Third Avenue Health & Rehab Center

Employee 2 (RN), despite Resident 1's consistent report that he had not received the medication that evening. A review of a facility investigative documentation contained a single witness statement from Employee 3 (LPN), who indicated she had not been informed that Resident 1 requested medication throughout the night shift and stated that Resident 1 told her he had asked a male nurse for his pain medication.

There was no documented evidence that either Employee 1 or Employee 2, both of whom recorded medication administration were interviewed or asked to provide written statements.

The facility failed to conduct a complete and accurate investigation by not identifying the staff members referenced by the resident as male or female, not obtaining written statements from all potentially involved staff, and not reconciling conflicting reports about the administration of the medication.

This failure resulted in an incomplete investigation that did not substantiate or disprove the allegation in accordance with facility policy. An interview with the Nursing Home Administrator and Director of Nursing on October 7, 2025, at approximately 11:00 AM confirmed the facility was unable to provide any additional witness statements from staff who documented the administration of the medication despite the resident's claim he did not receive any medication and acknowledged that the investigation contained no evidence identifying the male or female individuals referenced by the resident. 28 Pa.

Code 201.14 (a) Responsibility of licensee 28 Pa.

Code 201.18(e)(1) Management 28 Pa.

Code 201.29(a)(c) Resident Rights 28 Pa.

Code 211.10(d) Resident care policies.28 Pa.

Code 211.12(c)(d)(5) Nursing Services

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