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Three Rivers Nursing Home LLC

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About Three Rivers Nursing Home LLC

General Information

Legal Business NameThree Rivers Nursing Home L.L.C.
Ownership TypeFor Profit - Partnership
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareOctober 4, 2004 (12 years)
Capacity74
Residents24
Percent Occupied32%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsBoth
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Three Rivers Nursing Home LLC

Three Rivers Nursing Home LLC
was reviewed by Medicare to have a rating of 1 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Texas Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

October 20, 2016 - 5 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmHealth InspectionUse a registered nurse at least 8 hours a day, 7 days a week.
FManyPotential for HarmHealth InspectionMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
FManyPotential for HarmHealth InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
ESomePotential for HarmHealth InspectionPut firmly secured handrails on each side of hallways.
ESomePotential for HarmHealth InspectionMake sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
CManyPotential for Minimal HarmHealth InspectionTrain all employees on what to do in an emergency, and carry out unannounced staff drills.
CManyPotential for Minimal HarmHealth InspectionDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
DFewPotential for HarmHealth InspectionProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
BSomePotential for Minimal HarmHealth InspectionProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
BSomePotential for Minimal HarmHealth InspectionGive residents a notice of rights, rules, services and charges.

January 14, 2016 - 14 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.

October 21, 2015 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionAt least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
FManyPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
FManyPotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
FManyPotential for HarmHealth InspectionMake sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.
ESomePotential for HarmHealth Inspection1) Give or get tests or x-rays that meet hospital requirements; or 2) to obtain an agreement for these services from an approved provider or supplier.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmHealth InspectionKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
ESomePotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
ESomePotential for HarmHealth InspectionProvide residents with private access to a telephone.
ESomePotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
BSomePotential for Minimal HarmHealth InspectionProvide housekeeping and maintenance services.
BSomePotential for Minimal HarmHealth InspectionProvide proper discharge planning and communication, of the resident's health status and summary of the resident's nursing home stay.
BSomePotential for Minimal HarmHealth InspectionProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

August 14, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintChoose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility.

October 15, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmHealth InspectionUse a registered nurse at least 8 hours a day, 7 days a week.
BSomePotential for Minimal HarmHealth InspectionProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Three Rivers Nursing Home LLC require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

15min
2hr 5min
ReportedExpected
CNA
1hr 5min
30min
ReportedExpected
LPN
35min
45min
ReportedExpected
RN
1hr 50min
3hr 20min
ReportedExpected
Total Nursing

This facility also provides approximately 20min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

100.0%
100.0%
100.0%
100.0%
91.6%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
82.8%
90.0%
81.2%
91.7%
89.8%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
-
-
-
-
48.3%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of low risk long-stay residents who lose control of their bowels or bladder
42.9%
30.8%
20.8%
-
27.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of long-stay residents who received an antianxiety or hypnotic medication
21.4%
33.7%
28.8%
-
20.7%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of long-stay residents whose ability to move independently worsened
25.9%
21.4%
17.2%
18.2%
19.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who received an antipsychotic medication
25.9%
29.2%
4.3%
-
19.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of long-stay residents whose need for help with daily activities has increased
6.5%
20.4%
12.1%
-
7.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of long-stay residents who self-report moderate to severe pain
3.4%
3.3%
0.0%
4.2%
6.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who lose too much weight
-
-
-
-
6.3%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of high risk long-stay residents with pressure ulcers
12.5%
17.9%
13.0%
8.7%
4.9%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who have depressive symptoms
6.9%
6.7%
3.2%
16.7%
4.4%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents with a urinary tract infection
10.3%
10.0%
9.4%
4.2%
3.6%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents experiencing one or more falls with major injury
8.0%
7.5%
6.6%
4.2%
2.7%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents with a catheter inserted and left in their bladder
0.0%
0.0%
0.0%
0.0%
0.4%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

-
-
-
-
74.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
-
-
-
-
71.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
-
-
-
-
55.7%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who made improvements in function
-
-
-
-
14.2%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who self-report moderate to severe pain
-
-
-
-
3.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who newly received an antipsychotic medication
-
-
-
-
1.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents with pressure ulcers that are new or worsened