Three Rivers Health & Rehab Center

In the surveyor’s words

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

• Actual harm, isolatedF760Sep 13, 2023

  Based on staff interview, Ombudsman interview, family interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure one resident (Resident #2) was free from significant medication errors in a survey sample of four (4) residents, resulting in harm. For Resident #2, the facility discontinued all of the resident's cardiac, antihypertensive, and blood thinning medications after 30 days resulting in hospitalization for a stroke. The medications were Diltiazem, Metoprolol, and Apixaban anticoagulation (blood thinner) medication for new onset atrial fibrillation. The findings included: Resident #2 was admitted to the facility on [DATE] from the hospital. […]

• Actual harm, isolatedF686Jul 29, 2021

  Based on observation, resident interview, staff interview, clinical record review, and facility documentation review the facility staff failed to prevent, identify, and appropriately treat pressure wounds for 1 Resident (Resident #13) in a sample size of 22 Residents. This resulted in harm to Resident # 13. The findings included: 1. For Resident #13, the facility staff failed to identify, assess, notify provider, and appropriately treat a pressure wound on the left heel resulting in an unstageable pressure wound on the left heel. This is harm. On 07/27/2021 at approximately 10:40 A.M., the active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF727Mar 1, 2024

  Based on observation, staff interview, and facility document review, the facility staff failed to provide Registered Nurse coverage 8 consecutive hours per day for 16 days out of 180 days reviewed. The findings include: Facility staff failed to provide any Registered Nurse (RN) coverage in July 2023 on the 1st, 2nd, 15th, 16th, 29th, and 30th; August 2023 on the 12th and 13th; November 2023 on the 24th, 25th, and 26th; and December 2023 on the 9th, 10th, 23rd, 24th, and 25th. On 2/29/24 at approximately 10:00 AM, the facility's clinical staffing records from 7/1/23 through 12/31/23 were requested and received from the Staffing Coordinator. Review of the records revealed there was no RN coverage on the previously stated dates. […]

• No harm, potential for more than minimal, patternF883Mar 1, 2024

  Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide pneumococcal immunization for 5 residents, Residents #4, #7, #12, #30, and #36, out of 5 residents reviewed for pneumococcal immunization. The findings included: The facility staff failed to provide pneumococcal immunization for Residents #4, #7, #12, #30, and #36. On 2/28/24 at approximately 10:30 AM, clinical record reviews were performed and revealed the following: A. […]

• No harm, potential for more than minimal, patternF607Jul 29, 2021

  Based on staff interview and facility documentation review, the facility staff failed to implement their abuse policy regarding the screening of employees for 4 employees (CNA F, CNA G, LPN C, and RN B) in a sample of 25 employee records reviewed. CNA F, CNA LPN C faild to sign their sworn statements timely, or completely. RN B did not have reference checks. The findings included: On 7/28/21, a review of a sample of 25 of the facility's employee files was conducted by Surveyor E. The reviews revealed the following: 1. CNA F's hire date was confirmed as 8/10/20. CNA F signed a sworn statement on 1/23/2021. Therefore, CNA F had not sworn to not having any convictions or pending charges of barrier crimes from 8/10/20-1/23/21, prior to being permitted to provide direct care to Residents. […]