Vibra Rehabilitation Center

Inspectors wroteBased on clinical record review, review of select facility documents, and staff interviews, it was determined that the facility failed to provide adequate supervision and interventions to prevent accidents for one of 10 residents reviewed (Resident 5). Findings Include: Review of Resident 5's clinical record revealed diagnoses that included hypertension (high blood pressure) and depression. Review of Resident 5's fall care plan revealed a care plan, dated May 30, 2026, stating that Resident 5 was a high risk for falls related to impulsiveness. Review of Resident 5's ADL (activities of daily living) care plan revealed an intervention, dated May 30, 2026, stating that Resident 5's transfer status was a two moderate assist related to impulsiveness and unsteadiness. [...]

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for three of four residents reviewed for pressure ulcers (Residents 1, 2 and 4), which resulted in actual harm for Resident 2 as evidenced by increased size and surface area of the pressure ulcer. Findings Include: During an interview with the Director of Nursing (DON) on June 3, 2026, at 2:41 PM, it was revealed that the facility does not have a pressure ulcer policy. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the care plan was reviewed and revised to reflect the resident's current status for one of seven residents reviewed (Resident 4). Findings Include: Review of Resident 4's clinical record revealed Resident 4 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (CHF- when the heart muscle doesn't pump blood as well as it should, leading to a backup of fluid in the lungs and body tissues) and hypertension (elevated blood pressure). Review of Resident 4's admission nursing progress note, dated May 13, 2026, revealed the Resident was noted with a stage 2 pressure ulcer to the coccyx (tailbone). [...]

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services consistent with professional standards of practice for two of 7seven residents reviewed (Residents 1 and 7).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that its residents are free of any significant medication errors for two of seven residents reviewed (Residents 2 and 5).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided for a resident with hypoglycemia (low blood sugar) in accordance with professional standards of practice that meet each resident's physical, mental, and psychosocial needs, for one of 18 residents reviewed (Resident 1), which resulted in actual harm as evidenced by Resident 1 becoming unresponsive and requiring hospitalization. Findings Include: Review of Resident 1's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (a chronic condition where the body either resists the effects of insulin or doesn't produce enough of it) and congestive heart failure (CHF-when the heart muscle doesn't pump blood as well as it should, leading to a backup of fluid in the lungs and body tissues). [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident received care, consistent with professional standards of practice, to treat pressure ulcers for one of 18 residents reviewed (Resident 1). Findings Include: Review of Resident 1's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (a chronic condition where the body either resists the effects of insulin or doesn't produce enough of it) and congestive heart failure (CHF-when the heart muscle doesn't pump blood as well as it should, leading to a backup of fluid in the lungs and body tissues). Review of Resident 1's nursing progress notes revealed an eMAR note on April 23, 2026, at 5:03 AM, stating that Resident 1 was reporting a 4/10 buttock pain, concern for stage 2 pressure injury. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to maintain complete clinical records for one of 18 residents reviewed (Resident 1). Findings Include: Review of Resident 1's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (a chronic condition where the body either resists the effects of insulin or doesn't produce enough of it) and congestive heart failure (CHF-when the heart muscle doesn't pump blood as well as it should, leading to a backup of fluid in the lungs and body tissues). Review of Resident 1's TAR (treatment administration record) dated April 2026, revealed that on April 24, 2026, a treatment order was received for Resident 1's left elbow skin tear. [...]

Inspectors wroteBased on review of facility policy, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to establish Enhanced Barrier Precautions (EBP) and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections on two of two nursing units; and failed to maintain an effective infection control program related to the administration of medications for one resident observed during medication administration observation (Resident 63).

Inspectors wroteBased on facility policy review, personnel file review, and staff interviews, it was determined that the facility failed to implement their written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property by failing to determine residency status in order to perform the accurate criminal history background checks prior to hire for five of five personnel files reviewed (Employees 9, 10, 12, 13, and 14); and failed to validate and verify licensure status for one of two nurse personnel files reviewed (Employee 10).

Inspectors wroteBased on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen, in one of two nourishment centers (300/400 pantry), and in the creamery (an accessible lounge area).

Inspectors wroteBased on facility documentation review and staff interview, it was determined that the facility failed to ensure that the governing body was responsible and accountable for the facility Quality Assurance Performance Improvement (QAPI) program.

Inspectors wroteBased on review of the facility provided attendance sign-in sheets for the facility's Quality Assurance Performance Improvement (QAPI) Committee and staff interview, it was determined that two of the required members failed to attend at least one meeting in two out of three quarters.

Inspectors wroteBased on clinical record review and staff interviews, it was determined the facility failed to complete a comprehensive assessment after a significant change in condition for one of 13 residents reviewed (Resident 23).

Inspectors wroteBased on facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that met each resident's physical, mental, and psychosocial needs for one of 13 residents reviewed (Resident 49).

Inspectors wroteBased on observations, staff interview, and facility policy review, it was determined that the facility failed to store drugs and biologicals in accordance with accepted professional standards for one of one medication carts observed (300/400 hall medication cart).

Inspectors wroteBased on observations, clinical record review, and resident and staff interviews, it was revealed that the facility failed to ensure that five of 20 residents reviewed during meal service received a therapeutic diet per physician order (Residents 17, 19, 22, 40, and 59) .

Inspectors wroteBased on review of personnel training records and staff interviews, it was determined that the facility failed to ensure each nurse aide was provided with the required in-service training consisting of no less than 12 hours per year for one of five employee records reviewed (Employee 7); and failed to provide annual training that included dementia management for one of five employee records reviewed (Employee 8).

Inspectors wroteBased on clinical record review, facility policy review, review of investigation documentation, as well and resident and staff interviews, it was determined that the facility failed to ensure that residents were free from abuse, resulting in actual harm as evidenced by skin tears, bruising, and mental anguish caused by rough treatment, for one of four residents reviewed (Resident 1).

Inspectors wroteBased on document review and staff interview, it was determined that the facility failed to ensure information regarding its transferred residents is forwarded to a representative of the Office of the State Long-Term Care Ombudsman for 32 of 37 residents transferred to the hospital for 8 of 9 months reviewed (January 2024-August 2024). Findings Include: A review of the facility's hospital transfer information beginning January 2024 revealed information regarding 32 of the 37 residents transferred was not shared with the State Long-Term Care Ombudsman. An interview with the Director of Social Services (Employee 3) on September 17, 2024, at 10:03 AM, revealed an awareness of the information not being sent and the expression that the transferred resident information would be forwarded beginning September 2024. 28 Pa. Code 201.14 (a) Responsibility of licensee

Inspectors wroteBased on document review and staff interviews, it was determined that the facility failed to complete a performance review of every nurse aide at least once every 12 months for one of five nurse aide files reviewed (Employee 6). Findings Include: A performance appraisal, also referred to as a performance review, performance evaluation, development discussion, or employee appraisal, sometimes shortened to 'PA', is a periodic and systematic process whereby the job performance of an employee is documented and evaluated. A review of the facility's nurse aide information revealed a hire date for Employee 6 of August 10, 2021. A review of Employee 6's performance appraisal form revealed the most recent dated December 28, 2022. An interview with the Director of Nursing on September 18, 2024, at approximately 1:00 PM, revealed employees are to be evaluated on an annual basis. [...]

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure residents the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors for one of one facility survey results book reviewed (facility lobby area). Findings Include: An observation of the facility's designated survey results book revealed the most recent Federal and State survey information dated November 2023. A review of the facility's history revealed the most recent survey dated February 16, 2024. An interview with the Nursing Home Administrator on September 17, 2024, at 1:21 PM, confirmed the facility's survey book did not contain the most recent survey for resident review. 28 Pa. Code 201.14 (a) Responsibility of licensee

Inspectors wroteBased on facility policy review, personnel file review, and staff interviews, it was determined that the facility failed to implement their written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property by failing to perform criminal history background checks prior to hire for one of five personnel files reviewed (Employee 4); failing to verify the nurse aide registry prior to hire for one of five personnel files reviewed (Employee 4); and failing to perform reference checks prior to hire for two of five personnel files reviewed (Employees 4 and 5). Findings Include: [...]

Inspectors wroteBased on document review, clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure allegations of neglect are thoroughly investigated for one concern form reviewed (Resident 153). Findings Include: A review of the facility's policy, titled Abuse, Neglect, and Exploitation, effective November 1, 2017, read, in part, When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation will be initiated immediately. The policy defined neglect as failure of the Facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy continued, Components of an investigation may include: 3. Interview all witnesses separately. [...]

Inspectors wroteBased on document review and staff interview, it was determined that the facility failed to ensure the required in-service training for nurse aides include dementia management training and resident abuse prevention training for one of five nurse aide training documents reviewed (Employee 7). Findings Include: A review of the facility's annual training documentation for Employee 7 revealed none regarding resident abuse and none regarding dementia care. An interview with the Nursing Home Administrator on September 19, 2024, at 11:17 AM, revealed the required training for Employee 7 could not be located at the time of the survey. 28 Pa. Code 201.19 (7) Personnel policies and procedures

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for three of three residents reviewed (Residents 3, 4, and 6). Findings Include: Review of Resident 3's clinical record revealed diagnoses that included fracture of medial condyle of left femur (lower extremity of the upper leg bone near the knee) and chronic obstructive pulmonary disease (COPD - chronic inflammatory lung disease that causes obstructed airflow from the lungs). [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that medication was obtained and provided as ordered by the physician for three of three residents reviewed for medication administration (Residents 3, 4, and 6).

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to develop a person-centered care plan for two of 14 residents reviewed (Residents 1 and 71).

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure residents are assessed for medication self-administration for one of three residents reviewed for medication administration (Resident 74).

Inspectors wroteBased on a review of facility documentation, clinical record review, and staff interview, it was determined the facility failed to timely issue the Skilled Nursing Facility Advanced Beneficiary Notice form (SNF ABN CMS-10055), and a Notice of Medicare Non-Coverage form published by the Centers for Medicare and Medicaid Services (NOMNC CMS-10123), for one of three residents reviewed (Resident 77).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to conduct a comprehensive assessment after a significant change in health status for one of nine residents reviewed (Resident 2).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the faciliy failed to ensure accuracy of the resident assessment for one of nine residents reviewed (Resident 1).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure a baseline care plan was developed and implemented for one of nine residents reviewed (Resident 121).

Inspectors wroteBased on observation, staff interviews, and record review, it was determined that the facility failed to provide appropriate urinary catheter (tubing inserted into the bladder to drain urine into a bag) care for one of 11 residents reviewed (Resident 75).

Inspectors wroteBased on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure pain management was provided per order for one of nine residents reviewed (Resident 2).

Inspectors wroteBased on observation, facility policy review, and staff interviews, it was determined that the facility failed to ensure infection prevention strategies were implemented for one of two medication carts observed (300 hall medication cart).

Inspectors wroteBased on review of personnel records and staff interview, it was determined that the facility failed to complete annual training on dementia management, behavioral health, and abuse for one of five nurse aide personnel records reviewed (Employee 9), and the facility failed to complete annual training on abuse for one of five nurse aide personnel records reviewed (Employee 10).