Third Avenue Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Third Avenue Health & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF689May 30, 2025

  Based on review of clinical records, facility policies, documentation provided by the facility, and staff interviews, it was determined the facility failed to consistently provide adequate supervision and implement appropriate, individualized fall prevention interventions based on assessed needs to ensure the safety of one of 18 sampled residents (Resident 50), resulting in multiple unwitnessed falls and significant injury, including a traumatic subdural hemorrhage and multiple fractures of the arm. Findings include: A review of the facility policy titled Fall Prevention and Management Policy, last reviewed by the facility February 13, 2025, revealed it is the policy of the facility to assist in fall management and prevention. […]

• Actual harm, isolatedF689Jun 1, 2023

  Based on resident and staff interviews and a review of clinical records and select incident reports it was determined that the facility failed to consistently provide necessary precautionary measures planned to maintain resident safety and prevent injury during transport resulting in a fractured ankle and pain for one resident out of four sampled (Resident 55). Findings include: A review of the clinical record revealed that Resident 55 was admitted to the facility on [DATE], with diagnoses to include nontraumatic intracerebral hemorrhage (stroke) and muscle weakness. […]

• No harm, potential for more than minimal, widespreadF925Apr 16, 2024

  Based on observations and interviews with resident sand staff, it was determined that the facility failed to maintain an effective pest control program. Findings include: Observations during an environmental tour of the facility on April 16, 2024, at approximately 11:30 AM, down the service entrance hallway in the presence of the Director of Nursing, revealed that the doors to the kitchen, dry storage room, and mechanical room were open. Further observation revealed that the door from the mechanical room leading to the outside of the building was also open to the outside, providing a means of entry for pests. […]

• No harm, potential for more than minimal, widespreadF812Dec 19, 2022

  Based on observations during a tour of the dietary department and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for microbial growth in food, which increased the risk of food-borne illness. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. […]

• No harm, potential for more than minimal, patternF812May 30, 2025

  Based on observation, a review of facility-provided documents, and employee interviews, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination, including rodent activity, which increased the risk of food-borne illness in multiple areas of the kitchen. 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. […]