WINDSOR, NC - Federal health inspectors documented significant deficiencies in catheter care and urinary tract infection prevention at Three Rivers Health and Rehabilitation Center during a standard inspection conducted January 30, 2026.
Critical Gaps in Bladder and Bowel Care
The inspection revealed that Three Rivers Health failed to provide appropriate care for residents who require assistance with bladder and bowel management. This includes both continent and incontinent residents, as well as those requiring catheter care - a critical aspect of nursing home care that directly impacts resident health and comfort.
Federal inspectors classified the violation under regulatory tag F0690, which specifically addresses the facility's obligation to provide proper care for residents with continence issues and prevent urinary tract infections. The deficiency was rated as Scope/Severity Level D, indicating an isolated incident with potential for more than minimal harm to residents.
Medical Risks of Improper Catheter Care
Catheter care represents one of the most infection-prone procedures in healthcare settings. When facilities fail to follow proper protocols, residents face serious medical consequences. Improper catheter insertion, maintenance, or monitoring can lead to urinary tract infections, which in elderly residents can quickly progress to life-threatening complications including sepsis and kidney damage.
Standard catheter care protocols require strict sterile technique during insertion, regular assessment of catheter necessity, proper positioning to prevent tissue damage, and meticulous hygiene practices. Healthcare staff must also monitor for signs of infection, including changes in urine color, odor, or clarity, as well as resident reports of pain or discomfort.
Healthcare Standards for Continence Management
Federal regulations require nursing homes to maintain comprehensive continence care programs. This includes regular assessment of each resident's bladder and bowel function, development of individualized care plans, and implementation of evidence-based interventions to maintain or restore continence when possible.
For residents requiring catheter care, facilities must ensure that catheters are used only when medically necessary and that staff receive proper training in insertion techniques, daily care procedures, and infection prevention measures. The facility must also have protocols for regular catheter evaluation to determine if continued use is appropriate.
Infection Prevention Protocols
Preventing urinary tract infections requires systematic attention to multiple factors. Staff must maintain proper hand hygiene before and after any contact with catheters or the genital area. Catheter bags must be positioned below the bladder level to prevent backflow, and drainage systems should remain closed to minimize bacterial contamination.
Regular perineal cleaning with appropriate products, monitoring of fluid intake and output, and prompt response to any signs of infection are essential components of quality care. Facilities should also have protocols for catheter removal as soon as medically appropriate, since the risk of infection increases with duration of use.
Industry Impact and Resident Safety
Continence care deficiencies affect some of the most vulnerable nursing home residents. Many elderly residents already face increased infection risks due to compromised immune systems, multiple medical conditions, and age-related changes in bladder function. When facilities fail to provide appropriate care, these residents may experience unnecessary pain, hospitalization, or even life-threatening complications.
Proper continence management also significantly impacts resident dignity and quality of life. Residents who receive inadequate catheter care may experience discomfort, embarrassment, and reduced mobility, directly affecting their overall well-being and rehabilitation outcomes.
Facility Response and Correction
Three Rivers Health and Rehabilitation Center reported correction of the identified deficiencies as of February 20, 2026. The facility was required to submit a plan of correction addressing the specific failures in catheter care and urinary tract infection prevention protocols.
This violation was one of three deficiencies cited during the January inspection, indicating broader concerns about care quality at the facility. While no actual harm to residents was documented in this instance, federal inspectors determined there was potential for more than minimal harm, highlighting the serious nature of the care gaps identified.
The full inspection report provides additional details about the specific care failures documented and the facility's response to address these critical safety concerns.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Three Rivers Health and Rehabilitation Center from 2026-01-30 including all violations, facility responses, and corrective action plans.