Three Rivers Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Three Rivers Health and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Jan 30, 2026

  Based on observation and staff interviews, the facility failed to clean 1 of 1 deep fryer, 1 of 1 steamer, 1 of 1 tray line cooler, 1 of 4 kitchen walls, the floor of 1 of 1 walk-in refrigerator and 2 of 5 meal carts. These practices had the potential to affect food served to residents. The findings included: A continuous observation of the kitchen and interview with the Dietary Manager and Dietary Aide #1 was conducted on 1/28/26 from 10:25 AM through 10:48 AM. A white residue was observed on the tops and on the bottom inner surfaces of two meal carts. The Dietary Manager stated that the meal carts were cleaned weekly. Cloudy (white) oil was observed inside the deep fryer along with food crumbs along all areas surrounding the oil. […]

• No harm, potential for more than minimal, patternF755Nov 1, 2024

  Based on record review, staff interview, Medical Director/Physician interview, and Pharmacist interview the facility failed to have effective safeguards and systems in place to account for, and periodically reconcile controlled medications to protect the residents right to be free from potential drug diversion. This was for 7 of 14 residents reviewed for pharmacy services for controlled medication (Resident #9, Resident #205, Resident #210, Resident #211, Resident #212, Resident #213 and Resident #221). Findings included: a. Resident #205 was admitted to the facility on [DATE] with diagnoses that included aftercare for joint replacement surgery. […]

• No harm, potential for more than minimal, patternF756Jun 3, 2022

  Based on record review and facility staff and consultant pharmacist (CP) interviews, the facility failed to act upon pharmacy recommendations for 1 of 5 residents reviewed for unnecessary medications (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)]. Review of the electronic health record revealed an Abnormal Involuntary Movement Scale (AIMS) had been completed on Resident #1 on 5/20/21. AIMS is used to assess abnormal body movements in residents taking antipsychotic medications. Resident #1's annual Minimum Data Set, dated dated dated [DATE] indicated she received an antipsychotic medication for 7 days during the look back period. […]

• No harm, potential for more than minimal, patternF812Jun 3, 2022

  Based on observations, interviews with the Dietary Manager and record review the facility failed to store foods in the refrigerator after opening, failed to discard an expired food item, and failed to maintain pasta salad at or below 41 degrees Fahrenheit during 2 of 3 kitchen observations. This had the potential to affect 43 residents who received meal trays out of 45 total residents. The findings included: 1. On [DATE] at 9:25 AM an opened gallon size container of diced pickles was observed stored in the room temperature storage room. An open date was not observed on the container. The manufacturer label read the product was to be refrigerated after opening. […]

• No harm, potential for more than minimal, isolatedF690Jan 30, 2026

  Based on record review, observation and staff interviews, the facility failed to position a urinary drainage bag from touching the floor to reduce the risk of infection for 1 of 2 residents reviewed with urinary catheters (Resident #49).The findings included:Resident #49 was admitted to the facility on [DATE] with diagnoses which included suprapubic catheter due to neuromuscular dysfunction of the bladder.Resident #49's care plan revised on 9/10/2025 identified the suprapubic catheter with interventions including: keeping the catheter bag covered to maintain dignity and positioning the catheter bag and catheter tubing below the level of the bladder and away from the entrance door.Resident #49's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was severely… […]