Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Three Rivers Care during CMS and state inspections, most recent first.
Failure to complete AIMS assessment and monitor antidepressant side effects: A resident with major depressive disorder was receiving Abilify for depression, but the EHR did not show documentation of an AIMS assessment despite a care plan intervention calling for it. The same resident was also receiving Effexor, and although an order directed staff to monitor for antidepressant side effects every shift, the TAR showed only one shift of monitoring and no further ASE documentation was found in the record.
A resident admitted with major depressive disorder, anxiety, and PASRR-identified SMI for mood disorder/depression did not have a depression or antidepressant medication care plan in the EHR. The resident was receiving Abilify and Effexor for depression, and both the RCM/IP/LPN and DON/RN stated they expected a care plan to be in place for residents with depression and/or antidepressant use.
A resident with HTN received hydralazine without a recorded pulse even though the order required holding the med if pulse was below 60. Another resident with chronic pain syndrome received 2 tabs of hydrocodone-acetaminophen for pain scores of 4, despite orders for 1 tab for pain levels 1-5 and 2 tabs only for pain levels 6-10. The DON and an LPN confirmed the ordered parameters were not followed.
Failure to change oxygen tubing as ordered: A resident with COPD and emphysema was receiving continuous O2 via NC, and the facility’s policy and physician order required the tubing to be changed weekly. During observation, the tubing was still in place with an old date label, and an RN and the DON confirmed it should have been changed per the weekly schedule.
An open, nearly empty vial of PPD solution was found unlabeled in the East Hall med room refrigerator. An LPN, the Resident Care Manager/LPN, and the DON/RN all stated the vial should have been dated when first opened.
Unlabeled and undated resident food items were found in a nourishment refrigerator on West Hall. Two opened ice cream containers were not sealed and appeared partially eaten, and an opened salsa container had no resident name or open date. The Dietary Manager stated resident personal foods should be labeled with the resident's name and open date and not kept in the refrigerator for more than 7-10 days after opening.
Failure to Offer and Document Pneumococcal Vaccine: A resident’s EHR did not show that the pneumococcal vaccine was offered, declined, or medically contraindicated, and there was no documentation that vaccine education was provided. Staff said they usually offer COVID-19 and pneumonia vaccines on admission, but they could not find the required documentation, and the DON expected it to be documented in the EHR.
Failure to document COVID-19 vaccine offer and education: A resident admitted to the facility had a historical COVID-19 vaccination record, but the EHR did not show that the vaccine was offered, declined, medically contraindicated, or that education on risks, benefits, and side effects was provided. Staff said vaccines such as COVID-19 and pneumonia were typically offered on or shortly after admission, but they could not find documentation for this resident, and the DON expected the offer and education to be documented in the EHR.
Failure to complete AIMS assessment and monitor antidepressant side effects
Penalty
Summary
The facility failed to complete an AIMS assessment for a resident with major depressive disorder who was prescribed Abilify 10 mg at bedtime for depression. The resident’s physician orders dated 09/17/2025 showed the antipsychotic medication, and the September 2025 EMAR showed the medication was being administered. The resident’s antipsychotic medication care plan, dated 09/17/2025, included an intervention to complete an AIMS assessment as indicated, but the resident’s EHR did not show documentation that an AIMS test had been completed for the Abilify administration. The facility also failed to monitor for adverse side effects of antidepressant medication for the same resident. Physician orders dated 09/18/2025 showed Effexor 150 mg at bedtime for depression, and the September 2025 EMAR showed the medication was being administered. A physician order dated 09/17/2025, discontinued 09/18/2025, directed staff to monitor for antidepressant side effects every shift, but the TAR showed monitoring was completed only for one shift on 09/17/2025. The resident’s EHR did not show further documentation of ASE monitoring. Staff stated an AIMS test should have been done on admission for residents taking antipsychotic medication and that antidepressant side effects should be monitored, but no AIMS documentation or ongoing ASE monitoring was found in the record.
Missing Depression Care Plan for Resident on Antidepressants
Penalty
Summary
Failure to develop a depression baseline care plan within 48 hours of admission was identified for one resident who was admitted with multiple diagnoses, including major depressive disorder. The resident’s level 1 PASRR dated 09/15/2025 identified a Serious Mental Illness indicator of mood disorder/depression, and an updated level 1 PASRR dated 09/22/2025 identified mood disorder and anxiety disorder. The updated PASRR also documented that the resident had diagnoses of depression and anxiety and was taking Abilify and Effexor for depression. Record review showed physician orders for Abilify 10 mg at bedtime for depression and Effexor 150 mg at bedtime for depression, and the September 2025 EMAR showed the resident was receiving both medications. Review of the electronic health record care plans did not show a focus area related to depression and/or antidepressant medication use. In interviews, the RCM/IP/LPN stated that residents with a diagnosis of depression or taking antidepressant medication should have a care plan in place and could not find one for this resident, and the DON/RN stated she expected depression and antidepressant medication use care plans to be in place for residents with those diagnoses and medications.
Failure to Follow Medication Orders for Vital Sign Monitoring and PRN Pain Dosing
Penalty
Summary
The facility failed to follow a physician’s order for Resident 30, who was admitted with multiple diagnoses including essential hypertension and was documented as alert and oriented on the quarterly MDS. The order for hydralazine 10 mg twice daily directed staff to hold the medication for SBP less than 100 and pulse less than 60, but review of the MAR from 11/13/2024 through 06/12/2025 showed hydralazine was administered without a recorded pulse. During interview and record review, the Infection Preventionist/LPN stated the resident’s pulse should have been assessed and recorded before hydralazine was given, and the DON/RN stated that was the expected practice. The facility also failed to administer pain medication according to the ordered parameters for Resident 17, who had chronic pain syndrome and was documented as alert and orientated on the admission MDS. The MAR showed hydrocodone-acetaminophen 5-325 mg was ordered as 1 tablet every 6 hours as needed for pain level 1-5 and 2 tablets every 6 hours as needed for pain level 6-10. The MAR documented that Resident 17 received 2 tablets on 09/14/2025, 09/20/2025, and 09/21/2025 for pain levels of 4. During interview and record review, the DON stated nurses should follow the order when administering pain medication and that the resident should have received only 1 tablet for those pain levels.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when the facility failed to ensure oxygen tubing was changed for 1 of 1 sampled resident reviewed for respiratory care. Resident 7 was admitted with COPD and emphysema, was cognitively intact, and had physician orders for continuous oxygen at 1 liter via nasal cannula for end of life care and chronic respiratory failure every shift. The facility policy titled Oxygen Management, revised 08/2023, required oxygen tubing to be changed weekly or when soiled, impaired integrity, or as needed. Resident 7’s physician order directed that oxygen tubing be changed, labeled, and dated every Sunday night shift, and the ETAR showed the tubing was scheduled to be changed on 09/07/2025, 09/14/2025, and 09/21/2025 with check marks indicating it was administered. However, during observation on 09/22/2025, the resident’s oxygen tubing was still observed with white tape dated 9/8, and staff acknowledged it should have been changed. Staff interviews confirmed oxygen tubing was expected to be changed weekly by the night shift nurse, and the DON stated it was her expectation that oxygen tubing be changed weekly per physician orders.
Unlabeled Open PPD Vial in Medication Refrigerator
Penalty
Summary
The facility failed to ensure that an open vial of purified protein derivative (PPD) solution in the East Hall medication room refrigerator was labeled with the date it was opened, as expected under accepted professional standards of practice. During observation with an LPN, surveyors found the vial to be open, unlabeled, and almost empty. The LPN stated that the vial should have been labeled with the date it was first accessed. The Resident Care Manager/LPN and the DON/RN also stated that medications should be labeled with the date they were first opened.
Unlabeled and Undated Resident Food Items in Nourishment Refrigerator
Penalty
Summary
The facility failed to ensure opened resident food items were labeled and dated in 1 of 2 nourishment refrigerators reviewed on West Hall. During observation, two opened Tillamook ice cream containers, one Chocolate Peanut Butter and one Mudslide, were found in the nourishment refrigerator/freezer not sealed and appearing to have several scoops missing from both. The same refrigerator also contained an unlabeled, opened container of Tapatio Salsa Mild with no date opened and no resident name. The facility policy titled, Food: Safe Handling for Foods from Visitors, revised 01/2023, states that when food items are intended for later consumption, staff will ensure the food is stored separate or easily distinguishable from facility food, kept in a sealed container to prevent cross contamination, and labeled with the resident's name and current date. In interview, the Dietary Manager stated opened resident personal food items should have the resident's name and open date written on them and should not remain in the nourishment refrigerator for more than 7-10 days after opening.
Failure to Offer and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer the pneumococcal vaccine and failed to provide documentation of information and education regarding the vaccine’s risks, benefits, and potential side effects for one sampled resident. The resident was admitted to the facility on [DATE], and review of the electronic health record did not show documentation that the pneumococcal vaccine was offered, declined, or medically contraindicated, and did not show documentation that vaccine education was provided. The facility’s policy stated that all residents will be offered vaccines that aid in preventing infectious diseases unless medically contraindicated or already vaccinated, and that residents or legal representatives will be provided information and education before receiving vaccinations. The pneumococcal vaccine policy also stated that all residents will be offered pneumococcal vaccines and that vaccination status assessments will be conducted within five working days of admission. In interview, staff stated they usually offered immunizations such as COVID-19 and pneumonia vaccines the same day or the day after admission, but they could not find documentation that the resident was offered or declined the COVID-19 or pneumonia vaccine, and the DON stated she expected the vaccines to be offered, education to be provided, and documentation to be present in the EHR.
Failure to Document COVID-19 Vaccine Offer and Education
Penalty
Summary
The facility failed to offer the COVID-19 vaccine and/or provide information and education regarding the risks, benefits, and potential side effects of the vaccine for one sampled resident, Resident 42, who was reviewed for unnecessary medications. Resident 42 was admitted to the facility and was [AGE] years old. The resident's EHR showed a historical COVID-19 vaccination date of 11/04/2024, but the record did not show documentation that COVID-19 vaccination information or education was provided, or that the vaccine was offered, declined, or medically contraindicated. The facility's policy stated that all residents would be offered vaccines that aid in preventing infectious diseases unless medically contraindicated or already vaccinated, and that residents or legal representatives would be provided information and education before vaccination. In a joint interview, Staff D, the Infection Preventionist/Resident Care Manager/LPN, and Staff F, the Director of Infection Prevention/RN, stated they offered immunizations such as COVID-19 and pneumonia vaccines the same day or day after admission, but they could not find documentation that Resident 42 was offered or declined the COVID-19 or pneumonia vaccine, or that education was provided. Staff C, the DON/RN, stated she expected vaccinations were offered and education was provided upon admission and documented in the EHR.
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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 Centralia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Creek Post Acute | 1.1 mi | ★★★★★ | 20 | 0 |
| Sharon Care Center | 1.4 mi | ★★★★★ | 17 | 0 |
| Lacey Post Acute & Rehabilitation | 20.5 mi | ★★★★★ | 11 | 0 |
| Regency Olympia Rehabilitation And Nursing Center | 21.8 mi | ★★★★★ | 14 | 0 |
| Puget Sound Care | 22.3 mi | ★★★★★ | 13 | 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.