Nightingale Nursing And Rehab Center

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

diagnoses of subarachnoid hemorrhage (bleeding between the brain and membranes covering the brain), seizures, pressure ulcer of sacral region stage 4 (skin breakdown extending into muscle, tendon, ligament, cartilage or bone- involvement of the triangular bone in the lower back), and osteomyelitis (infection of bone). Resident Resident R3's MAR revealed a physician's order dated 10/18/2025, for Daptomycin IV Solution Reconstituted Use 725 milligrams (mg) IV in the afternoon for Daptomycin in Normal Saline (NS) 50 milliliter (ml) IV piggyback (IVPB) until 10/31/25, 23:59 Infuse 725 mg at 129 ml/hour over 30 minutes Start Date-10/18/25, 2:00 p.m Resident Resident R3's clinical record, including MAR, lacked evidence that he/she received the Daptomycin per physician's order on 10/18/25, 10/19/25, and 10/20/25 at 2:00 p.m. During an

interview on 10/23/25, at 4:05 p.m. the Director of Nursing (DON) confirmed that physician's orders were not followed for Resident Resident R2 and Resident R3 related to Cefepime and Daptomycin IV antibiotic medication administration respectively. The DON further confirmed that Resident Resident R2 and Resident R3's clinical record lacked evidence that Residents Resident R2 and Resident R3 received the IV antibiotics as prescribed by their physician. 28 Pa.

Code 211.12(d)(1)(5)Nursing services

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Nightingale Nursing and Rehab Center

607 East 26th Street Erie, PA 16504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of facility policy and clinical and facility records, and staff interview, it was determined that the facility failed to maintain accurate and complete documentation related to a resident's change of status for one of two closed records reviewed (Resident CR1). Findings include: Review of facility policy entitled Charting and Documentation dated 1/07/25, revealed All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between

the interdisciplinary team regarding the resident's condition and response to care. Resident CR1' s clinical

record revealed an admission date of 9/17/25, with diagnoses that included pneumonia (an infection of the lungs), Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease that causes ongoing inflammation and narrowing of the airways, making it difficult to breathe), acute respiratory failure with hypoxia (a condition when the lungs can't release enough oxygen into your blood), and severe protein-calorie malnutrition (a condition where a person does not consume enough protein and calories to meet their body's needs). Resident CR1's progress notes dated 9/28/25, 10:35 p.m. revealed resident continues to remove oxygen. Oxygen (O2) saturation 55% on room air. Reapplied oxygen and recheck O2 saturation O2 saturation at 77%. Resident is confused and talking to people that are not visible. Resident refusing all meds and refused dinner. Resident did drink his milkshake. Registered Nurse (RN) supervisor made aware of oxygen saturation. Will continue to monitor. Further review of Resident CR1 ' s clinical

record lacked evidence of further documentation of resident progress, nursing follow-up care and treatment, and physician notification related to low oxygen saturations and confusion. Review of facility provided nursing documentation, a nurse's written statement provided by the Nursing Home Administrator (NHA), for Resident CR1's care and treatment on 9/28/25, indicated per report resident non-compliant with oxygen therapy, oxygen low all day. After report, resident vital signs obtained by this writer. RN aware. Throughout shift resident assessed multiple times oxygen reapplied and education provided. Overnight shift resident restless and removing oxygen, as needed medications offered at time refused. This writer 1:1 resident in room [ROOM NUMBER]:00 a.m.-3:30 a.m. incontinence care provided by nursing assistant at 0330 this writer returned to desk 4:15 a.m. resident reassessed oxygen reapplied resident restless. During an

interview on 10/23/25, at 4:10 p.m. the NHA confirmed that the facility provided nursing documentation for Resident CR1's care and treatment provided 9/28/25, was not part of Resident CR1's permanent clinical record. The NHA further confirmed that Resident CR1's clinical record lacked evidence of the nursing response to Resident CR1's change in condition including resident's progress, changes, and communication between the interdisciplinary team regarding the resident's condition and response to care. 28 Pa. Code 211.5(f)(ii)(iii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Event ID:

Facility ID:

If continuation sheet