01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-01-30 | 3 | 2024-11-01 | 2 |
| Cycle 2 | 2024-11-01 | 3 | 2023-09-08 | 4 |
| Cycle 3 | 2023-09-08 | 0 | 2022-06-03 | 2 |
CMS CCN 3454042026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Three Rivers Health And Rehabilitation Center
1403 Conner Drive · Windsor, NC 27983 · Bertie County
Certified beds60CMS provider file
Recent citation rows14current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
14 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 2 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-01-30 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-02-202026-01-30 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-02-202026-01-30 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-02-202024-11-01 · HEALTHF0755Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Past Non-Compliance · 2023-10-27 · complaint2024-11-01 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2024-11-22 · complaint2024-11-01 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2024-11-222024-11-01 · FIREK0372Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2024-12-302024-11-01 · FIREK0521Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2024-12-302023-09-08 · FIREK0211Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2023-11-182023-09-08 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2023-11-182023-09-08 · FIREK0351Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2023-11-182023-09-08 · FIREK0521Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2023-11-182022-06-03 · FIREK0919Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the use of electrical equipment.
Correction field: Deficient, Provider has date of correction · 2022-08-142022-06-03 · FIREK0923Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2022-08-1403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- LIBERTY HEALTHCARE PROPERTIES OF BERTIE COUNTY LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 06/25/2025
- LIBERTY REAL PROPERTIES, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 06/25/2025
- THREE RIVERS HEALTH AND REHABILITATION CENTER, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 10/01/2002
- MCNEILL, JOHNIndividual · 5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 10/01/2002
- MCNEILL, RONALDIndividual · 5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 10/01/2002
- MCNEILL, JOHNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 12/15/2005
- MCNEILL, RONALDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 12/15/2005
- MILLER, ROBERTIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/01/2024
- CALCUTT, JOSEPHIndividual · CORPORATE OFFICERNOT APPLICABLE · since 06/25/2025
- LIBERTY HEALTHCARE MANAGEMENT INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2002
- BORK, MATTHEWIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/29/2007
- BROWN, PENNYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/25/2025
- MILLER, ROBERTIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2024
- SEVERA, JEFFREYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/25/2025
- WILSON, JEFFREYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2002
- MCNEILL, ROBERTIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 06/25/2025
- OLIVER, ANNAIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 06/25/2025
- PURVIS, JENNYIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 06/25/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.56per resident day
RN hours0.43per resident day
Weekend nurse hours3.24per resident day
Staff turnover48.9%CMS reported field
06 / LOCAL RECORDS
Open the Windsor ledger →