Kingston Health Care Center

F-F812

28 Pa. Code 201.18 (e)(2.1) Management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 395905

F-F925

28 Pa. Code 201.18 (e)(2.1) Management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 395905 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395905 B. Wing 05/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Third Avenue Health & Rehab Center 702 Third Avenue Kingston, PA 18704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or 48276 potential for actual harm Based on observations, a review of facility-provided documents, and resident and employee interviews, it Residents Affected - Some was determined the facility failed to maintain an effective pest control program, including observations made

on one of the three nursing units (Grey Unit- bedrooms of Residents 4, 23, and 39), experiences reported by one resident out of 18 sampled (Resident 23), and experiences reported by two residents during a group

interview (Residents 27 and 28).

Findings include:

According to the Centers for Disease Control (CDC), Controlling Wild Rodent Infestations, rodents can carry many diseases that can spread directly or indirectly to people, including through contact with rodent droppings, urine, or saliva. Signs of rodents include droppings (feces) and gnaw marks. The CDC indicates that to determine if the activity is current, regular cleaning and disinfecting are required. When droppings are identified following cleaning, it can confirm the presence of rodents.

During an interview on May 28, 2025, the Director of Maintenance indicated the facility has an external pest management company that provides services to the building about once a month. The Director of Maintenance explained the pest management company has not reported any identification of rodent activity.

The Director of Maintenance provided invoices for services rendered by the pest management company; however, a review of the invoices from December 2024 through May 2025 revealed the external company failed to identify any rodent activity.

A review of facility-provided pest control invoices from December 2024 through May 2025 revealed no documented evidence of rodent or other pest activity.

A facility tour and observations on May 28, 2025, revealed evidence of rodent activity in multiple resident rooms and common areas:

An observation at 9:40 AM of Resident 39's bedroom revealed several mouse-like droppings (small, long, black pellets that were tapered at the ends- resembling a black grain of rice) on the floor in the window-side corner of the room.

An observation at 12:38 PM of Resident 4's bedroom revealed over 20 mouse-like droppings in the window-side corner of the room. At the time of the observation, the Assistant Director of Nursing (ADON) confirmed the observation of the mouse-like droppings.

An observation at 12:48 PM of Resident 23's bedroom revealed several mouse-like droppings on the floor, against the wall, and behind the window-side bed. An interview with Resident 23 at the same time as the

observation revealed that he has seen mice a few times over the past few months running across the floor in his room.

An observation on May 28, 2025, at 1:15 PM, revealed evidence of mouse activity in the facility's main dining room. Over 50 mouse-like droppings were seen on the floor in the resident main dining room underneath a cabinet running along the kitchen-side wall.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 395905 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395905 B. Wing 05/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Third Avenue Health & Rehab Center 702 Third Avenue Kingston, PA 18704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 During an observation on May 28, 2025, at 1:20 PM, active signs of mouse activity were noted in two areas of the kitchen. The dry storage area contained mouse droppings on the floor under metal storage racks. In Level of Harm - Minimal harm or the corner of the kitchen, additional mouse-like droppings were identified scattered amongst silicone caulking potential for actual harm pieces found near a crevice in the wall, suggesting a potential entry point or an attempt by the mice to access the wall void. Residents Affected - Some

During a resident group interview, two out of eight residents interviewed (Residents 27 and 28) indicated

they observed rodents at the facility. Resident 27 recalled seeing a mouse last week in her bedroom. She explained she has been seeing the rodents for a few months and has reported it to staff. Resident 28 indicated that she saw mice a few months ago at the facility but has not had any recent experiences.

During an interview on May 30, 2025, at approximately 10:00 AM, the Nursing Home Administrator (NHA) confirmed the facility had no documented evidence of an effective pest management program, including identification of mouse activity, specifically, mouse-like droppings in the facility kitchen, dining room, and multiple resident rooms. The NHA confirmed it is the facility's responsibility to maintain an effective pest control program to ensure the facility is free of rodents.

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