B+
82/100Three Rivers Health and Rehabilitation Center Inspection Report, Violations & Safety Grade (Windsor, North Carolina)
1403 Conner Drive, Windsor, North Carolina 27983
Phone: 2527944441
CMS Overall:4/5
Overview & Bed Count
Certified Beds
60
Avg Residents/Day
49.6
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Bertie
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall4/5
Health4/5
Staffing2/5
Quality4/5
Nurse Staffing Check
| Metric | This Facility | North Carolina Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.37 | 0.62 | -0.25 |
| Total Nurse Hours per Resident per Day | 3.60 | 3.87 | -0.27 |
| CMS Staffing Rating | 2/5 | 2.7/5 | - |
| Nursing Staff Turnover | 48.8% | 48.7% | - |
Health Citation History
6 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-01-30 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2026-01-30 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2026-01-30 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-11-01 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E – Moderate Harm Potential |
| 2024-11-01 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2024-11-01 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
Fire Safety Citation History
12 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-01-30 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | E – Moderate Harm Potential |
| 2026-01-30 | Egress Deficiencies | Install proper backup exit lighting. | D – Moderate Harm Potential |
| 2026-01-30 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2026-01-30 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
| 2026-01-30 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2026-01-30 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | D – Moderate Harm Potential |
| 2024-11-01 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | D – Moderate Harm Potential |
| 2024-11-01 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | D – Moderate Harm Potential |
| 2023-09-08 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | E – Moderate Harm Potential |
| 2023-09-08 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D – Moderate Harm Potential |
| 2023-09-08 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2023-09-08 | Smoke Deficiencies | Install an approved automatic sprinkler system. | D – Moderate Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties
No penalty records found.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Windsor area at no cost.
Find Safe, Vetted Facilities Near Windsor
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Windsor area at no cost.
Find Safe, Vetted Facilities Near Windsor
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.