Deficiency Records for Third Avenue Health and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Third Avenue Health and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2023-07-17 | 2023-08-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-17 | 2023-08-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-01 | 2023-08-03 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-06-01 | 2023-07-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-01 | 2023-07-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-01 | 2023-07-17 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-06-13 | 2023-06-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-13 | 2023-06-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-13 | 2023-06-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-13 | 2023-06-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-13 | 2023-06-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-13 | 2023-06-30 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-12-19 | 2023-02-01 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-12-19 | 2023-02-01 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-12-19 | 2023-01-12 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-19 | 2023-01-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-19 | 2023-01-12 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-07-19 | 2022-08-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-19 | 2022-08-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-07-19 | 2022-08-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-07-19 | 2022-08-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-08 | 2022-08-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-08 | 2022-08-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-08 | 2022-08-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-15 | 2022-03-07 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-15 | 2022-03-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-21 | 2022-02-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-19 | 2021-10-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-24 | 2021-09-28 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-08-24 | 2021-09-28 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-08-24 | 2021-09-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-08-24 | 2021-09-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-24 | 2021-09-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-24 | 2021-09-28 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-08-19 | 2021-09-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-19 | 2021-09-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-19 | 2021-09-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-19 | 2021-09-23 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-08-19 | 2021-09-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-19 | 2021-09-23 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-19 | 2021-09-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-08-19 | 2021-09-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-18 | 2021-06-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-14 | Not Fixed | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-14 | Not Fixed | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-11-14 | Not Fixed | Y |
