Nightingale Nursing and Rehab Center

In the surveyor’s words

From the most serious findings on record at Nightingale Nursing and Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF580Jan 27, 2021

  Based on review of clinical records, facility policies and procedures, hospital records, and interviews with facility and medical staff, it was determined that the facility failed to notify the physician and the resident's responsible party in a timely manner of changes in one of three residents' (Resident R1) condition following a fall with injury, resulting in actual harm to the resident who experienced a delay in treatment and subsequent admission to the hospital with a cervical (neck) injury, nasal fracture, a nasal laceration with associated blood loss requiring blood [CONDITION(S)]. […]

• Actual harm, isolatedF684Jan 27, 2021

  Based on review of clinical records, facility policies and procedures, hospital records, and interviews with facility and medical staff, it was determined that the facility failed to ensure that one of three residents (Resident R1) sustaining a fall with injury, received treatment and care in accordance with professional standards of practice resulting in actual harm of a cervical (neck) injury, blood loss associated with a nasal fracture and laceration requiring blood [CONDITION(S)], and admission to the intensive care unit for treatment and monitoring. […]

• No harm, potential for more than minimal, widespreadF725Mar 31, 2023

  Based on observations, review of clinical records, facility policy and protocol, facility documentation, review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), and resident/resident family and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the well-being for 21 of 21 residents interviewed (Residents R3, R15, R23, R26, R27, R31, R33, R35, R41, R44, R51, R77, R86, R88, R89, R91, R100, R102, R259, R306, and R309). […]

• No harm, potential for more than minimal, patternF684Jul 10, 2026

  Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure medications were administered in accordance with physician's orders for three of five residents reviewed (Residents R1, R2, and Closed Record Resident CR3). Findings include: Facility policy entitled, Administering Medications dated 2/09/26, revealed medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. […]

• No harm, potential for more than minimal, patternF628Feb 20, 2026

  Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide the Resident and/or Resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day), and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital, for eight of eight residents reviewed (Residents R3, R9, R11, R14, R72, R95, R99, and R149).Findings include: Review of a facility policy entitled Transfer or Discharge, Facility-Initiated dated 2/9/26, indicated Notice of facility bed-hold and return policies are provided to the resident and representative within 24 hours of… […]