Three Rivers Care

In the surveyor’s words

From the most serious findings on record at Three Rivers Care, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF605Nov 18, 2025

  Based on interview and record review, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) test (a rating scale used to assess the severity of involuntary movements that sometimes develop as a side effect of treatment with antipsychotic medications [a class of drugs primarily used to treat mental health conditions such as hallucinations and delusions]) and/or failed to monitor for adverse side effects (ASE) of antidepressant medication (a class of drugs used to treat depression, a mental health condition characterized by persistent feelings of sadness, hopelessness, and/or loss of interest in activities) for 1 of 5 sampled residents (Resident 42) reviewed for unnecessary medications. […]

• No harm, potential for more than minimal, isolatedF655Nov 18, 2025

  Based on interview and record review, the facility failed to develop a depression (a mental health condition characterized by persistent feelings of sadness, hopelessness, and/or loss of interest or pleasure in activities) baseline care plan for 1 of 5 sampled residents (Resident 42) reviewed for unnecessary medications. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included. Resident 42 was admitted to the facility on [DATE] with multiple diagnoses to include major depressive disorder. Record review of Resident 42's level 1 Pre-admission Screening and Resident Review (PASRR), dated 09/15/2025, showed Resident 42 had a Serious Mental Illness Indicator (SMI) of Mood Disorder, depression. […]

• No harm, potential for more than minimal, isolatedF684Nov 18, 2025

  Based on interview and record review, the facility failed to follow physicians' orders to assess resident's pulse (heart rate) prior to medication administration for 1 of 5 residents (Resident 30) and to administer pain medication per physician's ordered parameters for 1 of 6 residents (Resident 17), reviewed for quality of care. These failures placed residents at risk of unmet care needs, medical complications and diminished quality of life.Findings included . Resident 30 was admitted to the facility on [DATE], with multiple diagnoses including Essential Hypertension (high blood pressure). […]

• No harm, potential for more than minimal, isolatedF695Nov 18, 2025

  Based on observation, interview and record review, the facility failed to ensure oxygen tubing was changed for 1 of 1 sampled resident (Resident 7) reviewed for respiratory care. This failure placed residents at risk of respiratory infections and a decreased quality of life. Findings Included. Record review of the facility's policy titled, Oxygen Management, revised 08/2023, documented .6. Change oxygen tubing weekly or when soiled, impaired integrity or as needed. Resident 7 was admitted to the facility on [DATE] with multiple diagnosis to include chronic obstructive pulmonary disease (COPD, a group of lung diseases that cause long-term breathing problems) and emphysema (a chronic lung disease that causes progressive damage to the air sacs in the lungs). […]

• No harm, potential for more than minimal, isolatedF761Nov 18, 2025

  Based on observation and interview, the facility failed to ensure a vial of purified protein derivative (PPD) solution (used in the skin test to diagnose tuberculosis, a lung infection), was dated with the date opened according to accepted professional standards of practice for 1 of 2 medication rooms (East Hall) reviewed for medication storage and labeling. This failure placed residents at risk of receiving expired medications and negative health outcomes.Findings included .During an observation of the East Hall medication room refrigerator with Staff E, Licensed Practical Nurse (LPN), on 09/22/2025 at 10:53 AM, the refrigerator was observed to have an open unlabeled vial of PPD solution that was almost empty. […]