Three Rivers Health and Rehabilitation Center
1403 Conner Drive, Windsor, NC 27983
Three Rivers Health and Rehabilitation Center is a nursing home in Windsor, North Carolina. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating4 of 5
- Last standard health inspectionJanuary 30, 2026 (9 months ago)
- Health citations since November 1, 20246 (North Carolina average 18)
- Fines in the past three yearsNone listed by CMS
- CMS flagsNone listed by CMS
Get an email when CMS publishes something new about this home
One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Health inspection on January 30, 2026
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on February 20, 2026.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on February 20, 2026.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on February 20, 2026.
CMS has cited this home for F0761 2 times since 2024.
Fire safety inspection on January 30, 2026
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation K0521. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on June 19, 2026.
CMS has cited this home for K0521 3 times since 2023.
Citation K0281. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install proper backup exit lighting.
CMS lists it as corrected on June 19, 2026.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on June 19, 2026.
CMS has cited this home for K0321 2 times since 2023.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on June 19, 2026.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 19, 2026.
Citation K0372. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on June 19, 2026.
CMS has cited this home for K0372 2 times since 2024.
CMS update of December 15, 2025
Name
CMS lists a new legal business name for this home.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Name
CMS lists a new name for this home. It was THREE RIVERS HEALTH AND REHAB.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.0 to 3.6 hours per resident per day.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Health inspection on November 1, 2024
3 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 3 citations
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on October 27, 2023.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on November 22, 2024.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on November 22, 2024.
Fire safety inspection on November 1, 2024
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0372. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on December 30, 2024.
Citation K0521. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on December 30, 2024.
CMS update of October 30, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of April 25, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
CMS update of December 21, 2023
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5.
Fire safety inspection on September 8, 2023
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation K0521. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on November 18, 2023.
Citation K0211. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on November 18, 2023.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on November 18, 2023.
Citation K0351. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on November 18, 2023.
CMS star ratings
- 4 of 5CMS overall star rating
- 4 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (252) 794-4441
- Last standard health inspection
- January 30, 2026 (9 months ago)
- Certified beds
- 60
- Residents per day, on average
- 49.6
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Liberty Healthcare Group LLC
- Chain
- Liberty Senior Living
- Takes part in
- Medicare and Medicaid
Fewer health citations than the North Carolina average (6 vs 18).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- LIBERTY HEALTHCARE PROPERTIES OF BERTIE COUNTY LLC5% or greater direct ownership interest · no percentage provided · since 06/25/2025
- LIBERTY REAL PROPERTIES, LLC5% or greater direct ownership interest · no percentage provided · since 06/25/2025
- THREE RIVERS HEALTH AND REHABILITATION CENTER, LLC5% or greater direct ownership interest · no percentage provided · since 10/01/2002
- MCNEILL, JOHN5% or greater direct ownership interest · no percentage provided · since 10/01/2002
- MCNEILL, RONALD5% or greater direct ownership interest · no percentage provided · since 10/01/2002
Show 6 more
- LIBERTY HEALTHCARE MANAGEMENT INCOperational/managerial control · not applicable · since 10/01/2002
- BORK, MATTHEWOperational/managerial control · not applicable · since 01/29/2007
- BROWN, PENNYOperational/managerial control · not applicable · since 06/25/2025
- MILLER, ROBERTOperational/managerial control · not applicable · since 09/01/2024
- SEVERA, JEFFREYOperational/managerial control · not applicable · since 06/25/2025
- WILSON, JEFFREYOperational/managerial control · not applicable · since 10/01/2002
Questions
When was Three Rivers Health and Rehabilitation Center last inspected?
CMS lists January 30, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Three Rivers Health and Rehabilitation Center have?
CMS lists 6 health citations since November 1, 2024. CMS also calls these deficiencies.
Has Three Rivers Health and Rehabilitation Center been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Three Rivers Health and Rehabilitation Center?
Its CMS overall star rating is 4 of 5.
Is Three Rivers Health and Rehabilitation Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.