01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-03-01 | 8 | 2024-03-01 | 3 |
| Cycle 2 | 2021-07-29 | 15 | 2021-07-29 | 0 |
| Cycle 3 | 2018-11-01 | 13 | 2018-11-01 | 3 |
CMS CCN 4953032026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Three Rivers Health & Rehab Center
2960 Chelsea Road · West Point, VA 23181 · King William County
Certified beds60CMS provider file
Recent citation rows42current CMS citation release
Penalty rows1current 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
42 rows in the current release
2 rows carry G–L scope/severity codes; 0 carry J–L. 8 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2024-03-01 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2024-04-012024-03-01 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2024-04-012024-03-01 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2024-04-012024-03-01 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2024-04-012024-03-01 · HEALTHF0727Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Correction field: Deficient, Provider has date of correction · 2024-04-012024-03-01 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-04-012024-03-01 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2024-04-012024-03-01 · HEALTHF0883Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2024-04-012024-03-01 · FIREK0291Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2024-03-152024-03-01 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-03-152024-03-01 · FIREK0918Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2024-03-152023-09-13 · HEALTHF0552Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Correction field: Deficient, Provider has date of correction · 2023-10-24 · complaint2023-09-13 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2023-12-15 · complaint2023-09-13 · HEALTHF0655Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2023-10-24 · complaint2023-09-13 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2023-10-24 · complaint2023-09-13 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2023-10-24 · complaint2023-09-13 · HEALTHF0760Severity G · isolated actual harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2023-10-24 · complaint2021-07-29 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2021-09-012021-07-29 · HEALTHF0574Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
The resident has the right to receive notices in a format and a language he or she understands.
Correction field: Deficient, Provider has date of correction · 2021-09-012021-07-29 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2021-09-012021-07-29 · HEALTHF0582Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Correction field: Deficient, Provider has date of correction · 2021-09-012021-07-29 · HEALTHF0607Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2021-09-012021-07-29 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2021-09-012021-07-29 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2021-09-0103 / 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 |
|---|---|---|---|
| 2023-09-13 | Fine | $8,492 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- VA 3 OPCO HOLDCO LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 03/01/2023
- BSD EOM IRREVOCABLE TRUSTOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST25% · since 03/01/2023
- HLHK IRREVOCABLE TRUSTOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST25% · since 03/01/2023
- SOUTH EAST VIRGINIA HOLD CO LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST25% · since 03/01/2023
- VOGUE NHC LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST25% · since 03/01/2023
- MONTFORDD, NICOLAIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 03/01/2023
- HARTSTEIN, JAKEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2023
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 hours3.15per resident day
RN hours0.47per resident day
Weekend nurse hours2.83per resident day
Staff turnover42.0%CMS reported field
06 / LOCAL RECORDS
Open the Virginia ledger →Other published facilities nearby
No second facility in the same city met the directory rule.