THREE RIVERS HEALTHCARE CENTER

This section preserves official CMS inspection text matched to this facility from the current provider page source.

Inspection Report:
2025-02-06
This report is the official CMS Statement of Deficiencies (Form 2567) filed after the most recent health inspection.
Each
11
is a federal standard the facility failed to meet.
Read the full inspection report
Survey: 2025-11-18 | Tag F0609 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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Survey: 2025-11-18 | Tag F0610 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Respond appropriately to all alleged violations.
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Survey: 2025-07-23 | Tag F0600 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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Survey: 2025-07-23 | Tag F0607 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
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Survey: 2025-07-23 | Tag F0609 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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Survey: 2025-07-23 | Tag F0610 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Respond appropriately to all alleged violations.
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Survey: 2025-07-23 | Tag F0628 | Resident Rights Deficiencies | Severity: D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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Survey: 2025-07-23 | Tag F0656 | Resident Assessment and Care Planning Deficiencies | Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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Survey: 2025-02-06 | Tag F0558 | Resident Rights Deficiencies | Severity: D
Reasonably accommodate the needs and preferences of each resident.
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Survey: 2025-02-06 | Tag F0842 | Resident Assessment and Care Planning Deficiencies | Severity: D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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Survey: 2025-02-06 | Tag F0812 | Nutrition and Dietary Deficiencies | Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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Survey: 2024-12-16 | Tag F0689 | Quality of Life and Care Deficiencies | Severity: G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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Survey: 2024-12-16 | Tag F0803 | Nutrition and Dietary Deficiencies | Severity: E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
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Survey: 2024-09-25 | Tag F0880 | Infection Control Deficiencies | Severity: D
Provide and implement an infection prevention and control program.
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Survey: 2024-08-15 | Tag F0583 | Resident Rights Deficiencies | Severity: D
Keep residents' personal and medical records private and confidential.
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Survey: 2024-08-15 | Tag F0761 | Pharmacy Service Deficiencies | Severity: D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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Survey: 2024-08-15 | Tag F0804 | Nutrition and Dietary Deficiencies | Severity: F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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Survey: 2024-06-13 | Tag F0580 | Resident Rights Deficiencies | Severity: D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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Survey: 2024-06-13 | Tag F0583 | Resident Rights Deficiencies | Severity: D
Keep residents' personal and medical records private and confidential.
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Survey: 2024-06-13 | Tag F0584 | Resident Rights Deficiencies | Severity: D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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Survey: 2024-06-13 | Tag F0677 | Quality of Life and Care Deficiencies | Severity: E
Provide care and assistance to perform activities of daily living for any resident who is unable.
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Survey: 2024-06-13 | Tag F0686 | Quality of Life and Care Deficiencies | Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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Survey: 2024-06-13 | Tag F0803 | Nutrition and Dietary Deficiencies | Severity: E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
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Survey: 2024-06-13 | Tag F0804 | Nutrition and Dietary Deficiencies | Severity: E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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Survey: 2024-06-13 | Tag F0805 | Nutrition and Dietary Deficiencies | Severity: E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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Survey: 2024-06-13 | Tag F0880 | Infection Control Deficiencies | Severity: E
Provide and implement an infection prevention and control program.
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Survey: 2022-05-19 | Tag F0550 | Resident Rights Deficiencies | Severity: D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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Survey: 2022-05-19 | Tag F0578 | Resident Rights Deficiencies | Severity: D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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Survey: 2022-05-19 | Tag F0582 | Resident Rights Deficiencies | Severity: D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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Survey: 2022-05-19 | Tag F0609 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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Survey: 2022-05-19 | Tag F0644 | Resident Assessment and Care Planning Deficiencies | Severity: D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
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Survey: 2022-05-19 | Tag F0684 | Quality of Life and Care Deficiencies | Severity: E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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Survey: 2022-05-19 | Tag F0755 | Pharmacy Service Deficiencies | Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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Survey: 2022-05-19 | Tag F0756 | Pharmacy Service Deficiencies | Severity: D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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Survey: 2022-05-19 | Tag F0760 | Pharmacy Service Deficiencies | Severity: D
Ensure that residents are free from significant medication errors.
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Survey: 2022-05-19 | Tag F0761 | Pharmacy Service Deficiencies | Severity: E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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Survey: 2022-05-19 | Tag F0812 | Nutrition and Dietary Deficiencies | Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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Survey: 2022-05-19 | Tag F0880 | Infection Control Deficiencies | Severity: F
Provide and implement an infection prevention and control program.
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Survey: 2024-01-26 | Tag F0609 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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Survey: 2024-01-26 | Tag F0610 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Respond appropriately to all alleged violations.
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Survey: 2023-11-21 | Tag F0880 | Infection Control Deficiencies | Severity: D
Provide and implement an infection prevention and control program.
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Survey: 2023-09-19 | Tag F0567 | Resident Rights Deficiencies | Severity: D
Honor the resident's right to manage his or her financial affairs.
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Survey: 2023-09-19 | Tag F0576 | Resident Rights Deficiencies | Severity: D
Ensure residents have reasonable access to and privacy in their use of communication methods.
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Survey: 2023-09-19 | Tag F0692 | Quality of Life and Care Deficiencies | Severity: E
Provide enough food/fluids to maintain a resident's health.
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Survey: 2023-09-19 | Tag F0761 | Pharmacy Service Deficiencies | Severity: D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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Survey: 2019-05-22 | Tag F0582 | Resident Rights Deficiencies | Severity: D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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Survey: 2019-05-22 | Tag F0758 | Pharmacy Service Deficiencies | Severity: D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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Survey: 2019-05-22 | Tag F0761 | Pharmacy Service Deficiencies | Severity: E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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Survey: 2019-05-22 | Tag F0812 | Nutrition and Dietary Deficiencies | Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Source: U.S. Centers for Medicare & Medicaid Services. Data reflects the most recent available inspection.