Third Avenue Health & Rehab: Medication Failures - PA
The failures were documented during a March 27, 2026, inspection of Third Avenue Health & Rehab Center, a nursing facility at 702 Third Avenue in Kingston. Inspectors reviewed clinical records and interviewed staff. What they found was straightforward: a physician had written a clear order, nurses took blood pressure readings that met the condition in that order, and then nobody gave the medication.
The resident, whose name was withheld in the inspection report, had been admitted to the facility with two serious diagnoses. Dementia had already compromised memory and reasoning. Congestive heart failure, specifically the combined systolic and diastolic form, meant the heart muscle was too weak both to pump effectively and to fill properly, leaving the body struggling to meet its own oxygen needs and causing fluid to back up in the lungs and throughout the body.
On February 7, 2026, a physician ordered Midodrine, a medication used to treat low blood pressure, at a dose of 5 milligrams by mouth, up to three times per day as needed, whenever the resident's systolic blood pressure, the top number in a reading, fell below 100 millimeters of mercury. The order was not ambiguous. A number below 100 meant give the medication.
The number fell below 100 four times. The medication was not given.
On February 10, at 1:35 in the afternoon, a nurse recorded a blood pressure of 98 over 60. On February 28, at 4:48 in the afternoon, the reading was 99 over 71. On March 1, at 11:49 in the morning, it was 97 over 65. On March 2, at 10:50 in the morning, it was 98 over 66. Each reading was documented in the medical record. Each one cleared the threshold the doctor had set. None of them resulted in the resident receiving Midodrine.
The omissions stretched across three weeks and involved at least two separate months of medication administration records, which inspectors reviewed in full from February 2 through March 25, 2026.
When inspectors interviewed the assistant director of nursing on March 26, 2026, the response was an acknowledgment rather than a defense. The assistant director confirmed that nursing staff had not followed acceptable standards of nursing practice related to medication administration. She confirmed that medications are to be administered as prescribed, in a safe and timely manner, and in accordance with physician orders.
There was no dispute about what happened. There was no claim that the readings had been misread, or that a clinical judgment had been made to withhold the medication, or that the order had been unclear. The assistant director simply agreed that the nurses had not done what they were supposed to do.
The facility's own medication administration policy, last reviewed as recently as February 24, 2026, three days before the final omission documented in this inspection, stated that staff must verify each time a medication is given that it is the correct dose, correct route, correct time, and for the correct resident, and that vital signs must be obtained when required by the medication order. The policy existed. The blood pressure readings were taken and recorded. The connection between those readings and the medication order was never made.
For a resident with congestive heart failure, blood pressure that falls too low is not a minor inconvenience. The heart is already failing to pump and fill as it should. When systolic pressure drops into the 90s, the body's ability to deliver oxygenated blood to organs and tissue is further compromised. That is precisely why the physician wrote the order in the first place, and precisely why the threshold was set where it was.
Pennsylvania's nursing practice standards, cited in the inspection findings, require licensed practical nurses to exercise sound judgment, document and maintain accurate records, and participate in the implementation of nursing care. Registered nurses are held to a standard of carrying out actions that promote, maintain, and restore the well-being of residents. The inspection cited violations of multiple Pennsylvania Department of Health codes governing medical records, pharmacy services, resident care policies, and nursing services.
The inspection rated the level of harm as minimal harm or potential for actual harm, the lower end of the federal harm scale, and identified the problem as affecting only a small number of residents sampled. One resident, out of five reviewed for unnecessary or improperly administered medications, had the documented omissions.
That framing is regulatory. What it describes is a person with a failing heart, already struggling with the cognitive losses of dementia, whose blood pressure dropped below the number a doctor had identified as the floor, four times across three weeks, and whose nurses did not give the medication that was ordered for exactly that situation.
The inspection report does not say whether the resident experienced any symptoms during those four episodes. It does not say whether anyone noticed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Third Avenue Health & Rehab Center from 2026-03-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
THIRD AVENUE HEALTH & REHAB CENTER in KINGSTON, PA was cited for violations during a health inspection on March 27, 2026.
The failures were documented during a March 27, 2026, inspection of Third Avenue Health & Rehab Center, a nursing facility at 702 Third Avenue in Kingston.
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.