Nightingale Nursing and Rehab: Missing Records - Erie, PA
The failure at Nightingale Nursing and Rehab Center came to light during a complaint inspection completed November 25, 2025. Inspectors reviewed two closed records and found problems in one of them, belonging to a resident identified only as Resident CR1.
CR1 had been admitted on September 17, 2025, with a serious cluster of diagnoses: pneumonia, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, and severe protein-calorie malnutrition. He was, by any measure, a medically fragile patient.
On the night of September 28, things got worse. A progress note timed at 10:35 p.m. recorded that CR1 had been pulling off his oxygen. When staff checked his oxygen saturation without the supplemental oxygen, it read 55%. A normal reading sits between 95% and 100%. Even after staff reapplied the oxygen, his saturation only climbed to 77%. He was confused, talking to people who weren't in the room, refusing his medications, and refusing dinner. He did drink a milkshake. The registered nurse supervisor was notified. The note ended with four words: "Will continue to monitor."
What the permanent record contained after that point was nothing. No follow-up notes. No documentation of how CR1 responded through the rest of the night. No record of anyone notifying a physician about the dangerously low oxygen readings or the new confusion.
What actually happened that night was captured somewhere else entirely. The nursing home administrator produced a separate handwritten nurse's statement, one that described a far more intensive response than the clinical record suggested. According to that statement, the nurse checked CR1's vital signs after receiving the shift report, reassessed him multiple times throughout the night, reapplied his oxygen repeatedly as he pulled it off, and offered him medications as needed, which he refused. Between 1:00 a.m. and 3:30 a.m., the nurse sat with CR1 one-on-one in his room. A nursing assistant provided incontinence care at 3:30 a.m. The nurse returned to the desk at 4:15 a.m. and then reassessed CR1 again, finding him still restless, still removing his oxygen.
That account, if accurate, describes a nurse who spent hours at a dying man's bedside through the middle of the night. But it was never filed in his chart.
When inspectors interviewed the nursing home administrator on October 23, 2025, she confirmed both facts directly. The handwritten statement was not part of CR1's permanent clinical record. And the permanent record contained no documentation of the nursing response to his change in condition, no evidence of progress notes, no communication between the interdisciplinary team about what was happening to him or how he was responding to care.
The facility's own charting policy, dated January 7, 2025, states that all services provided to a resident, progress toward care plan goals, and any changes in medical, physical, functional, or psychosocial condition shall be documented in the medical record, and that the record should facilitate communication between the interdisciplinary team about the resident's condition and response to care.
CMS rated the violation at a level of minimal harm or potential for actual harm, affecting few residents. The inspection covered one complaint and turned up one deficient practice across the two closed records reviewed.
The practical consequence of a gap like this extends beyond paperwork. When a resident with respiratory failure is pulling off his oxygen through the night, when his saturation is reading in ranges associated with organ damage, the medical record is how the next shift knows what happened, how a physician makes treatment decisions, how a family understands what their relative experienced. A handwritten statement kept somewhere outside the chart does none of that work.
CR1's record, as filed, shows a man in crisis at 10:35 p.m. on September 28, and then nothing until the record closes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nightingale Nursing and Rehab Center from 2025-11-25 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 25, 2025.
The failure at Nightingale Nursing and Rehab Center came to light during a complaint inspection completed November 25, 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.