Three Rivers Health And Rehabilitation Center
Three Rivers Health and Rehabilitation Center in Windsor, NC — inspection on January 30, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
catheter care, and appropriate care to prevent urinary tract infections.
record review, observation and staff interviews, the facility failed to position a urinary drainage bag
catheters (Resident #49).The findings included:Resident #49 was admitted to the facility on [DATE] with diagnoses which included suprapubic catheter due to neuromuscular dysfunction of the bladder.Resident #49's care plan revised on 9/10/2025 identified the suprapubic catheter with interventions including: keeping the catheter bag covered to maintain dignity and positioning the catheter bag and catheter tubing below the level of the bladder and away from the entrance door.Resident #49's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was severely cognitively impaired. Resident #49 was coded for an indwelling / (suprapubic) catheter.An initial observation was conducted on 1/28/2026 at 11:30 AM of Resident #49 as he was lying in his bed.
The bed was noted to be in the lowest position with the catheter bag lying on the floor wedged between the floor and the bed frame.
There was no tension noted on the catheter tubing.Additional observation on 1/28/2026 at 1:45 PM revealed Resident #49 was still lying in his bed.
The bed had been raised approximately 3 inches off the floor and the catheter bag remained on the floor with no barrier between the floor and the catheter bag.An interview was conducted with Nurse Aide (NA) #2 on 1/29/2026 at 9:18 AM.
She confirmed she had been assigned to Resident #49 on 1/28/2026. NA #2 stated Resident #49's catheter bag was secured on the right side of the bedframe and below the bladder. NA #2 stated the catheter bag may have fallen on the floor when they lowered the bed to feed him. NA #2 stated the catheter bag was not supposed to touch the floor and she would position the bag back onto the bedframe, so it did not touch the floor.
She explained she had checked on Resident #49 before lunch and again around 2:30 to 3:00 pm and stated Resident #49's catheter bag was not touching the floor during those times. NA #2 also stated education was provided during orientation on caring catheters.On 1/29/2026 at 11:18 AM an interview was conducted with Nurse #1.
She stated when she came in yesterday (1/28/2026 at 7:00 am) Resident #49's catheter bag was on the floor.
Nurse #1 stated she picked up the catheter bag and placed it on the bed frame.
Nurse #1 stated she did not assess if the catheter bag was on the floor at any other time on 1/28/26.
She stated catheter bags were to be off the floor to prevent possible infection.
Nurse #1 revealed she received annual education on catheter bag placement which included keeping the catheter bag from touching the floor.An interview was conducted with the Director of Nursing (DON) / Infection Preventionist on 01/29/2026 at 11:27 AM.
The DON stated the staff most likely did not understand that lowering the bed would cause the catheter bag to be on the floor.
The DON explained the staff should raise the bed so the catheter bag would be at least 2 to 3 inches off the floor to prevent possible infections and to check behind themselves prior to leaving the room regarding the position of catheter bag.
The DON stated the facility provided education regarding catheter care and placement during orientation to new staff and annually.On 01/29/2026 at 12:29 PM an interview was conducted with the Administrator.
The Administrator stated everyone should know the catheter bag should not be touching the floor.
She did not know why the NA did not identify the catheter bag on the floor.
345404 01/30/2026
Three Rivers Health and Rehabilitation Center 1403 Conner Drive Windsor, NC 27983
Based on observation, consulting Pharmacist and staff interviews, the facility failed to date an
reviewed for medication storage (200 hall medication cart).The findings include:Per manufacturer's recommendations insulin isophane human/insulin regular human 70/30 insulin pen can be stored at room temperature (59 to 86 degrees Fahrenheit) for 31 days.On 1/28/2026 at 2:58 PM, an observation of the 200-hall medication administration cart with Nurse #1 revealed one opened and undated multi-dose insulin isophane human/insulin regular human 70/30 insulin pen.
The insulin pen was assigned to Resident #55. An interview conducted on 1/28/2026 at 3:00 PM with Nurse #1, who was working from the 200-hall medication cart, revealed insulin pens should be dated when opened and she was not aware the insulin isophane human/insulin regular human 70/30 insulin pen was not dated.
Nurse #1 stated nurses were supposed to check their medication administration carts daily, but she did not check it that day (1/28/2026).
Nurse #1 did not offer an explanation as to why she had not checked the medication administration cart.On 1/29/2026 at 3:16 PM an interview was conducted with the consulting Pharmacist.
The consulting Pharmacist revealed she reviewed at a minimum two medication administration carts every two months that included reviewing the medications inside the cart for labels and open dates on insulin bottles and pens.
She stated there should be a label with an open date on any open insulin and the facility should inspect their medication administration carts monthly.On 1/29/2026 at 3:31 PM an interview was completed with the Director of Nursing (DON).
The DON indicated nurses were responsible for checking the medication administration carts they were assigned to daily and the Nurse Managers were responsible for inspecting medication carts monthly.
During these inspections the nurse's and Nurse Managers were observing for the date of opened medications and expired medications.
The DON was not certain why Nurse #1 had not checked her cart.On 1/29/2026 at 4:18 PM during an interview, the Administrator stated the nurses completed the labeling and dating of insulin pens.
She stated an insulin pen should be removed from the refrigerator and labeled when opened.
The Administrator stated the responsibility of checking medication administration carts included the Pharmacy Consultant who completed random checks monthly, the Nursing Administration Manager completed random checks monthly, and the nurses should check prior to administering medications.
During a follow-up interview with the Dietary Manager on 1/29/26 at 2:05 PM, she revealed that each task on the Kitchen Cleaning Checklist Log should be completed weekly, and she expected staff to date and sign when completed.
The Dietary Manager indicated the cleaning log was supposed to be posted weekly in December 2025 but did not happen due to many holiday events.
The cleaning log for 1/1/26 through 1/11/26 could not be found.
The Dietary Manager stated that cleaning tasks were rotated each week, but some staff did not do what they were supposed to do.
The interview further revealed the deep fryer was broken from 1/4/26 until 1/20/26 or 1/21/26 (unsure of exact date) because it was not reaching the proper temperature and was last cleaned on 1/16/26.
The first time it was used was on 1/23/26 and then again on 1/27/26.
The Dietary Manager stated that the last training was completed on 1/22/26 for all kitchen staff related to hand hygiene, food contamination, and single use gloves.
The Administrator was interviewed on 1/30/26 at 8:34 AM and stated the kitchen cleaning schedules should be followed.
345404 01/30/2026
Three Rivers Health and Rehabilitation Center 1403 Conner Drive Windsor, NC 27983