Third Avenue Health & Rehab Center

Review of the facility admission Agreement revealed the agreement included services, charges and fees, termination of the agreement, and miscellaneous areas to be reviewed with each newly admitted resident and/or resident representative.

The admission Agreement included an admission Agreement signature page.

Clinical record review revealed Resident 63 was admitted to the facility on [DATE], with diagnoses that included cervical myelopathy (compression of the spinal cord in the neck which may cause pain, weakness, or difficulty with movement) and generalized muscle weakness (reduced muscle strength). Resident 63 was discharged from the facility on February 21, 2026.

Review of Resident 63's admission Minimum Data Set assessment (MDS, a federally required standardized assessment used to evaluate resident needs and develop a plan of care) dated January 5, 2026, revealed Resident 63 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a structured cognitive screening tool used to assess memory and orientation; a score of 13-15 indicates intact cognition).

Documentation indicated that the resident and resident representative participated in the assessment process.

Review of Resident 63's clinical record, including social service documentation and communication with the resident's family, failed to include documented evidence that required admission information was provided and acknowledged at the time of admission.

Documentation did not include evidence the resident and/or resident representative received written information regarding patient portion liability (the amount the resident is responsible to pay), daily rate cost structure, resident rights, appeal rights (the right to formally dispute decisions regarding care or services), consent to treatment (permission allowing the facility to provide care), the right to choose ancillary services (services such as therapy providers or pharmacy), bed hold policy (a policy describing whether the facility will hold a resident's bed during hospitalization and any associated cost), or consequences for failure to pay.

During an interview on March 27, 2026, at 9:30 AM the Nursing Home Administrator (NHA) confirmed that admission paperwork is to be reviewed with each resident and/or resident representative upon admission to the facility.

The NHA failed to provide documented evidence that admission paperwork was completed as required for Resident 63. 28 Pa.

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

Code 211.5 (f)(i)(xi) Medical records. 28 Pa.

Code 211.10 (c)(d) Resident care policies

395905 03/27/2026

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

Review of the facility policy titled General Dose Preparation and Medication Administration last reviewed by the facility on February 24, 2026, revealed that prior to administration of medication facility staff should take all measures required by facility policy and applicable law, including verify each time a medication is administered that it is at the correct dose (amount of medication given), correct route (how the medication enters the body, such as by mouth), correct rate (how fast the medication is given, when applicable), correct time, and for the correct resident.

The policy indicated staff should obtain vital signs (measurements of basic body functions such as blood pressure, pulse, breathing rate, and temperature) when required by the medication order. A clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and chronic combined systolic (phase when the heart squeezes) and diastolic (phase when the heart relaxes) congestive heart failure (heart muscle is both too weak to pump effectively and fill properly leading to inability to meet the body's oxygen needs, causing fluid congestion in the lungs and body).

Review of a physician's order dated February 7, 2026, revealed an order for Midodrine (medication used to treat low blood pressure) 5 mg one tablet by mouth for systolic blood pressure (top number in a blood pressure reading) less than 100 mm/Hg (milliliters of mercury) three times per day as needed.

Review of the Medication Administration Record (MAR) for February 2, 2026, through February 28, 2026, and March 1, 2026, through March 25, 2026, revealed Midodrine was not administered on four occasions when the resident's systolic blood pressure was below 100 mm/Hg, as evidenced by the following documented blood pressure readings: February 10, 2026, 1:35 PM BP 98/60 mm/Hg February 28, 2026, 4:48 PM BP 99/71 mm/Hg March 1, 2026, 11:49 AM BP 97/65 mm/Hg March 2, 2026, 10:50 AM BP 98/66 mm/Hg These medication omissions occurred despite the physician's explicit parameters to administer the medication for a systolic reading of less than 100 mm/Hg.

During an interview on March 26, 2026, at 11:00 AM, the assistant director of nursing (ADON) acknowledged that nursing staff did not follow acceptable standards of nursing practice related to medication administration.

The ADON confirmed medications are to be administered as prescribed, in a safe and timely manner, and in accordance with physician orders. 28 Pa.

Code 211.5(f)(ii)(ix) Medical records. 28 Pa.

Code 211.9 (a)(1)(d) Pharmacy services. 28 Pa.

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

Code 211.12 (c)(d)(1)(3)(5) Nursing services.

395905 03/27/2026

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

During an initial facility tour of the facility on March 24, 2026, at 12:12 PM, Resident 65 was observed seated in a wheelchair in the main dining room with an oxygen tank attached to the back of the wheelchair.

The oxygen tank gauge indicated the tank was empty.

This observation was confirmed by the Director of Nursing (DON).

Review of the clinical record revealed Resident 65 was admitted to the facility on [DATE], with diagnoses including respiratory failure with hypoxia (not enough oxygen passes from the lungs to the blood, making it difficult to breath), centrilobular emphysema (type of chronic obstructive pulmonary disease characterized by the destruction of air sacs in the center of the lung nodule, causing shortness of breath, coughing, and reduced oxygen exchange), and pneumothorax (collapsed lung). A physician's order dated March 19, 2026, specified oxygen at 3 liters/minute via nasal cannula (flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen), to be administered continuously.

Review of the admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 24, 2026, indicated the resident was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 represents severe cognitive impairment) and required extensive assistance from staff for activities of daily living, bed mobility, and transfers, indicating reliance on staff to ensure ordered treatments were implemented. An observation conducted on March 25, 2026, at 9:45 AM, revealed Resident 65 lying in bed on the left side, asleep, without oxygen in use.

The oxygen concentrator (bedside machine that concentrates ambient air to supply an oxygen-rich gas stream) and nasal cannula were observed 3.5 feet away from the resident, with the oxygen tubing and nasal canula lying directly on the floor and not in use.

This observation was confirmed by Employee 2 Licensed Practical Nurse (LPN).

The facility failed to ensure consistent delivery and monitoring of physician ordered oxygen therapy, failed to maintain oxygen equipment in a ready-to-use state, and failed to follow facility policy for oxygen administration.

During an interview on March 26, 2026, at 10:45 AM, the DON revealed the facility was unable to provide documentation identifying the frequency of monitoring oxygen tanks.

The DON acknowledged that the facility failed to ensure oxygen therapy was administered as ordered for Resident 65. 28 Pa.

Code 211.12 (d)(1)(5) Nursing services. 28 Pa.

Code 211.10 (c)(d) Resident Policies.

395905 03/27/2026

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

Review of the facility policy titled Emergency Deliveries, dated February 24, 2026, revealed the facility is to immediately notify the pharmacy when a physician order requires emergency medication delivery to ensure medications are available for administration as prescribed.

Review of the Medication Administration Record (MAR) dated March 17, 2026, at 9:00 PM and a nurse's note dated March 18, 2026, at 3:07 AM revealed the ordered degludec insulin was not available for administration at the scheduled time of 9:00 PM on March 17, 2026.

Documentation indicated the medication was not administered until 3:00 AM on March 18, 2026. At that time, Resident 7's blood glucose level measured 346 mg/dL (milligrams per deciliter, a unit used to measure the amount of sugar in the blood; normal fasting levels are generally 70-120 mg/dL), indicating significantly elevated blood sugar levels.

During an interview on March 26, 2026, at 9:30 AM, Resident 7 confirmed the ordered insulin was not available at the scheduled time and reported staff awakened him during the early morning hours (in the middle of the night) to administer the injection.

During an interview on March 27, 2026, at 9:30 AM, the Director of Nursing (DON) confirmed the facility had sent notifications to the pharmacy requesting the prescribed degludec insulin on March 16, 2026, at 10:27 PM and March 17, 2026, at 6:25 PM prior to depletion of the medication supply for Resident 7.

There was no documented evidence the facility ensured the medication was obtained and available for administration as ordered. 28 PA.

Code 211.10 (c)(d) Resident care policies. 28 PA.

Code 211.12(c)(d)(1)(3)(5) Nursing services.

395905 03/27/2026

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

Observation of the food cart located in the hallway outside Resident 66's room revealed the resident's breakfast tray was not present on the cart.

Interview with Employee 3 NA (nurse aide) on March 25, 2026, at 8:10 AM confirmed she delivered a breakfast tray to Resident 66's roommate but did not see a tray for Resident 66.

Employee 3 NA indicated that meal trays are not always placed on the cart in room number order.

The Food Service Director (FSD) arrived at the nursing unit at that time and confirmed Resident 66's meal tray should have been present on the food delivery cart designated for the resident's room number.

The FSD returned to the food and nutrition services department to have a breakfast meal prepared and delivered to Resident 66. Resident 66 received her breakfast tray at 8:15 AM.

During a resident group interview conducted on March 25, 2026, at 10:00 AM, Residents 23 and Resident 8 reported they have experienced missed meal trays. Resident 23 stated the missed tray happened just last week, and Resident 8 stated missed trays occur once in a while.

Both residents reported that when they notify nursing staff, the food and nutrition services department sends a tray.

Interview with the FSD on March 26, 2026, at 8:15 AM confirmed that a meal ticket (printed document generated from the computerized meal tray program identifying each resident's ordered diet and meal) is printed for each resident for every meal to ensure each resident receives the correct diet as ordered.

The FSD confirmed meal tickets are counted prior to meal service to ensure a ticket is present for each resident.

The FSD confirmed Resident 66's breakfast tray was delayed on March 25, 2026, due to a missing meal ticket.

The FSD indicated that when staff notify the food and nutrition services department that a resident did not receive a tray, a meal is prepared according to the ordered diet and delivered to the nursing unit.

Interview with the Nursing Home Administrator on March 26, 2026, at 10:00 AM confirmed meal trays are expected to be delivered in a timely manner, and a meal ticket is to be printed for each resident at each meal to ensure meal service accuracy and timeliness.

The facility failed to effectively manage the food and nutrition services department to ensure a meal ticket was generated for Resident 66, resulting in delayed delivery of the resident's breakfast meal on March 25, 2026.

The facility also failed to ensure consistent systems were in place to prevent missed meal trays as reported by Residents 23 and 8. 28 Pa.

Code 201.18 (b)(3)(e)(3)(6) Management.

395905 03/27/2026

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

Review of the Occupational Therapy Discharge summary dated [DATE], indicated the resident achieved the short-term goal of maintaining midline positioning while seated using adaptive equipment for greater than eight hours.

Interventions included trial of alternative wheelchair cushions and supports and training of staff and caregivers in positioning techniques.

The discharge summary failed to identify the specific positioning devices or modifications required for continued implementation of the positioning program.

Review of therapy documentation revealed no evidence staff received training regarding positioning techniques, devices, or schedules as required by facility policy.

Observation on March 25, 2026, at 8:25 AM and again at 8:40 AM revealed Resident 12 seated in common areas with unsupported left lateral trunk and cervical positioning.

The Broda chair lateral supports were not positioned as identified in the care plan.

Interviews with multiple staff, including the Nursing Home Administrator and Physical Therapist, revealed staff were unable to explain or demonstrate the care plan intervention described as invert bilateral upper wing support.

During an interview on March 25, 2026, at 2:40 PM, the Director of Rehabilitation confirmed cervical positioning devices were not identified in the discharge summary and confirmed staff training regarding positioning interventions and devices had not been documented.

The Director of Rehabilitation further confirmed the resident's family provided the neck pillow.

The facility failed to ensure therapy-identified positioning needs were translated into clearly defined and individualized care plan interventions, failed to ensure specialized rehabilitative services recommendations were implemented following therapy discharge, and failed to ensure staff were trained and competent to carry out the positioning program as evidenced by observations of the resident without appropriate support to maintain functional body alignment necessary to support safe swallowing, comfort, and prevention of complications associated with abnormal positioning. 28 Pa.

Code 211.12 (d)(5) Nursing services.28 Pa.

Code 211.10 (c)(d) Resident care policies.