Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Three Rivers Health and Rehabilitation Center
Windsor, NC · 60 certified beds · Last Life Safety survey January 30, 2026
CMS Certification Number 345404 · first certified March 1992
Ownership
Operated by LIBERTY SENIOR LIVING · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within NC
12 citations — more than 58% of the 419 certified nursing homes in NC. Compared within NC rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys on file averaged 3. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens March 2027 — about 4 months from now. This facility’s last Life Safety survey was January 2026. Facilities in NC are typically surveyed 14–15 months after the last one (median 14), measured over 458 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to about three years in Virginia. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
How that compares
Compared with the median facility in NC, and nationally. Surveyors differ markedly between states, so the NC figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 12 |
| Median facility in NC | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 8, 2023 | 4 |
| November 1, 2024 | 2 |
| January 30, 2026 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 3 | 2026-01-30 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2026-01-30 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2026-01-30 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2023-09-08 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2023-09-08 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2026-01-30 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2026-01-30 |
| K-0281 | Install proper backup exit lighting. | 1 | 2026-01-30 |
What the citations cover
- Smoke Deficiencies 7
- Services Deficiencies 3
- Egress Deficiencies 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Services Deficiencies | 3 |
| Egress Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 30, 2026 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (June 19, 2026) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (June 19, 2026) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 19, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 19, 2026) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (June 19, 2026) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (June 19, 2026) |
November 1, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 30, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (December 30, 2024) |
September 8, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (November 18, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (November 18, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (November 18, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (November 18, 2023) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.