Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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 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 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 August 2026) and official state health department websites.