Third Avenue Health & Rehab: Pain Medication Investigation Failure - PA
The complaint inspection, completed December 1, 2025, found that Third Avenue failed to conduct a complete investigation into the allegation, leaving unresolved a direct conflict between what a resident reported and what staff had documented.
The resident, identified in inspection records as Resident 1, said he had asked a male nurse for his pain medication during the night and never received it. That account was consistent across multiple conversations with staff. The facility opened an investigation. What it produced was thin: one written statement, from a licensed practical nurse identified as Employee 3, who said she had not been informed that Resident 1 had been requesting medication throughout the night. She noted the resident told her he had asked a male nurse.
That was it. One statement. From someone who, by her own account, wasn't there for the central events.
The two staff members who actually mattered, Employee 1 and Employee 2, a registered nurse, were the ones who had recorded the medication as administered. Neither was interviewed. Neither provided a written statement. The investigation contained no evidence that anyone had asked them what happened.
It also contained no effort to determine whether the nurse Resident 1 described as male or female matched either of those employees. The resident had said he asked a male nurse. The facility never established whether Employee 1 or Employee 2 fit that description, or whether a third person entirely might have been involved. The inspection report found the facility failed to identify the individuals referenced by the resident as male or female, failed to obtain statements from the staff who signed off on the medication, and failed to reconcile the conflicting accounts.
The result was an investigation that could neither confirm nor disprove what the resident said happened to him.
On October 7, 2025, inspectors sat down with the Nursing Home Administrator and the Director of Nursing. Both acknowledged that the facility could not produce any additional witness statements from the staff who had documented the administration. Both confirmed the investigation contained no evidence identifying the male or female individuals the resident had described.
There is a straightforward conflict at the center of this case. A resident said he was in pain and asked for medication and received nothing. Two staff members documented that the medication was given. Those two facts cannot both be true. Either the documentation is wrong, or the resident's account is wrong, or something else happened that no one has explained. A proper investigation would have put that question directly to the people whose names are on the medication record.
Nobody did.
The inspection cited the facility under multiple Pennsylvania nursing home regulations, covering the responsibilities of the licensee, management obligations, resident rights, resident care policies, and nursing services standards.
Resident 1 spent a night requesting pain relief. Whether he received it remains, officially, unknown.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Third Avenue Health & Rehab Center from 2025-12-01 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 21, 2026 · Our methodology
THIRD AVENUE HEALTH & REHAB CENTER in KINGSTON, PA was cited for violations during a health inspection on December 1, 2025.
The resident, identified in inspection records as Resident 1, said he had asked a male nurse for his pain medication during the night and never received it.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.