Third Avenue Health & Rehab: Positioning Care Failures - PA
Nobody filled in the gap. Nobody trained the staff. And when federal inspectors arrived on the morning of March 25, 2026, they found the resident seated in a common area with his left side unsupported, his neck bent without any positioning device, and the lateral supports on his Broda chair not set up the way his care plan described. They came back fifteen minutes later. He was still sitting that way.
Resident 12 has a left lateral neck contracture, a permanent tightening of the muscles that pulls the neck into an abnormal position he cannot correct on his own. The condition affects his ability to function and, according to his own therapy records, puts him at risk for developing wounds where his body presses against the chair. Occupational therapy had flagged the problem in a February 24, 2026 evaluation, noting that the right side of his torso was pressing against the side of the Broda chair and his left arm was hanging over the edge entirely.
Therapy worked with him. He met his goal. The discharge summary, dated sometime after that evaluation, confirmed he could maintain a midline seated position using adaptive equipment for more than eight hours.
But the summary never identified what that adaptive equipment was.
When inspectors interviewed staff, including the Nursing Home Administrator and the facility's physical therapist, none of them could explain or demonstrate what the care plan actually called for. The instruction written into the plan, to "invert bilateral upper wing support," placing the Broda chair's cushions upside down on the upper side supports, was not something staff could carry out. Not because they hadn't tried. Because no one had ever shown them how.
The Director of Rehabilitation, interviewed that afternoon, confirmed it directly. The cervical positioning devices were not identified in the discharge summary. The staff training had not been documented. And then came one more detail: the neck pillow the resident used had been brought in by his family. The facility had not provided it.
His care plan, meanwhile, contained no mention of his cervical contracture at all. There were no measurements taken when the contracture was identified. There were no specific interventions written to maintain his head and neck alignment. The plan lacked what inspectors described as clear, measurable, and individualized instructions, the basic components that would tell a nursing assistant, on any given morning, what to do before wheeling him to breakfast.
This matters beyond comfort. Abnormal neck positioning in a resident who cannot self-correct affects more than posture. Inspectors noted the failure to maintain proper alignment put at risk his ability to swallow safely, his comfort, and his protection from the complications that follow when a body is held in a wrong position, day after day, without intervention.
The occupational therapy process, on paper, worked. A problem was identified. Goals were set. The resident met them. But the bridge between what therapy learned and what floor staff did every morning was never built. The discharge summary that was supposed to carry that knowledge across instead left a blank where the specific devices and techniques should have been. No one followed up to fill it.
Inspectors cited the facility under Pennsylvania nursing home regulations covering nursing services and resident care policies.
On the morning of March 25, Resident 12's family had supplied the one piece of equipment keeping his neck from being entirely unsupported. The facility, after months of occupational therapy, had not.
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.
They came back fifteen minutes later.
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.