Pennsylvania Department of Health
NIGHTINGALE NURSING AND REHAB CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

NIGHTINGALE NURSING AND REHAB CENTER
Inspection Results For:

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NIGHTINGALE NURSING AND REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey and an Abbreviated Complaint Survey, completed February 28, 2025, it was determined that Nightingale Nursing and Rehab Center, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to label a multi-dose insulin (medication to treat elevated blood sugar levels) vial with the date it was opened and discard an expired multi-dose insulin vial; and failed to prevent the opportunity for unauthorized access to medications in three of five medication carts (Unit D North, Unit E, and Unit C South); and failed to store Schedule II-V medications in a separately locked, permanently affixed compartment in two of five medication rooms (Unit C North and Unit D South).

Findings include:

A facility policy entitled, "Security of Medication Cart" dated, 1/07/25, revealed that medication carts must be securely locked at all times when out of the nurse's view.

A facility policy entitled, "Storage of Medications" dated, 1/07/25, revealed that unlocked medication carts are not left unattended, and Schedule II-V controlled medications are stored in separately locked permanently affixed compartments.

A facility policy entitled, "Insulin Administration" dated, 1/07/25, revealed to check expiration date, if drawing from an opened multi-dose vial; if opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening).

Observation on 2/26/25, at 8:52 a.m. of the Unit D North medication cart revealed one multi-dose vial of Lantus (long-acting insulin) labeled with an opened date of 1/22/25, (36 calendar days prior) and a pharmacy label that indicated to discard after 28 days opened.

During an interview at that time, Licensed Practical Nurse (LPN) Employee E6 confirmed that the multi-dose vial was expired and should have been discarded.

Observation on 2/26/25, at 10:13 a.m. of the Unit E medication cart revealed one opened multi-dose vial of insulin glargine (long-acting type of insulin) and lacked an opened date.

During an interview at that time, Registered Nurse Employee E3 confirmed that the vial should contain an opened date and that he/she was unable to determine a discard date.

Observation on 2/26/25, at 1:26 p.m. of the Unit C North medication refrigerator rack contained a locked compartment with two boxes of injectable lorazepam (controlled substance used to treat anxiety disorders). The rack of the refrigerator was not permanently affixed.

During an interview at that time, the Assistant Director of Nursing confirmed that the refrigerator rack was not permanently affixed.

Observation on 2/26/25, at 1:37 p.m. of the Unit S South medication refrigerator rack contained a locked compartment with one box of injectable lorazepam. The rack of the refrigerator was not permanently affixed.

During an interview at that time, LPN Employee E1 confirmed that the refrigerator rack was not permanently affixed.

Observation on 2/27/25, at 11:04 a.m. revealed the Unit C South medication cart was unsecured and unattended outside of a resident room (approximately 25 feet from nurse's station and was unable to be seen from nurse's station). Several staff and residents walked by the unsecured cart, and LPN Employee E4 approached the medication cart from nurse's station area.

During an interview at that time, LPN Employee E4 confirmed that the medication cart should have been locked.

During an interview on 2/27/25, at 11:35 a.m. the Director of Nursing confirmed the medication cart should have been locked when not attended to and/or in view.

28 Pa. Code 201.18(b)(1) Management

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.9(a)(1) Pharmacy services

28 Pa. Code 211.10(c) Resident care policies

Plan of Correction - To be completed: 04/03/2025

Immediately upon discovery, the Maintenance team permanently affixed the racks containing the locked controlled substance box to the locked refrigerators in the locked medication rooms. When the Registered Nurse Supervisor is checking refrigerator temperatures, he/she will audit that all controlled substances are accounted for in the refrigerators. All outdated and undated insulin was removed from service at the time of discovery. Immediate education was provided to all nursing staff regarding the proper dating and storage of insulin, as well as the requirement to lock medication carts when not attended or within view. To ensure continued compliance, the Director of Nursing (DON) or designee will perform three medication cart audits per week for two weeks, followed by one audit per week for four weeks, and then one audit per month for two months for outdated or undated insulin rotating carts to ensure all 5 carts are audited. The results of these audits will be reviewed during Quality Assurance and Performance Improvement (QAPI) meetings, and any identified concerns will be addressed with additional education or corrective actions as needed. Additionally, the DON or designee will conduct random observational audits to ensure medication carts are being locked when not attended or within view, performing these checks three times per week for two weeks, once per week for four weeks, and once per month for two months.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Observations:

Based on review of the Pennsylvania Code Title 49. Professional and Vocational Standards, facility job descriptions, clinical records, and facility documents, and staff interviews, it was determined that the facility failed to follow nursing standards of practice to ensure medications were administered appropriately and residents were assessed and treated in a timely manner for one of 24 residents reviewed (Resident R108).

Findings include:

Review of Pennsylvania Code Title 49. Professional and Vocational Standards 21.145. Functions of the Licensed Practical Nurse (LPN), "(a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place."

Review of the facility job description for an LPN included: prepare and administer medication as ordered by the physician; be knowledgeable of nursing and medical practices and procedures, as well as, laws, regulations, and guidelines; must possess the ability to make independent decisions when circumstances warrant such action; implement and maintain established nursing objectives and standards; administer professional services; and monitor seriously ill residents as necessary.

A facility policy entitled, "Administering Oral Medications" dated 1/07/25, included verifying the physician's medication order, and instructing the resident to place sublingual (situated beneath the tongue) medications under the tongue and allow the drug to dissolve.

A facility policy entitled, "Assessment of Chest Pain" dated 1/07/25, revealed that assessing a resident experiencing chest pain in a skilled nursing facility requires prompt and systematic action to ensure resident safety, and included the following:
1. Immediate assessment and monitoring: pain evaluation- quickly assess the characteristics of the chest pain; vital signs monitoring- measure and document vital signs.
2. Medication administration: administer medications as per standing orders, and resident's care plan.

Resident R108's clinical record revealed an admission date of 10/20/24, with diagnoses that included heart disease, heart failure, and anxiety. The clinical record revealed a physician's order dated 1/07/25, to give Nitrostat (nitroglycerin- prevents and treats chest pain by relaxing your blood vessels) 0.4 milligram tablet sublingual every five minutes as needed for chest pain every five minutes up to three doses. The clinical record revealed a care plan entitled "Altered cardiovascular status" with interventions including assess for chest pain, administer medications as ordered and monitor for side effects and effectiveness.

Observations on 2/27/25 revealed the following:

-At 2:09 p.m. female voice heard yelling "help, nurse" from behind a closed door. Resident R108 stated, "Please help. I am having chest pain." Resident R108's right leg was over the side of bed, his/her oxygen tubing was laying on bed, and the call bell was under the bed. Licensed Practical Nurse (LPN) Employee E4 was observed seated at the nurse's station and was notified of Resident R108's report of chest pain, and responded "Three people have already been in there" and remained seated at nurse's station.
-At 2:10 p.m. the Director of Nursing inquired of Resident R108's as needed medications, and was informed by LPN Employee E3 of the available nitroglycerin.
-At 2:15 p.m. LPN Employee E3 sat at nurse's station with an amber plastic pharmacy bag containing nitroglycerin.
-At 2:33 p.m. LPN Employee E3 entered Resident R108's room, administered one tablet of nitroglycerin with water to Resident R108 to swallow, and then returned to the nurse's station.
-At 2:41 p.m. LPN Employee E3 remained at the nurse's station and was notified by the Assistant Director of Nursing that Resident R108 required another administration of nitroglycerin.
-At 2:44 p.m. LPN Employee E3 entered Resident R108's room, administered one tablet of nitroglycerin with water to Resident R108 to swallow, and then returned to the nurse's station.
-At 2:59 p.m. Emergency Medical Services arrived on the unit to transport Resident R108 to the hospital and LPN Employee E3 was observed seated at the nurse's station.

LPN Employee E3 entered Resident R108's room twice to administer nitroglycerin with water and failed to assess Resident R108's medical condition and/or monitor for changes in condition.

During an interview on 2/27/25, at approximately 3:05 p.m. the Director of Nursing confirmed that the Nitrostat should have been given sublingual and that having the resident swallow the medication was inappropriate. The Director of Nursing also confirmed that LPN Employee E3 failed to act within his/her professional standards in response to Resident R108's calling out about chest pain and possible medical condition.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

28 Pa. Code 211.10(c) Resident care policies

Plan of Correction - To be completed: 04/03/2025

Immediately upon discovery, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) assessed Resident R108 within one minute of being alerted to the situation. The ADON remained with the resident throughout, ensuring continuous monitoring and support. The resident's vital signs remained stable, and there was no harm identified. Upon return to the facility, the resident required no new physician orders and remained at baseline. There were no other residents affected. Immediate education was provided to all nursing staff regarding the proper assessment of chest pain complaints and the appropriate administration of medication per physician orders. To protect residents in a similar situation, continuing education will be provided the proper assessment of chest pain complaints and the appropriate administration of medication per physician orders. To ensure continued compliance, the DON or designee will complete three medication administration competency evaluations per week for two weeks, followed by one per week for four weeks, and then two per month for two months. Audits will be completed on all 3 units and all 3 shifts. The results of these evaluations will be reviewed during monthly Quality Assurance and Performance Improvement (QAPI) meetings, and any identified concerns will be addressed with additional education or corrective action as needed. To sustain compliance, the facility will integrate medication administration audits into its ongoing quality improvement processes. Continued staff education and training will reinforce proper protocols for assessing and responding to chest pain complaints, and all new nursing staff will undergo competency evaluations during orientation to ensure adherence to best practices.

§ 211.9(j.1) (1) - (5) LICENSURE Pharmacy services.:

(j.1) The facility shall have written policies and procedures for the disposition of medications that address all of the following:
(1) Timely and safe identification and removal of medications for disposition.
(2) Identification of storage methods for medications awaiting final disposition.
(3) Control and accountability of medications awaiting final disposition consistent with standards of practice.
(4) Documentation of actual disposition of medications to include the name of the individual disposing of the medication, the name of the resident, the name of the medication, the strength of the medication, the prescription number if applicable, the quantity of medication and the date of disposition.
(5) A method of disposition to prevent diversion or accidental exposure consistent with applicable Federal and State requirements, local ordinances and standards of practice.

Observations:

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to document the type and quantity of medication disposition for two of three closed records reviewed (Closed Record Residents CR117 and CR118).

Findings include:

A facility policy entitled, "Disposition of Medications" dated 1/07/25, indicated that medications discontinued by prescriber order, resident's death, or discharge to hospital are either destroyed on site or returned to the pharmacy for destruction or storage with disposition being recorded in the electronic health record or paper form.

Resident CR117's clinical record revealed an admission date of 11/14/24, with diagnoses that included end stage renal disease and dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), respiratory failure, and cirrhosis of the liver (chronic liver disease that occurs when healthy liver tissue is replaced by scar tissue).

Facility provided information that revealed Resident CR117 ceased to breathe on 11/29/24, at the facility.

The clinical record lacked documentation of the type and quantity of medication disposition for Resident CR117 at the time he/she passed away.

Resident CR118's clinical record revealed an admission date of 1/02/25, with diagnoses that included respiratory failure, heart disease, and congestive heart failure (long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply).

Facility provided information that revealed Resident CR118 was admitted to the hospital on 1/17/25, and was discharged to home from the hospital.

The clinical record lacked documentation of the type and quantity of medication disposition for Resident CR118 at the time he/she was admitted to the hospital where he/she was later discharged to home.

During an interview on 2/28/25, at 10:16 a.m. Medical Records Employee confirmed that the facility failed to properly document disposition of medications for Residents CR117 and CR118.

Plan of Correction - To be completed: 04/03/2025

Upon discovery, the Director of Nursing (DON) immediately created a Disposition of Medication form to be used when a resident ceases to breathe or is discharged to the hospital from the facility. Education was provided to nursing staff on the proper use of this new form. The nursing staff will be responsible for completing the form at the time of discharge to hospital or if the resident ceases to breathe, and the medical records department will be responsible for uploading the form to the resident's record. To ensure compliance, the DON or designee will perform an audit weekly for four weeks on 50% of residents who cease to breathe or are discharged to the hospital, followed by monthly audits for two months on 25% of such residents. The results of these audits will be reviewed during Quality Assurance and Performance Improvement (QAPI) meetings, and any identified concerns will be addressed with additional education or corrective action as needed.

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