Deficiency Records for Three Rivers Healthcare Center
Updated as of December 01, 2018
This is not the most recent data for Three Rivers Healthcare Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-06-04 | 2018-06-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-03-07 | 2018-03-26 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-10-26 | 2017-11-17 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-10-26 | 2017-11-17 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-10-26 | 2017-11-17 | Y |
| Quickly tell the resident's doctor the results of laboratory tests. | Health | 2017-10-26 | 2017-11-17 | Y |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2017-04-06 | 2017-05-05 | N |
| Have exits that are accessible at all times. | Fire Safety | 2017-04-06 | 2017-05-05 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2017-04-06 | 2017-05-05 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-04-06 | 2017-05-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-04-06 | 2017-05-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-04-06 | 2017-05-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-04-06 | 2017-05-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-04-06 | 2017-05-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-04-06 | 2017-05-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-04-06 | 2017-05-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-04-06 | 2017-05-05 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-04-06 | 2017-05-05 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-04-06 | 2017-05-05 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-04-06 | 2017-05-05 | N |
| Send unopened mail from residents and promptly deliver unopened mail to residents. | Health | 2017-04-06 | 2017-05-05 | Y |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-04-06 | 2017-05-05 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2016-07-20 | 2016-08-12 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-07-20 | 2016-08-12 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-07-20 | 2016-08-12 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-07-20 | 2016-08-12 | Y |
| Exits that are accessible at all times. | Fire Safety | 2016-02-03 | 2016-03-21 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2016-02-03 | 2016-03-21 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-02-04 | 2016-03-21 | N |
| Provide housekeeping and maintenance services. | Health | 2016-02-04 | 2016-03-21 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-02-04 | 2016-03-21 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-02-04 | 2016-03-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2016-02-04 | 2016-03-21 | N |
