Third Avenue Health & Rehab: Oxygen Failures - PA
It was just after noon on March 24, 2026. The Director of Nursing was standing right there and confirmed what inspectors saw.
The resident, identified in inspection records as Resident 65, had been ordered oxygen continuously at 3 liters per minute through a nasal cannula. The order was dated March 19, less than a week before the inspection. The resident's diagnoses read like a catalog of breathing emergencies: respiratory failure with hypoxia, centrilobular emphysema, and pneumothorax, a collapsed lung. Their cognitive assessment score was a 3 out of 15, placing them in the range of severe impairment. They could not advocate for themselves, could not reattach their own tubing, could not flag down a nurse and explain what was wrong. They needed staff to ensure the oxygen was flowing. It wasn't.
That was day one.
The following morning, March 25 at 9:45 a.m., inspectors found Resident 65 in bed, asleep on their left side, with no oxygen in use at all. The concentrator, the bedside machine that pulls oxygen from room air and delivers it through tubing, was sitting 3.5 feet away. The nasal cannula and oxygen tubing were on the floor. Not hung up, not set aside on a table. On the floor. A licensed practical nurse was present and confirmed the observation.
Two separate failures, on two consecutive days, for a resident whose physician had ordered continuous oxygen and whose medical history made any interruption a serious matter.
The facility's own oxygen administration policy, last reviewed on February 24, 2026, less than a month before the inspection, required staff to monitor oxygen delivery systems, including checking tank gauges to make sure an adequate supply was available. The policy existed. The tank still ran dry while the resident sat in the dining room.
When inspectors interviewed the Director of Nursing on March 26, the response was direct and damaging. The facility could not produce any documentation showing how often oxygen tanks were being monitored. There was no log, no checklist, no record of anyone systematically checking whether tanks were full or equipment was in place. The Director of Nursing acknowledged the facility had failed to ensure oxygen therapy was administered as ordered.
That acknowledgment is notable for what it implies about the period before inspectors arrived. The empty tank on March 24 did not become empty the moment inspectors walked in. The oxygen tubing on the floor on March 25 did not fall there as nurses watched. These were conditions that existed because nobody had checked, or because checking was not happening with any documented consistency.
Resident 65 required extensive staff assistance for basic movement, bed mobility, and transfers. They could not get up and refill a tank. They could not reach across 3.5 feet of floor to retrieve their own tubing. The inspection record describes a person entirely dependent on the facility to receive a treatment their doctor ordered around the clock.
The violation was cited at a level of minimal harm or potential for actual harm, the lower end of the federal harm scale. Whether the resident experienced oxygen deprivation during either incident, and for how long the tank had been empty before inspectors noticed it, the inspection report does not say.
What it does say is that the Director of Nursing confirmed the empty tank on March 24. A nurse confirmed the equipment on the floor on March 25. And on March 26, the facility could not show inspectors a single record of anyone ever checking.
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 18, 2026 · Our methodology
THIRD AVENUE HEALTH & REHAB CENTER in KINGSTON, PA was cited for violations during a health inspection on March 27, 2026.
It was just after noon on March 24, 2026.
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.