Nightingale Nursing and Rehab: Medication Oversight Failure - PA
The finding came from a complaint inspection completed November 19, 2025. Inspectors reviewed medication records for a resident identified in the report as CR2, who had been admitted on September 20, 2025, with diagnoses that included anxiety, diabetes, and high blood pressure.
On the day of admission, a physician ordered Lorazepam, a sedative in the benzodiazepine family, at 0.5 milligrams by mouth every eight hours as needed for anxiety. Five days later, on September 25, a second order added a routine nightly dose at bedtime, along with keeping the as-needed order in place.
Between September 21 and September 26, staff administered the as-needed Lorazepam six times: twice on the 21st, then once each on the 22nd, 23rd, 24th, and 26th. Inspectors reviewed both the medication administration record and clinical progress notes for each of those six instances. They found no documentation, anywhere, that staff had attempted a non-pharmacological intervention before reaching for the medication.
Non-pharmacological interventions are exactly what they sound like: talking to a resident, repositioning them, offering a snack, playing music, reducing noise, or any number of other approaches intended to address anxiety without sedation. The facility's own written policy, dated January 7, 2025, stated that such approaches are used, unless contraindicated, to minimize the need for medications, allow for the lowest possible dose, and permit discontinuation when possible.
The policy existed. The documentation did not.
When a nursing home administrator was reached by phone on the morning of the inspection, November 19, at 9:24 a.m., the administrator confirmed it. The facility, the administrator acknowledged, lacked evidence that non-pharmacological interventions had been attempted before the PRN Lorazepam was given, for any of the six administrations.
The violation was cited under F0605, which addresses the use of unnecessary psychotropic medications, and was classified as causing minimal harm or potential for actual harm, affecting few residents.
That classification matters, but so does what it describes. Lorazepam is not a mild drug. Benzodiazepines carry well-documented risks for older adults, including sedation, confusion, increased fall risk, and dependence. The point of requiring non-drug approaches first is not paperwork for its own sake. It is a check on the instinct to medicate distress rather than address it.
CR2 arrived at the facility on a Saturday. By Sunday, the as-needed Lorazepam was being used. By the following Friday, it had been administered six times, and a standing nightly dose had been added. The clinical record contained no indication that anyone had tried to calm this resident through any other means.
The inspection covered four residents total for unnecessary medication review. The problem was identified in one of them.
Whether CR2's anxiety responded to the medication, worsened, or led to further prescribing changes, the inspection report does not say. What it says is that a resident in the first week of a nursing home admission, already diagnosed with anxiety, received a controlled sedative repeatedly, and the people responsible for that resident's care left no record of having tried anything else.
The facility's own policy said they should have.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nightingale Nursing and Rehab Center from 2025-11-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
NIGHTINGALE NURSING AND REHAB CENTER in ERIE, PA was cited for violations during a health inspection on November 19, 2025.
The finding came from a complaint inspection completed November 19, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.