Three Rivers Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF689Dec 16, 2024

  THE 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. […]

• No harm, potential for more than minimal, widespreadF812Feb 6, 2025

  Based 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. Findings include: 1. Observation on 02/03/25 at 9:15 A.M. of the facility's dry storage area revealed the following items: an opened undated bag of baking powder wrapped in plastic wrap, an opened bag of marshmallows wrapped in plastic wrap dated 08/20/23, an opened 12 quart plastic container of chocolate chips with an open date of 12/10/24 and discard date of 01/10/25, an opened undated bag of egg… […]

• No harm, potential for more than minimal, widespreadF804Aug 15, 2024

  Based 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. Findings include: Review of the facility menu for 08/05/24 revealed the lunch entree was Dijon pork loin. Observation on 08/05/24 at 11:50 A.M. revealed [NAME] #126 removed a tray of pork loin from the oven that had been cooked in its own juices. On the tray line there was a container of a thick yellow substance which [NAME] #126 identified as gravy. […]

• No harm, potential for more than minimal, widespreadF880May 19, 2022

  Based 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. Findings include: 1. Review of the medical record of Resident #13 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF803Dec 16, 2024

  Based 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. Findings include: Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses including alcohol dependence, respiratory failure, depression, psychoactive substance abuse, anxiety, chronic pain, and insomnia. Review of the Minimum Data Set (MDS) assessment for Resident #12 dated 09/01/24 revealed the resident had no cognitive deficits and required supervision with activities of daily living (ADLs). […]