Home › North Carolina › Bertie County › Three Rivers Health and Rehabilitation Center
Three Rivers Health and Rehabilitation Center
1403 Conner Drive, Windsor, NC 27983 · CMS Certification Number (CCN) 345404
At a glance
- CMS overall rating
- ★★★★☆ 4 of 5
- Health inspection citations
- 6 in the last 3 inspection cycles (0 immediate jeopardy, 0 actual harm, 2 from complaints)
- Fire safety citations
- 12
- Fines (last 3 years)
- 0 fines, total $0
- Payment denials
- 0
- Most recent standard inspection
- January 30, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Overall | ★★★★☆ 4 of 5 | 2.9 | 3 |
| Health inspections | ★★★★☆ 4 of 5 | 2.9 | 2.8 |
| Staffing | ★★★☆☆ 3 of 5 | 2.7 | 2.9 |
| Quality measures | ★★★★☆ 4 of 5 | 3.3 | 3.6 |
| Long-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
| Short-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | January 30, 2026 | 3 | 3 | 0 |
| Cycle 2 | November 1, 2024 | 3 | 3 | 2 |
CMS weighted health inspection score: 16 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
6 health citations across 2 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
January 30, 2026: 3 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/20/2026 |
| D | F-0761 | 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 | Standard | Deficient, Provider has date of correction Corrected 02/20/2026 |
| D | F-0690 | 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 | Standard | Deficient, Provider has date of correction Corrected 02/20/2026 |
November 1, 2024: 3 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0761 | 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 | Standard | Deficient, Provider has date of correction Corrected 11/22/2024 |
| D | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 11/22/2024 |
| E | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard + Complaint | Past Non-Compliance Corrected 10/27/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
12 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 01/30/2026 | E | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 06/19/2026 |
| 01/30/2026 | D | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/19/2026 |
| 01/30/2026 | D | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/19/2026 |
| 01/30/2026 | D | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/19/2026 |
| 01/30/2026 | D | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/19/2026 |
| 01/30/2026 | D | K-0281 | Install proper backup exit lighting. Egress Deficiencies | Deficient, Provider has date of correction Corrected 06/19/2026 |
| 11/01/2024 | D | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 12/30/2024 |
| 11/01/2024 | D | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 12/30/2024 |
| 09/08/2023 | E | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 11/18/2023 |
| 09/08/2023 | D | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 11/18/2023 |
| 09/08/2023 | D | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 11/18/2023 |
| 09/08/2023 | D | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies | Deficient, Provider has date of correction Corrected 11/18/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
No fines or payment denials published for this facility in the CMS Penalties file (last 3 years).
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.56 | 3.85 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.43 | 0.62 | 0.69 |
| LPN/LVN hours per resident per day | 1.17 | Not published | Not published |
| Nurse aide hours per resident per day | 1.96 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.24 | Not published | Not published |
| RN hours per resident per day, weekends | 0.34 | Not published | Not published |
| Total nursing staff turnover (%) | 48.9 | 49 | 45.8 |
| Registered nurse turnover (%) | 20 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Liberty Healthcare Group LLC
- Ownership type
- For profit - Limited Liability company
- Chain
- Liberty Senior Living (37 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 60
- Average residents per day
- 47.2
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- March 12, 1992
- County/parish
- Bertie
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
21 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| LIBERTY HEALTHCARE PROPERTIES OF BERTIE COUNTY LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| LIBERTY REAL PROPERTIES, LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| THREE RIVERS HEALTH AND REHABILITATION CENTER, LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| MCNEILL, JOHN | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Individual | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| MCNEILL, RONALD | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Individual | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| MCNEILL, JOHN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCNEILL, RONALD | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MILLER, ROBERT | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CALCUTT, JOSEPH | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LIBERTY HEALTHCARE MANAGEMENT INC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BORK, MATTHEW | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BROWN, PENNY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MILLER, ROBERT | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SEVERA, JEFFREY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WILSON, JEFFREY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCNEILL, ROBERT | TRUSTEE OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| OLIVER, ANNA | TRUSTEE OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| PURVIS, JENNY | TRUSTEE OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LONG TERM CARE MANAGEMENT SERVICES LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| CALCUTT, JOSEPH | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MILLER, ROBERT | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Three Rivers Health and Rehabilitation Center. Full inspection reports, quality measures and staffing.
- DHSR Complaint Intake Unit: File a Complaint. The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.