Cycle 1
Health 2026-01-30 · Fire 2024-11-01
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Windsor, NC
Three Rivers Health and Rehabilitation Center
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1403 Conner Drive, Windsor, NC
(252) 794-4441
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Liberty Senior Living
Operator or chain grouping
Approved since
1992-03-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
35 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.46
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.51
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,195
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9879
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.28
Baseline 19.32% · Performance 19.45% · Measure score 4.28 · Achievement 4.28 · Improvement 0
Healthcare-associated infections
5.10
Baseline 5.14% · Performance 6.31% · Measure score 5.10 · Achievement 5.10 · Improvement 0
Total nurse turnover
2.27
Baseline 47.62% · Performance 54.39% · Measure score 2.27 · Achievement 2.27 · Improvement 0
Adjusted total nurse staffing
1.82
Baseline 3.44 hours · Performance 3.60 hours · Measure score 1.82 · Achievement 1.82 · Improvement 0.15
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.57% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 224 · Observed rate 9.82% · Lower 95% interval 7.51% |
| Discharge to community | 61.59% |
50.57%
11 pts better
|
Better than the National Rate · Eligible stays 229 · Observed rate 58.95% · Lower 95% interval 55.65% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 144 · Denominator 144 |
| Falls with major injury | 0.69% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 144 |
| Discharge self-care score | 48.33% |
53.69%
5.4 pts worse
|
Numerator 58 · Denominator 120 |
| Discharge mobility score | 51.67% |
50.94%
0.7 pts better
|
Numerator 62 · Denominator 120 |
| Pressure ulcers or injuries, new or worsened | 4.86% |
2.29%
2.6 pts worse
|
Numerator 7 · Denominator 144 · Adjusted rate 5.01% |
| Healthcare-associated infections requiring hospitalization | 6.31% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 130 · Observed rate 4.62% · Lower 95% interval 3.76% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 73 |
| Staff flu vaccination coverage | 1.39% |
42%
40.6 pts worse
|
Numerator 1 · Denominator 72 |
| Discharge function score | 67.5% |
56.45%
11 pts better
|
Numerator 81 · Denominator 120 |
| Transfer of health information to provider | 95.65% |
95.95%
0.3 pts worse
|
Numerator 22 · Denominator 23 |
| Transfer of health information to patient | 89.81% |
96.28%
6.5 pts worse
|
Numerator 97 · Denominator 108 |
| Resident COVID-19 vaccinations up to date | 2.47% |
25.2%
22.7 pts worse
|
Numerator 2 · Denominator 81 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
91.5%
7.1 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.7% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.6%
0.6 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.7% · Q4 11.1% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.3% |
4.8%
3.5 pts worse
|
11.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 6.1% · Q3 12.1% · Q4 9.4% · 4Q avg 8.3% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
7.2%
4.5 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 10.3% · Q4 0.0% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.1% |
21.6%
4.5 pts worse
|
19.6%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 22.2% · Q3 27.6% · Q4 30.0% · 4Q avg 26.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.7% |
15.0%
1.3 pts better
|
16.7%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 8.3% · Q3 15.4% · Q4 20.0% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.7% |
21.5%
13.8 pts better
|
16.3%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.0% |
16.8%
9.8 pts better
|
14.9%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 12.5% · Q3 3.8% · Q4 0.0% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
2.6%
1.9 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.0% |
21.2%
6.2 pts better
|
19.8%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 6.6% · Q3 12.5% · Q4 12.9% · 4Q avg 15.0% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
6.0%
1.3 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 8.5% · Q3 1.9% · Q4 3.7% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
79.9%
18.7 pts better
|
81.7%
16.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 100.0% · Q3 98.5% · Q4 96.8% · 4Q avg 98.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.2% |
13.2%
8 pts worse
|
12.0%
9.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 19.1% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 1.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.0% |
78.1%
18.9 pts better
|
79.7%
17.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
22.9%
1.8 pts better
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 18.4% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-01 · Fire 2023-09-08
3 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-09-08 · Fire 2022-06-03
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-30
D · Potential for more than minimal harm
2024-11-01
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-30
E · Potential for more than minimal harm
2023-09-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-18
D · Potential for more than minimal harm
2023-09-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-18
D · Potential for more than minimal harm
2023-09-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-11-18
D · Potential for more than minimal harm
2023-09-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-18
E · Potential for more than minimal harm
2022-06-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-08-14
D · Potential for more than minimal harm
2022-06-03
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-08-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-02-20
D · Potential for more than minimal harm
2026-01-30
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2026-02-20
D · Potential for more than minimal harm
2026-01-30
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2026-02-20
E · Potential for more than minimal harm
2024-11-01
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-27
D · Potential for more than minimal harm
2024-11-01
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-11-01
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-11-22
Penalties and ownership
What sits behind the stars
Ownership
Bork, Matthew
Operational/Managerial Control · Individual
Brown, Penny
Operational/Managerial Control · Individual
Calcutt, Joeseph V
Corporate Officer · Individual
John A Mcneill Jr 2012 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Liberty Healthcare Group LLC
5% Or Greater Indirect Ownership Interest · Organization
Liberty Healthcare Management Inc
Operational/Managerial Control · Organization
Liberty Healthcare Properties Of Bertie County LLC
5% Or Greater Direct Ownership Interest · Organization
Liberty Long Term Care LLC
5% Or Greater Direct Ownership Interest · Organization
Liberty Real Properties
5% Or Greater Direct Ownership Interest · Organization
Mcneill, John
5% Or Greater Direct Ownership Interest · Individual
Mcneill, John
5% Or Greater Indirect Ownership Interest · Individual
Mcneill, John
Corporate Director · Individual
Mcneill, Ronald
5% Or Greater Direct Ownership Interest · Individual
Mcneill, Ronald
5% Or Greater Indirect Ownership Interest · Individual
Mcneill, Ronald
Corporate Director · Individual
Miller, Robert
Operational/Managerial Control · Individual
Miller, Robert
Corporate Director · Individual
Ronald B And Cynthia J Mcneill 2013 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Severa, Jeffrey
Operational/Managerial Control · Individual
Three Rivers Health And Rehabilitation Center, LLC
5% Or Greater Direct Ownership Interest · Organization
Wilson, Jeffrey
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Windsor Rehabilitation and Healthcare Center
Windsor, NC
1-star overall rating with 1-star inspections with abuse icon flag with $249,991 in total fines with 22 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
The Carrolton of Plymouth
Plymouth, NC
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Chowan River Nursing and Rehabilitation Center
Edenton, NC
4-star overall rating with 4-star inspections with 5 recent health deficiencies
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