Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vibra Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Treat Hypoglycemia and Document Interventions: A resident with DM2 and CHF had blood glucose readings of 57 and 44 documented on the MAR, but no glucose gel or glucagon was given at those times, and there was no nursing note, assessment, provider notification, or repeat BG check. Later, the resident was found unresponsive with BG 47, received glucagon, vomited, had a repeat BG of 37, received a second dose of glucagon, and was transferred to the hospital.
A resident with DM2 and CHF developed a stage 2 pressure injury to the sacrum/buttock area, and the record showed zinc oxide paste was applied and a foam dressing had been in place. However, the skin inspections and related documentation did not include wound measurements, wound characteristics, healing progress, possible complications, infection status, or a pain assessment, and the DON stated the facility did not have a pressure ulcer policy.
Incomplete clinical record for a resident with DM and CHF: the chart lacked documentation of how a left elbow skin tear occurred, when Steri-Strips were applied, and by whom. The TAR/eTAR showed the wound treatment was intermittently held with notes stating Steri-Strips were in place, but there was no record of the NP applying them or of the resident’s explanation that she bumped her elbow against a side table.
Surveyors found that the facility did not have an infection prevention and control program in place, resulting in a deficiency related to infection control practices.
The facility did not verify state residency status to ensure accurate criminal background checks for multiple new hires and failed to validate the active status and standing of a nurse's compact license, as required by policy. Staff interviews confirmed that only state background checks were performed and that licensure verification documentation was lacking.
Multiple food items in the kitchen, nourishment center, and creamery were found open, not securely closed, and lacking date markings or proper labeling. Additionally, the ice machine in the creamery was observed with a black moist substance and had not received required preventive maintenance, and a damp towel with brown stains was left under the sink. Staff confirmed these practices did not meet facility policy or professional standards for food safety and sanitation.
The facility's governing body did not ensure proper oversight of the QAPI program, as neither the NHA nor the MD attended QAPI meetings for a six-month period. The on-site administrator confirmed that required communications and documentation regarding QAPI activities were not consistently shared with the NHA or governing body.
Required members of the QAPI Committee, including the Medical Director and NHA, did not attend any meetings in two out of three quarters reviewed. The Executive Director signed in as the NHA but later confirmed he was not the NHA, and neither the NHA nor the Medical Director participated in the QAPI meetings. Communication with the NHA occurred by phone, but QAPI minutes were not routinely shared.
A resident with multiple medical conditions was admitted to hospice, but the required comprehensive MDS assessment following this significant change in condition was not completed on time. Staff confirmed that the assessment was still incomplete during the review and had only just been submitted.
A resident did not receive treatment and care in accordance with physician orders and their documented preferences and goals, as observed by surveyors and confirmed through record review.
Surveyors found that an insulin pen in use for a resident was not labeled with the date it was opened, and a box of single-use eye drop applicators on a medication cart contained items with lot numbers that did not match the box. The DON confirmed that both practices were not in line with facility policy and accepted standards.
Several residents with diabetes were not provided with their prescribed no concentrated sweets diet, receiving pudding instead of the required fruit cup during meal service. This failure to follow physician orders was confirmed by staff and noted during meal observation.
A review of staff records and interviews revealed that one nurse aide did not complete the required 12 hours of annual in-service training, and another did not receive any dementia management education. Facility leadership confirmed these training deficiencies.
A resident with chronic health conditions suffered skin tears and bruising due to rough treatment by a CNA during toileting assistance. The CNA was verbally aggressive and physically rough, leading to the resident feeling scared and shaken. The incident was witnessed by another CNA, who intervened and reported the mistreatment. The resident was later hospitalized due to a decline in condition.
The facility did not forward information about 32 of 37 residents transferred to the hospital to the State LTC Ombudsman over eight months. The Director of Social Services was aware of this oversight.
The facility did not complete a required annual performance review for a nurse aide, Employee 6, whose last appraisal was in December 2022. Despite the policy of annual evaluations, the facility could not find a more recent review for this employee, as confirmed by the DON and Nursing Home Administrator.
The facility did not ensure residents could view the most recent survey results. The survey book in the lobby contained outdated information from November 2023, while the latest survey was from February 2024. The Nursing Home Administrator confirmed the oversight during an interview.
The facility failed to conduct necessary pre-employment checks, including background checks, nurse aide registry verification, and reference checks, for two employees. Employee 4 began working before a background check was completed, and there was no evidence of registry verification until months later. Employee 5 was hired without reference checks. These actions violated the facility's policies and state regulations.
A resident with hypertension and Diabetes Mellitus Type II reported that a Nurse Aide was rude and refused to assist her in transferring to a wheelchair. The facility failed to conduct a thorough investigation as per their policy, lacking witness statements and timely interviews. The Assistant Director of Nursing and Nursing Home Administrator acknowledged the concern but did not provide sufficient investigative information.
The facility failed to provide required in-service training for nurse aides, specifically in dementia management and resident abuse prevention. A review of training records for a nurse aide, Employee 7, showed no documentation of such training. The Nursing Home Administrator confirmed the absence of these records during an interview.
Failure to Treat Hypoglycemia and Document Interventions
Penalty
Summary
The facility failed to provide care and services for a resident with Type 2 diabetes mellitus and CHF in accordance with the resident’s blood glucose monitoring and PRN hypoglycemia orders. The resident’s MAR showed blood glucose checks ordered for 6:00 AM and 9:00 PM, along with PRN glucose gel for blood glucose less than 60 if alert enough to swallow and PRN glucagon for blood glucose less than 60 if not alert enough to swallow. On May 9, 2026 at 9:00 PM, the resident’s blood glucose was documented as 57, but neither glucose gel nor glucagon was given, and there was no nursing progress note, assessment, provider notification, or follow-up blood glucose check. On May 10, 2026 at 6:00 AM, the resident’s blood glucose was documented as 44, and again there was no documented intervention, assessment, provider notification, or repeat blood glucose check. Later that morning, a nurse entered the resident’s room and found her appearing to be sleeping; blood glucose was checked and found to be 47. PRN glucagon was administered, the RN supervisor was notified, and when staff attempted to reposition the resident she became unresponsive and had projectile vomiting. The note stated the glucagon was not effective, the blood glucose was rechecked at 37, a second dose of glucagon was given, and 911 was called. The DON stated the facility did not have policies on insulin administration, blood glucose monitoring, or hypoglycemia, and confirmed there was no documentation of actions taken for the blood glucose readings of 57 and 44. The resident was transferred to the hospital after becoming unresponsive.
Incomplete Pressure Ulcer Assessment and Treatment Documentation
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care for one resident with Type 2 diabetes mellitus and CHF. The resident reported buttock pain and was noted to have a suspected stage 2 pressure injury, after which zinc oxide paste was applied. The nursing note documented that the resident had a foam dressing on the buttock prior to the pressure injury being found, and the facility form titled Skin Inspection Daily on admission x 72 hours identified a stage 2 pressure ulcer to the sacrum with zinc oxide applied. The clinical record showed that the skin inspection forms for April 23 and April 28 documented a stage 2 pressure ulcer, but neither form included measurements, a description of wound characteristics, progress toward healing, identification of potential complications, mention of infection, or, on the later form, a pain assessment. The TAR ordered zinc oxide paste to be applied to the buttocks every shift for a stage 2 pressure injury, and the MDS coded the resident as having one stage 2 pressure ulcer not present on admission. The DON stated the facility did not have a pressure ulcer policy and said the zinc was being applied preventatively, but no additional information was provided when questioned about the lack of wound assessment details.
Incomplete Clinical Record for Left Elbow Skin Tear
Penalty
Summary
The facility failed to maintain complete clinical records for one resident with diagnoses including Type 2 Diabetes Mellitus and congestive heart failure. The resident had a left elbow skin tear, and the treatment order received on April 24, 2026 directed staff to cleanse the area with normal saline and apply bordered gauze every day shift. The clinical record did not include any documentation describing how the resident obtained the skin tear, and the record also did not show when the Steri-Strips were placed or by whom. The TAR for May 2026 showed the left elbow treatment was signed off as 5, meaning hold/see nurses note, on May 3, 5, 6, 7, 8, and 9, 2026, and there was no documentation that the treatment was completed on May 4. The corresponding eTAR progress notes for those dates documented that Steri-Strips were in place, but the record contained no documentation identifying when they were applied or by whom. On May 21, 2026, the facility provided a statement from the NP stating that the NP had placed the Steri-Strips and that the resident said she bumped her elbow against the side table, but this information was not documented in the resident’s clinical record. During an interview on May 22, 2026, the DON provided no additional information.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
Failure to Verify Background Checks and Nursing Licensure
Penalty
Summary
The facility failed to implement its written policies and procedures designed to prohibit and prevent abuse, neglect, and exploitation of residents, as well as misappropriation of resident property, by not determining residency status to perform accurate criminal history background checks prior to hiring. Personnel file reviews for five employees showed that while Pennsylvania State Criminal Background checks were completed, there was no documentation verifying the employees' state residency status to determine if additional or different background checks were required. Staff interviews confirmed that the facility relied on applicants to enter their own address history into a hiring database, but no one at the facility reviewed this information to ensure the correct type of background check was performed. The Human Resources Director stated that only state background checks were completed for all new hires, regardless of residency history. Additionally, the facility failed to validate and verify the licensure status for one nurse. The personnel file for this nurse included a copy of a Florida compact nursing license, but there was no documentation that the license was verified as active and in good standing, nor that it was free from allegations of abuse, neglect, exploitation, or misappropriation of resident property. The Human Resources Director indicated that licensure verification was generally handled by a corporate recruiter, but could not provide documentation that this process was completed for the nurse in question. The Executive Director and Director of Nursing confirmed that no further information was available for the employees involved.
Failure to Store and Serve Food in Accordance with Professional Standards
Penalty
Summary
The facility failed to store and serve food and beverages in accordance with professional standards for food safety in multiple areas, including the kitchen, a nourishment center, and the creamery. Observations revealed several food items in the walk-in freezer, refrigerator, and dry storage that were open, not securely closed, and lacked date markings. Items such as muffins, marble cake, cheeses, ziti, raisins, granola, cookies, and onions were found either uncovered, not dated, or not properly labeled. Additionally, individually wrapped sugar cookies and a vanilla shake in the nourishment center refrigerator were not dated, and a Styrofoam container of buffalo wings and celery lacked both a resident identifier and a date. Facility policy requires all food items to be labeled with content and date, and for foods to be monitored for use-by dates, but these procedures were not followed as confirmed by staff interviews. In the creamery, a damp towel with brown liquid marks was found under the sink, and the drip shield inside the ice machine contained a black moist substance that could be wiped away, indicating inadequate cleaning. The ice machine's preventive maintenance was overdue, with no documentation of recent service, despite facility policy and manufacturer guidelines requiring bi-annual cleaning. Staff confirmed that the ice machine needed cleaning and that food items should be date marked and labeled. The towel and soiled drip shield remained unaddressed upon re-observation, further demonstrating non-compliance with food safety and sanitation standards.
Failure of Governing Body to Oversee QAPI Program
Penalty
Summary
The facility failed to ensure that its governing body was responsible and accountable for the Quality Assurance Performance Improvement (QAPI) program. Documentation review showed that the QAPI Plan assigned ultimate oversight of the QAPI committee to the governing body, with the owner/president having direct oversight and the QAPI committee, including the medical director, responsible for compliance and quality improvement. However, attendance records for QAPI meetings from January through June 2025 revealed that neither the Medical Director (MD) nor the Nursing Home Administrator (NHA) attended any of the monthly meetings during this period. A memorandum indicated that the designated NHA had appointed another employee (Employee 3) as the full-time, on-site administrator, while the NHA remained engaged with facility operations and communicated regularly with Employee 3. Despite this arrangement, Employee 3 confirmed that the NHA and MD did not attend QAPI meetings and that he did not consistently share QAPI meeting minutes or updates with the NHA. No written documentation was provided to show communication between Employee 3 and the NHA or governing body regarding QAPI matters or ensuring MD attendance at QAPI meetings.
Required QAPI Committee Members Absent from Meetings
Penalty
Summary
The facility failed to ensure that the required members of the Quality Assurance Performance Improvement (QAPI) Committee, specifically the Medical Director and the Nursing Home Administrator (NHA), attended at least one meeting in two out of three quarters reviewed. Attendance sign-in sheets for the QAPI meetings from January through June 2025 did not show participation by either the Medical Director or the NHA. Instead, the Executive Director (Employee 3) signed in as the NHA, but later confirmed during a staff interview that he is not the NHA and that neither the NHA nor the Medical Director had attended the QAPI meetings. Employee 3 also stated that while he communicates with the NHA regularly by phone, he does not necessarily send QAPI meeting minutes for review.
Failure to Complete Timely Comprehensive Assessment After Significant Change
Penalty
Summary
The facility failed to complete a comprehensive assessment following a significant change in condition for one resident. The resident, who had diagnoses including cerebrovascular disease, atrial fibrillation, and hypertension, was admitted to hospice services. Review of the clinical record showed that the Minimum Data Set (MDS) assessment, which is required to evaluate all care areas after a significant change, was not completed in a timely manner. At the time of review, the MDS assessment was still in progress with several sections incomplete, and staff interviews confirmed that the significant change MDS had not been submitted as required.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the established care plan or documented resident wishes. Specific details regarding the nature of the care or the resident's medical history and condition at the time of the deficiency are not provided in the report.
Improper Medication Storage and Labeling on Medication Cart
Penalty
Summary
Surveyors observed that the facility failed to store drugs and biologicals in accordance with accepted professional standards on the 300/400 hall medication cart. Specifically, an insulin pen that had been opened and previously used for a resident was found without an open date written on the pen, contrary to facility policy which requires insulin products to be labeled with the date when first used. Additionally, the medication cart contained a manufacturer's box of single-use polyvinyl alcohol 1.4% eye drop applicators, but the lot number on the box did not match the lot numbers printed on the individual applicators inside. These findings were confirmed in the presence of the DON, who acknowledged that insulin pens should be labeled with the date of opening and that medications should remain in their original manufacturer's containers with matching lot numbers. The observations were made during a review of the medication cart and through staff interviews, indicating non-compliance with both facility policy and professional standards for medication storage and labeling.
Failure to Provide Physician-Ordered Therapeutic Diets to Diabetic Residents
Penalty
Summary
The facility failed to ensure that five residents with diabetes mellitus received their prescribed therapeutic diets as ordered by their physicians. Clinical record reviews showed that these residents had physician orders for a no concentrated sweets diet, yet during meal service, they were served pudding instead of the required fruit cup for dessert. This discrepancy was observed during tray line service, and it was confirmed by the Food Service Director that the correct substitution should have been made. One resident expressed concern that the meals were carbohydrate heavy, which was consistent with the observed failure to follow the prescribed diet orders.
Deficient Nurse Aide Training and Missing Dementia Education
Penalty
Summary
The facility failed to ensure that nurse aides received the required annual in-service training, as evidenced by a review of personnel training records and staff interviews. Specifically, one nurse aide had only completed 9.5 hours of annual training, falling short of the mandated 12 hours, and another nurse aide had not completed any training in dementia management. These deficiencies were confirmed by the Human Resources Director and the DON during staff interviews, who acknowledged the lack of compliance with training requirements for nurse aides. The findings were based on a review of employee records and direct confirmation from facility leadership.
Resident Harmed Due to Rough Treatment by CNA
Penalty
Summary
The facility failed to ensure that residents were free from abuse, resulting in actual harm to a resident. The incident involved a Certified Nurse Aide (CNA), identified as Employee 1, who was responsible for providing care to a resident with chronic congestive heart failure and B-cell lymphoma. The resident required assistance with toileting and had a potential for bleeding complications due to anticoagulant use. During care, Employee 1 was reported to have been verbally aggressive and physically rough, leading to skin tears and bruising on the resident's left hand, forearm, and shin. The incident was witnessed by another CNA, Employee 2, who intervened and reported the mistreatment to the Licensed Practical Nurse (LPN) and Registered Nurse (RN) supervisor. Employee 2 described Employee 1's behavior as inappropriate and aggressive, noting that the resident was very weak and had difficulty standing. The resident expressed feeling scared and shaken after the incident, and the skin tears were observed to be bleeding and of significant size. The RN supervisor and Assistant Director of Nursing (ADON) were informed of the incident, and the resident was assessed to have additional bruising and was later hospitalized due to a decline in condition. The resident's roommate corroborated the account of rough treatment, describing Employee 1 as rude and impatient. Despite having received abuse prevention training, Employee 1's actions resulted in physical and emotional harm to the resident.
Plan Of Correction
1. The facility implemented quick and decisive action in accordance to our abuse policy upon abuse allegations from Resident 1 regarding Employee 1. Employee 1 was immediately suspended, and RN performed a skin check on Resident 1, the provider was notified, and statements were obtained. Within 24 hours the Department of Health was notified, the police department was notified and intent to press charges occurred; the Cumberland County Office of Aging was notified as well as the Pennsylvania Department of Aging. Resident 1 was immediately tended to by staff regarding his skin tears and first aide was administered appropriately. 2. The facility will continue to perform weekly skin checks on remaining residents, observe the grievance policy, and conduct routine care plan meetings in order to determine any other residents who may be at risk for similar issues. We did interview other residents on Employee 1 assignment and no other residents had complaints. 3. The facility provides annual mandatory abuse training to all staff with the most recent training having been completed in October of 2024. The facility conducted immediate retraining of all staff upon receiving the complaint of abuse and will increase the abuse training from annual to quarterly x 12 months to ensure all staff receive the appropriate training and understand such training. 4. The facility will continue to follow the abuse policy, will continue to perform background checks prior to hire, will continue to perform reference checks prior to hire, will continue to perform annual performance evaluations for all staff, will continue to monitor grievances submitted by residents and family for the potential for abuse, will continue to perform weekly skin checks of all residents, and will continue with routine care plan meetings with residents and family to ensure any indication of potential abuse is investigated and handled appropriately. The Director of Nursing or designee will review all grievances submitted to ensure appropriate investigation and follow up continue. The audits will include 5 random grievances weekly x 4 weeks then 5 random grievances monthly x 2 months. Findings will be discussed at QAPI. 5. Date of Compliance: 2/10/25.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure that information regarding residents transferred to the hospital was forwarded to a representative of the Office of the State Long-Term Care Ombudsman. This deficiency affected 32 out of 37 residents transferred over a period of eight months, from January 2024 to August 2024. The issue was identified during a review of the facility's hospital transfer information, which revealed that the required notifications were not sent. An interview with the Director of Social Services confirmed awareness of the oversight, acknowledging that the information had not been forwarded as required.
Failure to Conduct Annual Performance Review for Nurse Aide
Penalty
Summary
The facility failed to complete a performance review for one of its nurse aides, identified as Employee 6, within the required 12-month period. Employee 6 was hired on August 10, 2021, and their most recent performance appraisal was dated December 28, 2022. During an interview with the Director of Nursing on September 18, 2024, it was confirmed that employees are supposed to be evaluated annually. However, the Nursing Home Administrator confirmed on September 19, 2024, that the facility could not locate a more recent performance evaluation for Employee 6 after the December 2022 appraisal. This deficiency is a violation of the facility's personnel policies and procedures as outlined in 28 Pa. Code 101.19 (2).
Failure to Provide Access to Recent Survey Results
Penalty
Summary
The facility failed to ensure that residents had the right to examine the results of the most recent survey conducted by Federal or State surveyors. An observation of the facility's designated survey results book revealed that it contained survey information dated November 2023, while the most recent survey was conducted on February 16, 2024. This discrepancy was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the survey book did not contain the most recent survey for resident review. This failure was identified in the facility lobby area, where the survey results book was located.
Failure to Conduct Pre-Employment Checks
Penalty
Summary
The facility failed to implement its policies and procedures designed to prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. Specifically, the facility did not conduct necessary background checks, verify the nurse aide registry, or perform reference checks prior to hiring certain employees. Employee 4, a nurse aide, was hired and began working before a Pennsylvania State Police background check was completed, which was only conducted after the employee had started working. Additionally, there was no evidence that the nurse aide registry was verified until several months after the hire date, and no reference checks were completed or attempted for Employee 4. Similarly, Employee 5 was hired without any reference checks being completed or attempted. Interviews with the Human Resources Coordinator and the Nursing Home Administrator confirmed these oversights, acknowledging that the required checks were either not performed or not documented as per the facility's policy. These lapses in following established procedures were in violation of the facility's own policies and applicable state regulations, as outlined in the facility's policy titled 'Abuse, Neglect and Exploitation' dated November 1, 2017.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident, identified as Resident 153, who reported an incident to the Director of Social Services. The resident, who has a medical history of hypertension and Diabetes Mellitus Type II, alleged that a Nurse Aide, referred to as Employee 8, was rude and refused to assist her in transferring from her bed to a wheelchair to use the bathroom. The grievance log indicated that the resident reported this incident, and Employee 8 received a verbal warning for substandard work and rudeness, as documented in an Employee Warning Notice. Despite the allegation, the facility did not conduct a comprehensive investigation as required by their policy on Abuse, Neglect, and Exploitation. The Assistant Director of Nursing admitted that there were no witness statements or documentation from the alleged perpetrator, Employee 8, and the resident was only interviewed a week after the incident. The facility did not consider the allegation as abuse or neglect and lacked additional investigative information to make a final determination. The Nursing Home Administrator acknowledged the concern but did not provide further details on the investigation process.
Deficiency in Nurse Aide Training for Dementia and Abuse Prevention
Penalty
Summary
The facility failed to ensure that the required in-service training for nurse aides included dementia management training and resident abuse prevention training. This deficiency was identified during a review of the facility's annual training documentation for one of the nurse aides, referred to as Employee 7. The documentation revealed that there was no record of training related to resident abuse or dementia care for this employee. During an interview with the Nursing Home Administrator, it was confirmed that the required training documentation for Employee 7 could not be located at the time of the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mechanicsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fox Subacute At Mechanicsburg | 0.4 mi | ★★★★★ | 7 | 0 |
| Bethany Village Retirement Center | 1.6 mi | ★★★★★ | 7 | 0 |
| Messiah Lifeways At Messiah Village | 2.4 mi | ★★★★★ | 4 | 0 |
| Camp Hill Skilled Nursing And Rehabilitation Ctr | 4.9 mi | ★★★★★ | 15 | 0 |
| Gardens At West Shore, The | 4.9 mi | ★★★★★ | 5 | 1 |
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