Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Nightingale Nursing And Rehab Center during CMS and state inspections, most recent first.
A facility failed to provide written bed-hold notices and failed to ensure required transfer information was communicated to the receiving provider for eight residents with multiple hospital transfers. The records for residents with diagnoses including CVA, dementia, ESRD on dialysis, CHF, DM, chronic respiratory failure, and other conditions lacked evidence that the resident/rep received the bed-hold policy or that key clinical details, such as contact info, advance directives, diagnoses, meds, and precautions, were sent with the transfer.
A resident with dementia and anxiety had a PRN order for Lorazepam for anxiety, and the MAR showed the medication was given 11 times. The clinical record did not show that non-pharmacological interventions were attempted before each dose, and the DON confirmed the lack of documentation and that such interventions should be attempted before giving psychotropic medication.
Missed Dialysis-Day Medications: A resident receiving hemodialysis with diagnoses including renal dialysis dependence, atrial fibrillation, and chronic pain did not receive several ordered meds as scheduled. The MARs showed missed doses of Carafate, Gabapentin, Hydralazine, Losartan, and Insulin Lispro, including sliding scale insulin, and there was no documentation that the MD was notified to hold or change the timing of the meds; the DON confirmed the meds were not administered on dialysis days as ordered.
Medication labeling and storage were not maintained properly in the D-North med room and med cart. An opened Tubersol PPD vial lacked an open date, an open Fluticasone Propionate inhaler was expired based on its discard instructions, and an open Trelegy inhaler did not have a resident name. The DON and an LPN confirmed the labeling and dating problems.
A resident with respiratory and nutritional issues experienced low oxygen saturation and confusion, but there was no evidence of immediate physician notification. Additionally, two residents with complex medical conditions did not receive their prescribed IV antibiotics as ordered, with the DON confirming the omissions in medication administration records.
A resident with multiple serious diagnoses experienced significant changes in condition, including low oxygen saturation, confusion, and refusal of medications and meals. Although some nursing actions were recorded in a written statement, these were not included in the permanent clinical record, and there was no documentation of follow-up care or physician notification. The facility failed to maintain accurate and complete documentation as required by policy and regulation.
A resident with anxiety, diabetes, and hypertension received PRN Lorazepam multiple times without documented evidence that non-pharmacological interventions were attempted beforehand, as required by facility policy. The Nursing Home Administrator confirmed the absence of such documentation for each administration.
The facility failed to properly label and store medications, including expired insulin vials and unsecured medication carts. Insulin vials were either expired or lacked opened dates, and medication carts were left unattended. Controlled substances were not stored in permanently affixed compartments, violating facility policies.
A resident with heart disease and anxiety experienced chest pain and called for help. An LPN failed to promptly assess the resident and incorrectly administered sublingual nitroglycerin with water, instructing the resident to swallow it. The Director of Nursing confirmed the medication should have been given sublingually, and the LPN's actions did not meet professional standards, leading to delayed treatment and hospital transport.
Failure to Provide Bed-Hold Notice and Transfer Information
Penalty
Summary
The facility failed to provide residents and/or their representatives with a written notice of the facility bed-hold policy, including how long a bed could be held during a leave of absence and the cost per day, and failed to ensure that necessary resident information was communicated to the receiving health care provider when residents were transferred to the hospital. The deficiency was identified for eight of eight residents reviewed: R3, R9, R11, R14, R72, R95, R99, and R149. Review of the facility policy titled "Transfer or Discharge, Facility-Initiated" dated 2/9/26 stated that notice of the facility bed-hold and return policies are to be provided to the resident and representative within 24 hours of emergency transfer, and that information conveyed to the receiving provider includes practitioner contact information, resident representative contact information, advance directive information, special instructions or precautions, comprehensive care plan goals, resident status, diagnosis and allergies, medications, and most relevant labs. Clinical records for each of the eight residents showed hospital transfers on multiple dates, but the records lacked evidence that the required clinical information was communicated to the receiving health care provider and lacked evidence that the resident and/or representative received a copy of the bed-hold policy upon transfer. Resident R3 had diagnoses including cerebral infarction, muscle weakness, and dysphagia, with transfers noted on 8/16/25, 9/19/25, and 12/25/25. Resident R9 had diagnoses including dependence on renal dialysis, atrial fibrillation, and chronic pain, with transfers on 11/3/25, 12/3/25, and 2/1/26. Resident R11 had diagnoses including dementia, anxiety, and hypertension, with multiple transfers documented between 4/19/25 and 12/20/25. Resident R14, R72, R95, R99, and R149 also had documented hospital transfers and diagnoses including spinal stenosis, osteoarthritis, hypertension, chronic diastolic heart failure, type 2 diabetes, morbid obesity, chronic respiratory failure, hyperlipidemia, sleep apnea, and hypothyroidism. During interview on 2/19/26 at 2:13 p.m., the DON confirmed the records lacked evidence of the required communication to the receiving healthcare provider and lacked evidence that the bed-hold policy was provided upon transfer.
Failure to Document Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The facility failed to provide evidence that non-pharmacological interventions were attempted before administering PRN psychotropic medication for one resident. Resident R11 was admitted on 12/12/24 with diagnoses including dementia, anxiety, and hypertension, and had a physician order for Lorazepam 0.5 mg by mouth every 12 hours PRN for anxiety. Review of the February 2026 MAR showed the PRN Lorazepam was administered 11 times on 2/1/26, 2/3/26, 2/4/26, 2/5/26, 2/6/26, 2/10/26, 2/11/26, 2/12/26, 2/13/26, 2/14/26, and 2/18/26. The clinical record lacked evidence that non-pharmacological interventions were attempted prior to each of those 11 administrations. During interview, the DON confirmed that the record did not show non-pharmacological interventions were attempted before giving the PRN Lorazepam and stated that such interventions should be attempted prior to administering psychotropic medication.
Missed Dialysis-Day Medications
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders for a resident receiving hemodialysis. The resident had diagnoses including dependence on renal dialysis, atrial fibrillation, and chronic pain, and the physician ordered that medication and treatment timing be changed from the facility’s routine schedule to accommodate dialysis treatment. Ordered medications included Carafate before meals and at bedtime, Gabapentin three times daily, Hydralazine three times daily, Insulin Lispro before meals, Insulin Lispro sliding scale before meals, and Losartan in the afternoon. Review of the resident’s progress notes and MARs for November 2025 through February 2026 showed multiple missed doses on dialysis days, including Carafate, Gabapentin, Hydralazine, Losartan, Insulin Lispro, and Insulin Lispro sliding scale. The record did not contain documentation that the physician was notified to hold or change the timing of these medications on the days they were not given as ordered. During interview, the DON confirmed that the medications were not administered on dialysis days as ordered by the physician.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Medications and biologicals were not properly labeled and stored in accordance with facility policy and accepted professional principles. Review of the facility’s Medication Labeling and Storage policy showed that medication labels must include the resident’s name, and opened multi-dose vials must be dated and discarded within 28 days unless the manufacturer specifies a different timeframe. Manufacturer guidance for Tubersol PPD stated that opened vials in use for 30 days should be discarded. During observation of the D-North medication room refrigerator, an opened vial of Tubersol PPD was found without an open date, and the DON confirmed staff could not determine the discard date. In the D-North medication cart, an open Fluticasone Propionate inhaler had an open date of 1/9/26 and was expired based on the 30-day discard instruction, and an open Trelegy inhaler did not have a resident name. An LPN confirmed the expired inhaler should have been discarded and the Trelegy inhaler should have had a resident name.
Failure to Notify Physician of Change in Condition and Omission of Prescribed IV Antibiotics
Penalty
Summary
The facility failed to adhere to professional standards of care by not providing immediate physician notification for a resident who experienced a significant change in condition, and by not administering prescribed medications as ordered for two other residents. Specifically, one resident with diagnoses including pneumonia, COPD, acute respiratory failure with hypoxia, and severe protein-calorie malnutrition exhibited low oxygen saturation levels (as low as 55% and 77% after oxygen was reapplied), confusion, and refusal of medications and meals. Despite these changes, there was no documented evidence that the physician was notified of the resident's deteriorating condition, as confirmed by the Nursing Home Administrator. Additionally, two residents did not receive their prescribed intravenous antibiotics according to physician orders. One resident with end stage renal disease, dialysis dependence, a history of falls, and diabetes mellitus type 2 did not receive a scheduled dose of Cefepime IV antibiotic for infection. Another resident with a history of subarachnoid hemorrhage, seizures, a stage 4 sacral pressure ulcer, and osteomyelitis did not receive Daptomycin IV antibiotic as ordered on three consecutive days. The Director of Nursing confirmed that the clinical records lacked evidence of administration of these medications as prescribed.
Failure to Maintain Accurate and Complete Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete documentation regarding a resident's change of status. According to the facility's own policy, all services provided, progress toward care plan goals, and any changes in a resident's condition must be documented in the medical record to facilitate communication among the interdisciplinary team. In the case reviewed, a resident with diagnoses including pneumonia, COPD, acute respiratory failure with hypoxia, and severe protein-calorie malnutrition experienced significant changes in condition, such as low oxygen saturation, confusion, refusal of medications and meals, and removal of oxygen. While some nursing actions and observations were recorded in a written statement provided by the Nursing Home Administrator, these were not included in the resident's permanent clinical record. Further review of the clinical record revealed a lack of documentation regarding nursing follow-up care, treatment, and physician notification related to the resident's low oxygen saturations and confusion. The Nursing Home Administrator confirmed that the provided nursing documentation was not part of the official clinical record and that there was no evidence of communication between the interdisciplinary team about the resident's condition and response to care. This failure to document and maintain complete records was found to be out of compliance with both facility policy and state regulations.
Failure to Attempt Non-Pharmacological Interventions Before PRN Psychotropic Medication
Penalty
Summary
The facility failed to provide evidence that non-pharmacological interventions were attempted prior to administering a PRN psychotropic medication to a resident. According to facility policy, non-pharmacological approaches should be used to minimize the need for medications unless contraindicated. Review of the clinical record for a resident with diagnoses including diabetes, anxiety, and high blood pressure showed that the resident had physician orders for Lorazepam, both as a routine and PRN medication for anxiety. The Medication Administration Record indicated that PRN Lorazepam was administered six times over several days. Documentation review revealed no evidence that non-pharmacological interventions were attempted before each administration of the PRN Lorazepam. This lack of documentation was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the facility did not have evidence of such interventions being tried prior to each use of the PRN anti-anxiety medication for the resident.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, as evidenced by several observations and staff interviews. A multi-dose vial of Lantus insulin was found on the Unit D North medication cart with an opened date of 36 days prior, exceeding the pharmacy's recommendation to discard after 28 days. Additionally, a vial of insulin glargine on the Unit E medication cart lacked an opened date, making it impossible to determine its discard date. These lapses were confirmed by the respective nursing staff during interviews. Furthermore, the facility did not ensure the security of medication carts and storage of controlled substances. On Unit C South, a medication cart was left unsecured and unattended, allowing unauthorized access. This was confirmed by an LPN and the Director of Nursing. In the medication rooms of Unit C North and Unit D South, Schedule II-V medications were stored in locked compartments that were not permanently affixed, as confirmed by the Assistant Director of Nursing and an LPN. These findings indicate a failure to comply with facility policies regarding medication security and storage.
Failure to Administer Medication Correctly and Timely Assessment
Penalty
Summary
The facility failed to adhere to nursing standards of practice, resulting in improper medication administration and delayed assessment for a resident experiencing chest pain. The resident, who had a history of heart disease, heart failure, and anxiety, called for help due to chest pain. Despite the resident's distress, an LPN remained at the nurse's station and did not promptly assess the resident's condition or administer the prescribed sublingual nitroglycerin as ordered. Instead, the LPN administered the medication with water, instructing the resident to swallow it, which was inappropriate for the sublingual medication. The Director of Nursing confirmed that the medication should have been administered sublingually and acknowledged the LPN's failure to act within professional standards. The LPN's inaction and incorrect administration of medication led to a delay in appropriate treatment for the resident, who was eventually transported to the hospital by emergency medical services. The report highlights the facility's failure to ensure that medications were administered correctly and that residents were assessed and treated in a timely manner.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Erie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lecom At Village Square, Llc | 0.9 mi | ★★★★★ | 3 | 0 |
| Sarah Reed Senior Living | 1 mi | ★★★★★ | 4 | 0 |
| Pennsylvania Soldiers And Sailors Home | 1.6 mi | ★★★★★ | 9 | 0 |
| Lecom At Elmwood Gardens, Llc | 2.3 mi | ★★★★★ | 1 | 0 |
| Twinbrook Healthcare And Rehabilitation Center | 3.1 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.