B82

Three Rivers Health and Rehabilitation Center

Grade B 82/100 composite score

For profit - Corporation

CMS Star Ratings

Overall
4/5
Health Insp.
4/5
Quality
4/5
Staffing
2/5
RN Staffing
Not rated

Certified Beds

60

Ownership

For profit - Corporation

Total Fines

None

Last Survey

N/A

1403 Conner Drive, Windsor, NC 27983
2527944441

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.44h
LPN
1.01h
CNA
1.91h
Total
3.36h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

LIBERTY HEALTHCARE PROPERTIES OF BERTIE COUNTY LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Jun 2025

LIBERTY LONG TERM CARE LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Oct 2002

LIBERTY REAL PROPERTIES

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Jun 2025

THREE RIVERS HEALTH AND REHABILITATION CENTER, LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Oct 2002

MCNEILL, JOHN

Individual5% OR GREATER DIRECT OWNERSHIP INTERESTSince Oct 2002

MCNEILL, RONALD

Individual5% OR GREATER DIRECT OWNERSHIP INTERESTSince Oct 2002

JOHN A MCNEILL JR 2012 IRRV TR

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jun 2025

LIBERTY HEALTHCARE GROUP LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jun 2025

RONALD B AND CYNTHIA J MCNEILL 2013 IRRV TR

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jun 2025

MCNEILL, JOHN

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jun 2025

MCNEILL, RONALD

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jun 2025

LIBERTY HEALTHCARE MANAGEMENT INC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Oct 2002

BORK, MATTHEW

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jan 2007

BROWN, PENNY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jun 2025

MILLER, ROBERT

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Sep 2024

SEVERA, JEFFREY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jun 2025

WILSON, JEFFREY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Oct 2002

MCNEILL, JOHN

IndividualCORPORATE DIRECTORSince Dec 2005

MCNEILL, RONALD

IndividualCORPORATE DIRECTORSince Dec 2005

MILLER, ROBERT

IndividualCORPORATE DIRECTORSince Sep 2024

CALCUTT, JOESEPH V

IndividualCORPORATE OFFICERSince Jun 2025

Penalties & Fines

No penalties or fines on record.

Health Inspection Deficiencies (11)

November 1, 2024Health3 deficiencies
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Nov 22, 2024
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Oct 27, 2023
0757DMinimal harm, Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

Corrected Nov 22, 2024
June 3, 2022Health8 deficiencies
0554DMinimal harm, Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Corrected Jul 1, 2022
0644DMinimal harm, Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Corrected Jul 1, 2022
0655DMinimal harm, Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Corrected Jul 1, 2022
0690DMinimal harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Jul 1, 2022
0756EMinimal harm, Pattern

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Corrected Jul 1, 2022
0758DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Jul 1, 2022
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Jul 1, 2022
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Jul 23, 2022

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Frequently Asked Questions

What is the CareGrader rating for Three Rivers Health and Rehabilitation Center?

Three Rivers Health and Rehabilitation Center in Windsor, North Carolina has a CareGrader grade of B (Good), with a composite score of 82.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for Three Rivers Health and Rehabilitation Center?

Three Rivers Health and Rehabilitation Center has an overall CMS star rating of 4 out of 5, a health inspection rating of 4/5, and a staffing rating of 2/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does Three Rivers Health and Rehabilitation Center have?

Three Rivers Health and Rehabilitation Center has 11 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

How many beds does Three Rivers Health and Rehabilitation Center have?

Three Rivers Health and Rehabilitation Center has 60 certified beds with approximately 50 current residents (83% occupancy). The facility is located at 1403 Conner Drive, Windsor, North Carolina 27983. It is a for profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.