dietary Manager reporting it had last been cleaned several days earlier and that shrimp had been fried the previous evening, after which it should have been cleaned. Brown and white substances were seen on the inner bottom surface and bottom doors of the tray line cooler, and a buildup of yellow and white flaky material was present on top of the dishwasher. Additional unclean conditions were observed on kitchen walls, equipment, and storage areas. Drip marks were seen covering the wall behind the fryer, steamer, and convection oven; the Dietary Manager stated the wall could not be cleaned because the equipment was attached to gas lines and could not be moved. A black substance was observed around the edges of a large plastic bin holding steamer pans on the clean rack, and two full-size perforated steamer pans had a black substance on their inner surfaces, even though the Dietary Manager stated these items were no longer used but acknowledged they should not be dirty. A white liquid substance was found on the floor under boxes holding milk cartons in the walk-in refrigerator; the Dietary Manager reported she did not know how long it had been there, and a dietary aide stated he had seen the spill earlier but did not clean it up. Review of the Kitchen Cleaning Checklist Logs for December and part of January showed inconsistent and incomplete documentation of weekly cleaning tasks, with blank spaces and varying methods of recording dates and signatures. According to these logs, the deep fryer had not been cleaned since late December, the steamer had not been cleaned since an unspecified date in December, and the dishwasher had not been cleaned since mid-January. Staff interviews revealed that some cleaning tasks were not completed due to workload, with day and evening staff each indicating that missed cleaning was left for other shifts, and that some staff did not follow the assigned cleaning schedule. The Dietary Manager acknowledged that she did not consistently verify that assigned cleaning tasks were completed and that cleaning logs were not consistently posted or maintained during the holiday period, contributing to the unclean conditions observed in the kitchen and food service areas.
Improper Positioning of Urinary Drainage Bag on Floor
Penalty
Summary
Facility staff failed to maintain proper positioning of a urinary drainage bag to prevent infection for a resident with a suprapubic catheter. The resident was admitted with neuromuscular dysfunction of the bladder and had a care plan intervention to keep the catheter bag covered for dignity and positioned below the level of the bladder and away from the entrance door. A quarterly MDS documented that the resident was severely cognitively impaired and had an indwelling suprapubic catheter. During an observation, the resident was lying in bed with the bed in the lowest position and the catheter bag lying on the floor, wedged between the floor and the bed frame, with no tension on the catheter tubing. A subsequent observation the same day showed the bed had been raised slightly, but the catheter bag remained on the floor with no barrier between it and the floor. In interviews, the NA assigned to the resident stated the catheter bag was secured to the bedframe and below the bladder, and suggested it may have fallen to the floor when the bed was lowered for feeding, acknowledging that the bag was not supposed to touch the floor. She reported checking on the resident before lunch and again mid-afternoon and stated the bag was not on the floor at those times. A nurse reported that when she arrived for her shift that morning, she found the catheter bag on the floor and placed it back on the bedframe, and did not reassess its position later that day. The DON/Infection Preventionist stated staff likely did not understand that lowering the bed could cause the catheter bag to rest on the floor and described that the bag should be kept several inches off the floor. The Administrator stated that everyone should know the catheter bag should not be touching the floor and could not explain why the NA did not identify the bag on the floor.
Undated Open Insulin Pen Found on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in medication labeling and storage when they observed an opened, undated multi-dose insulin isophane human/insulin regular human 70/30 pen assigned to Resident #55 in the 200-hall medication administration cart. Manufacturer instructions for this insulin specify that once opened, the pen may be stored at room temperature for 31 days, which requires clear dating of the opening to determine usability. During the observation of the 200-hall cart with Nurse #1, the insulin pen was found without an open date label. In interviews, Nurse #1 stated that insulin pens should be dated when opened and acknowledged she was unaware that this particular pen was not dated. She also stated that nurses were supposed to check their medication carts daily but admitted she had not checked the cart that day and did not provide an explanation for this omission. The consulting pharmacist reported that she reviews at least two medication carts every two months, including checking labels and open dates on insulin, and stated that open insulin should have an open-date label and that carts should be inspected monthly. The DON stated that nurses are responsible for daily checks of their assigned carts and Nurse Managers for monthly inspections, specifically to look for open and expired medications, and the Administrator confirmed that nurses are responsible for labeling and dating insulin pens when they are removed from refrigeration and opened, and that multiple parties are responsible for checking medication carts.
Controlled Medication Mismanagement in LTC Facility
Penalty
Summary
The facility failed to maintain effective safeguards and systems to account for and periodically reconcile controlled medications, leading to potential drug diversion. This deficiency affected seven residents who were prescribed controlled medications such as Oxycodone and Hydrocodone-Acetaminophen. The facility's documentation revealed discrepancies between the number of medications delivered and those accounted for after administration, with significant quantities of medications unaccounted for upon reconciliation attempts. For instance, one resident was prescribed Oxycodone 5 mg tablets, with 28 tablets delivered and only 4 doses administered, leaving 24 tablets unaccounted for. Another resident had 90 capsules of Oxycodone delivered, with 28 doses administered, leaving 62 capsules unaccounted for. Similar discrepancies were noted for other residents, with missing narcotic count sheets and unaccounted medications upon attempts to reconcile discontinued medications for return to the pharmacy. The facility's process for handling discontinued controlled medications was solely managed by a single Director of Nursing (DON), who was responsible for collecting and securing these medications until they were returned to the pharmacy. This process lacked adequate tracking and oversight, as there was no system in place to monitor the medications from the time they were removed from the medication cart to when they were placed in the controlled medication return box. This lack of oversight and accountability contributed to the misappropriation of medications, as evidenced by the missing medications and the resignation of the DON involved.
Unsecured Medication Cart on 200 Hall
Penalty
Summary
The facility failed to secure resident medications stored in an unattended medication cart on the 200 hall. During an observation, the medication cart was found parked between rooms, facing the hallway, and not visible from the nurses' station. A Nurse Aide was working on the hall, and a resident was sitting next to the medication cart in her wheelchair. The cart's push lock was not engaged, indicating it was unlocked. Medication Aide #1 was observed leaving the cart unlocked twice while attending to other tasks. In interviews, both Medication Aide #1 and the Administrator confirmed that the cart should be locked when not in use. The Director of Nursing also stated that the medication cart should be locked when not in use.
Unnecessary Antipsychotic Medication Prescribed Due to Miscommunication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically the use of an antipsychotic medication, Seroquel, without a proper indication or diagnosis. The resident in question, who was admitted to the facility with a diagnosis of schizophrenia, did not have a history or diagnosis of schizophrenia according to her hospital discharge summary. The medication was initially prescribed during a hospital stay for a brief psychotic episode related to advanced dementia, with the intention to discontinue it after a short period. The deficiency occurred when Nurse #1, who was being trained and was handling her first admission, entered the resident's medication orders into the system. She relied on the hospital discharge summary, which did not specify a diagnosis for Seroquel. When she asked the DON for guidance, she was told that Seroquel is used for schizophrenia, which she then entered as the diagnosis. The DON did not verify the hospital discharge summary or realize that Nurse #1 was entering this information into the resident's medical record. The error was discovered when the resident's responsible party and Physician #1 clarified that the resident did not have schizophrenia and that the medication was intended for short-term use. The facility's process for verifying mental health diagnoses during the MDS assessment was not yet completed, which could have caught the error earlier. The diagnosis of schizophrenia was subsequently removed, and the medication was discontinued once the mistake was identified.
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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 Windsor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windsor Rehabilitation And Healthcare Center | 0.1 mi | ★★★★★ | 15 | 0 |
| The Carrolton Of Plymouth | 13.6 mi | ★★★★★ | 0 | 0 |
| Chowan River Nursing And Rehabilitation Center | 19.5 mi | ★★★★★ | 0 | 0 |
| Ahoskie Health And Rehabilitation Center | 20.3 mi | ★★★★★ | 9 | 0 |
| The Carrolton Of Williamston | 20.5 mi | ★★★★★ | 4 | 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.