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Deficiency Records for Three Rivers Healthcare Center
A list of the most recent deficiencies for Three Rivers Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Three Rivers Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2024-09-25 | 2024-10-11 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2024-08-15 | 2024-08-19 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-08-15 | 2024-08-19 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-08-15 | 2024-08-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-06-13 | 2024-07-10 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2024-06-13 | 2024-07-10 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-06-13 | 2024-07-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-13 | 2024-07-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-06-13 | 2024-07-10 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-06-13 | 2024-07-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-06-13 | 2024-07-10 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-06-13 | 2024-07-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-06-13 | 2024-07-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-26 | 2024-02-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-26 | 2024-02-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-21 | 2023-12-14 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-09-19 | 2023-10-06 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-09-19 | 2023-10-06 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-19 | 2023-10-06 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-09-19 | 2023-10-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-07 | 2023-03-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-07 | 2023-03-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-07 | 2023-03-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-15 | 2022-10-14 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-09-15 | 2022-10-14 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-15 | 2022-10-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-29 | 2022-10-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-29 | 2022-10-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-29 | 2022-10-14 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-05-19 | 2022-06-29 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-05-19 | 2022-06-29 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-05-19 | 2022-06-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-19 | 2022-06-29 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-05-19 | 2022-06-29 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-19 | 2022-06-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-19 | 2022-06-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-19 | 2022-06-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-19 | 2022-06-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-19 | 2022-06-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-19 | 2022-06-29 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-19 | 2022-06-29 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2022-05-09 | 2022-06-29 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-05-09 | 2022-06-29 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-05-09 | 2022-06-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-09 | 2022-06-29 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-05-09 | 2022-06-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-09 | 2022-06-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-09 | 2022-06-29 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-05-09 | 2022-06-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-09 | 2022-06-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-05-09 | 2022-06-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-09 | 2022-06-29 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-05-22 | 2019-06-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-05-22 | 2019-06-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-05-22 | 2019-06-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-22 | 2019-06-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-21 | 2019-06-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-21 | 2019-06-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-21 | 2019-06-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-21 | 2019-06-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-05-21 | 2019-06-30 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-05-21 | 2019-06-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-21 | 2019-06-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-21 | 2019-06-30 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-06-21 | 2018-07-20 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-06-21 | 2018-07-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-06-21 | 2018-07-20 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-06-21 | 2018-07-20 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-06-21 | 2018-07-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-06-21 | 2018-07-20 | N |
| Provide appropriate foot care. | Health | 2018-06-21 | 2018-07-20 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-06-21 | 2018-07-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-06-21 | 2018-07-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-21 | 2018-07-20 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-06-21 | 2018-07-20 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-06-21 | 2018-07-20 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2018-06-21 | 2018-07-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-06-20 | 2018-07-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-06-20 | 2018-07-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-06-20 | 2018-07-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-06-20 | 2018-07-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-06-20 | 2018-07-20 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-06-20 | 2018-07-20 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2018-06-20 | 2018-07-20 | N |
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