C80

THREE RIVERS HEALTH & REHAB CENTER

Grade C 80/100 composite score

For profit - Limited Liability company

CMS Star Ratings

Overall
4/5
Health Insp.
3/5
Quality
5/5
Staffing
2/5
RN Staffing
Not rated

Certified Beds

60

Ownership

For profit - Limited Liability company

Total Fines

$8,492

Last Survey

N/A

2960 CHELSEA ROAD, WEST POINT, VA 23181
7578434323

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.54h
LPN
0.95h
CNA
1.99h
Total
3.48h
Facility
State Average

Turnover Rates

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

Ownership

VA 3 OPCO HOLDCO LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Mar 2023

100%

BSD EOM IRREVOCABLE TRUST

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Mar 2023

25%

HLHK IRREVOCABLE TRUST

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Mar 2023

25%

SOUTH EAST VIRGINIA HOLD CO LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Mar 2023

25%

VOGUE NHC LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Mar 2023

25%

HARTSTEIN, JAKE

IndividualCORPORATE OFFICERSince Mar 2023

MONTFORDD, NICOLA

IndividualW-2 MANAGING EMPLOYEESince Mar 2023

Penalties & Fines (1)

$8,492total fines
DateTypeDescriptionAmount
Sep 13, 2023Fine$8,492

Health Inspection Deficiencies (36)

March 1, 2024Health8 deficiencies
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Apr 1, 2024
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 1, 2024
0658DMinimal harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 1, 2024
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Apr 1, 2024
0727EMinimal harm, Pattern

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.

Nursing and Physician Services Deficiencies

Corrected Apr 1, 2024
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 Apr 1, 2024
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Apr 1, 2024
0883EMinimal harm, Pattern

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies

Corrected Apr 1, 2024
September 13, 2023Health6 deficiencies1 severe
0552DMinimal harm, Isolated

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Corrected Oct 24, 2023
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Dec 15, 2023
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 Oct 24, 2023
0658DMinimal harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 24, 2023
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Oct 24, 2023
0760GActual harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Oct 24, 2023
July 29, 2021Health15 deficiencies1 severe
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Sep 1, 2021
0574DMinimal harm, Isolated

The resident has the right to receive notices in a format and a language he or she understands.

Resident Rights Deficiencies

Corrected Sep 1, 2021
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Sep 1, 2021
0582DMinimal harm, Isolated

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Rights Deficiencies

Corrected Sep 1, 2021
0607EMinimal harm, Pattern

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Sep 1, 2021
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Sep 1, 2021
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Sep 1, 2021
0686GActual harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Sep 1, 2021
0688DMinimal harm, Isolated

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Corrected Sep 1, 2021
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Sep 1, 2021
0732DMinimal harm, Isolated

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies

Corrected Sep 1, 2021
0755DMinimal harm, Isolated

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

Pharmacy Service Deficiencies

Corrected Sep 1, 2021
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Sep 1, 2021
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 Sep 1, 2021
0840DMinimal harm, Isolated

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Administration Deficiencies

Corrected Sep 1, 2021
November 1, 2018Health7 deficiencies
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Dec 7, 2018
0582DMinimal harm, Isolated

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Rights Deficiencies

Corrected Dec 7, 2018
0622DMinimal harm, Isolated

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Resident Rights Deficiencies

Corrected Dec 7, 2018
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Dec 7, 2018
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 Dec 7, 2018
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Dec 7, 2018
0755DMinimal harm, Isolated

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

Pharmacy Service Deficiencies

Corrected Dec 7, 2018

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Frequently Asked Questions

What is the CareGrader rating for THREE RIVERS HEALTH & REHAB CENTER?

THREE RIVERS HEALTH & REHAB CENTER in WEST POINT, Virginia has a CareGrader grade of C (Average), with a composite score of 79.8 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 & REHAB CENTER?

THREE RIVERS HEALTH & REHAB CENTER has an overall CMS star rating of 4 out of 5, a health inspection rating of 3/5, 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 & REHAB CENTER have?

THREE RIVERS HEALTH & REHAB CENTER has 36 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.

Has THREE RIVERS HEALTH & REHAB CENTER been fined?

Yes. THREE RIVERS HEALTH & REHAB CENTER has $8,492 in total fines from CMS enforcement actions across 1 penalty.

How many beds does THREE RIVERS HEALTH & REHAB CENTER have?

THREE RIVERS HEALTH & REHAB CENTER has 60 certified beds with approximately 50 current residents (83% occupancy). The facility is located at 2960 CHELSEA ROAD, WEST POINT, Virginia 23181. It is a for profit - limited liability company 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.