Three Rivers Healthcare Center

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to timely report an allegation of abuse to the state agency. This affected one (Resident #1) of three residents reviewed for abuse. The facility census was 101 residents.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to initiate an investigation of an abuse allegation in a timely manner and failed to protect residents during an abuse investigation. This affected one (Resident #1) of three residents reviewed for abuse. The facility census was 101 residents.

Inspectors wroteBased on record review, staff and resident interviews, review of Self-Reported Incident (SRI), review of facility policy, the facility failed to prevent resident to resident sexual abuse. This affected two (#64 and #500) of the six residents reviewed for abuse. The facility census was 106. Review of Resident #500's chart revealed Resident #500 was admitted to the facility on [DATE] with Alzheimer's disease, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, primary generalized osteoarthritis, major depressive disorder, alcohol abuse, anxiety disorder, mixed hyperlipidemia, depression and history of falling. Resident #500 discharged from the facility on 07/18/25. [...]

Inspectors wroteBased on staff interview, review of Self-Reported Incidents (SRIs) and record review, the facility failed to implement their abuse policy for an allegation of resident to resident sexual abuse. This affected one (#500) of six residents reviewed for abuse. The facility census was 106. Review of Resident #500's chart revealed Resident #500 was admitted to the facility on [DATE] with Alzheimer's disease, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, primary generalized osteoarthritis, major depressive disorder, alcohol abuse, anxiety disorder, mixed hyperlipidemia, depression and history of falling. Resident #500 discharged from the facility on 07/18/25. [...]

Inspectors wroteBased on staff interview, review of Self-Reported Incidents (SRIs), and record review, the facility failed to report an allegation of resident to resident sexual abuse to the state surveying agency. This affected one (#500) of the six residents reviewed for abuse. The facility census was 106. Review of Resident #500's chart revealed Resident #500 was admitted to the facility on [DATE] with Alzheimer's disease, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, primary generalized osteoarthritis, major depressive disorder, alcohol abuse, anxiety disorder, mixed hyperlipidemia, depression and history of falling. Resident #500 discharged from the facility on 07/18/25. [...]

Inspectors wroteBased on record review, staff interviews, Review of Self-Reported Incidents (SRI) and review of facility policy, the facility failed to investigate an allegation of resident to resident sexual abuse. This affected one (#500) of six residents reviewed for abuse. The facility census was 106. Review of Resident #500's chart revealed Resident #500 was admitted to the facility on [DATE] with Alzheimer's disease, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, primary generalized osteoarthritis, major depressive disorder, alcohol abuse, anxiety disorder, mixed hyperlipidemia, depression and history of falling. Resident #500 discharged from the facility on 07/18/25. [...]

Inspectors wroteBased on staff interview, record review and review of facility policy, the facility failed to ensure a resident and the resident's power of attorney (POA) received a discharge notice. This affected one (#500) of the three residents reviewed for discharges. The facility census was 106. Review of Resident #500's chart revealed Resident #500 was admitted to the facility on [DATE] with Alzheimer's disease, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, primary generalized osteoarthritis, major depressive disorder, alcohol abuse, anxiety disorder, mixed hyperlipidemia, depression and history of falling. Resident #500 discharged from the facility on 07/18/25. [...]

Inspectors wroteBased on staff interview, record review, and review of facility policy, the facility failed to develop and implement a comprehensive, person-centered care plan for a resident who exhibited inappropriate sexual behaviors towards other residents. This affected one (#500) of six residents reviewed for care planning. The facility census was 106. Review of Resident #500's chart revealed Resident #500 was admitted to the facility on [DATE] with Alzheimer's disease, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, primary generalized osteoarthritis, major depressive disorder, alcohol abuse, anxiety disorder, mixed hyperlipidemia, depression and history of falling. Resident #500 discharged from the facility on 07/18/25. [...]

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure food was stored and served in a manner to prevent the potential spread of foodborne illness. This had the potential to affect 108 of 111 residents. The facility identified three (Residents #37, #172, and #169) who did not receive food from the kitchen. The facility census was 111 residents.

Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to ensure resident dining choices were honored. This affected one (Resident #19) of nine residents observed in the main dining room. The facility census was 111 residents.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure staff documented medication administration accurately in the electronic medical record. This affected one (Resident #99) of five residents reviewed for unnecessary medications. The facility census was 111 residents.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of hospital records, resident interview, staff interview, and review of the facility policy, the facility failed to properly transfer a resident using a mechanical lift (Hoyer) and the assistance of two staff per the resident's care plan. Actual harm occurred on 10/28/24 when Certified Nursing Assistant (CNA) #35 completed a hands-on pivot transfer of Resident #11 from the bed to the wheelchair without the assistance of additional staff or use of a gait belt. Resident #11 sustained a fall to the floor during the transfer which resulted in a left femur fracture. This affected one (Resident #11) of three residents reviewed for falls. The facility census was 115 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and the resident interview, the facility failed to maintain an adequate supply of food during tray service and failed to follow the facility menu. This affected four (Residents #12, #18, #19, and #20) of four residents observed for meal service. The facility census was 115 residents.

Inspectors wroteReview of medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff maintained proper infection control practices during tracheostomy care. This affected one (Resident #17) of three residents reviewed for tracheostomy care. The facility census was 111 residents.

Inspectors wroteBased on review of the facility menu, observation, staff interview, resident interview, and review of the facility recipes, the facility failed to serve palatable and appetizing food to the residents. This had the potential to affect all residents residing in the facility with the exception of two facility identified residents (#51, #111) who had orders to receive nothing by mouth. The facility census was 117 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff provided visual privacy while providing incontinence care to residents. This affected one (Resident #37) of two residents observed for incontinence care. The facility census was 117 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy the facility failed to ensure staff discarded expired medication. This affected one (Residents #04) of two facility-identified residents with orders for multivitamins with minerals. The facility census was 117 residents.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to ensure personal hygiene was provided for residents. This affected three (Residents #72, #79, and #102) of three residents reviewed for personal hygiene. The census was 117.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the food portions and liquids as planned by a Registered Dietitian. This affected nine (Residents #7, #11, #39, #50, #57, #72, #81, #89 and #98) residents. The facility total census was 117.

Inspectors wroteBased on record review, interview and policy review, the facility failed to prepared fortified foods according to the recipe for increased nutritional value . This affected six (Residents #19, # 46, #47, #50, #79 and #89) of six residents ordered a fortified meal. The census was 117.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to ensure thickened liquids were served as ordered. This affected four (Residents #72, #79, #89 and #98) of four residents reviewed for thickened liquid diets. The census was 117.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to ensure staff changed gloves , performed hand hygiene and wore the proper personal protective equipment. This affected five (Residents #7, #10, #102, #53 and #38) residents. The census was 117.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure the Power of Attorney (POA) was contacted when a resident experienced a change of condition. This affected one (Resident #72) of three residents reviewed for notification of a change in condition. The census was 117.

Inspectors wroteBased on record review, observation interview and policy review, the facility failed to ensure privacy was provided. This affected one (Resident #7) of one resident reviewed for privacy. The census was 117.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a homelike environment was maintained. This affected two (Residents #2 and #86) of three residents reviewed for homelike environment. The census was 117.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to ensure a wound was cleaned properly. This affected one (Resident #102) of three residents reviewed for pressure ulcers. The facility identified nine residents with pressure ulcers. The census was 117.

Inspectors wroteBased on medical record review, staff interview, review of self-reported incidents, review of pharmacy documents, review of written statements, and policy review, the facility failed to report an allegation of misappropriation to the State Survey Agency. This affected one (#100) of two residents reviewed for misappropriation. The facility census was 95.

Inspectors wroteBased on medical record review, staff interview, review of self-reported incidents, review of pharmacy documents, review of written statements, and policy review, the facility failed to thoroughly investigate an allegation of misappropriation. This affected one (#100) of two residents reviewed for misappropriation. The facility census was 95.

Inspectors wroteBased on record review, observations, staff interviews, review of facility policy, and review of online resources from the Centers for Disease Control (CDC), the facility failed to ensure the staff practiced proper hand hygiene during wound care. This affected one (#14) of the three residents reviewed for wound care. The facility census was 103.

Inspectors wroteBased on record review, staff interview, and review of a facility policy, the facility failed to obtain timely re-weights for residents who experienced a five pound or greater weight loss from the previous weight per the facility policy. This affected five (#22, #23, #27, #54, and #58) of five residents reviewed for weight loss. The facility census was 96.

Inspectors wroteBased on review of resident trust accounts, resident interview, and staff interview, the facility failed to ensure residents had access to their funds in in a timely manner. This affected three (#7, #23, and #50) of three residents reviewed for resident funds access. The facility census was 96.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents had the right to access a telephone where calls could not be overheard. This affected three (#89, #92, and #99) of three residents reviewed for resident rights. The facility census was 96.

Inspectors wroteBased on medical record review, observation, staff interview, and review of a facility policy, the facility failed to store medications in an appropriate manner. This affected two (#87 and #93) of four residents observed for medication administration. The facility census was 96.

Inspectors wroteBased on observation, record review, staff interview, review of the facility's policy, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure a resident exhibiting a potential COVID-19 symptom was tested timely, failed to ensure proper Personal Protective Equipment (PPE) was worn when staff sorted potentially infectious dirty laundry, and failed to ensure the infection control log had the recorded information necessary to analyze and control infections. This affected one resident (#13) and had the potential to affect all 94 residents residing in the facility.

Inspectors wroteBased on medical record review, review of facility policy, and staff interview, the facility failed to complete weekly skin assessments and weekly weights as ordered by the physician. This affected four (#13, #30, #39, and #290) of six residents reviewed for physician orders. The facility census was 94.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure opened medication bottles were properly labeled and medications were not kept beyond their expiration date. This affected three of six medication carts and two of three medication rooms. The facility identified all residents received assistance with medication administration. The facility census was 94.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure food was properly stored in the refrigerator and maintain a sanitary refrigerator and freezer on the Elm unit. This had the potential to affect 30 of 32 residents residing on the Elm unit who received food from the kitchen. The facility identified two residents (#17 and #290) on the elm unit, who did not receive food from the nourishment refrigerators or kitchen. The facility census was 94.

Inspectors wroteBased on record review, observation, and resident and staff interviews, the facility failed to ensure residents were served meals in a dignified manner. This affected three residents (#43, #292, and #392) residents observed in the dining room. The facility census was 94.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure advanced directives were correctly documented in the resident's medical record. This affected two (Residents #5 and #28) of two residents reviewed for advanced directives. The facility census was 94.

Inspectors wroteBased on record review and staff interview, the facility failed to timely provide a resident with an explanation of services terminated and provide information to the residents so they can decided if they wish to continue receiving the skilled services that may not be paid for Medicare and assume financial responsibility. This affected three (Residents #14, #26 and #291) of three residents reviewed for benefit changes. The facility census was 94.

Inspectors wroteBased on medical record review, review of the facility's Self-Reported Incident (SRIs), staff interview, and policy review, the facility failed to implement their abuse policy and ensure allegations of resident abuse were reported to the Director of Nursing, Administrator, and State Survey Agency. This affected one (Resident #51) of one resident reviewed for abuse. The facility census was 94.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to complete a new pre-admission screening and resident review (PASARR) when a resident received a new diagnosis of schizophrenia. This affected one (Resident #30) of three residents reviewed for PASARR. The facility census was 94.

Inspectors wroteBased on observation, staff interviews, record review, and policy review, the facility failed to ensure residents received medications as physician ordered. This affected two (Residents #25 and #60) of six residents reviewed for medication administration. The facility census was 94.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure timely physician follow-up to monthly pharmacy recommendations. This affected one (Resident #31) of six residents reviewed for unnecessary medications. The facility census was 94.

Inspectors wroteBased on staff interviews, record review, and policy review, the facility failed to ensure residents were free from of any significant medication errors. This affected one (Residents #60) of six residents reviewed for medication administration. The facility census was 94.

Inspectors wroteBased on observtions, policy review and staff interview, the facility failed to store medications in a safe manner. This had the potential to affect four (#9, #11, #85 and #90) residents in the 300 to 310 hall, and seven (#3, #8, #34, #47, #52, #53, and #66) residents in the 200 hall identified by the facility as cognitively impaired and independently mobile. The facility census was 92.

Inspectors wroteBased on observation, policy/procedure review and staff interviews, the facility failed to label, and date food items from the walk-in refrigerator. The facility also failed to serve food in a sanitary environment. This had the potential to affect 86 of 86 residents who receive food from the kitchen. The facility identified six residents (#24, #51, #55, #71, #91, and #96) that eat nothing by mouth. Facility census was 92.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide Notice of Medicare Non-Coverage (NOMNC) review form for two (#58 and #302) of three residents reviewed for Beneficiary Notices given when discharged from Medicare Part A services. The facility census was 92.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide stop dates for as needed (PRN) psychotropic medications and/or discontinue psychotropic's medications as needed when not administered for more than 14 days. This affected one (#87) of five residents reviewed for unnecessary medications. The facility census was 92.