Health inspection·September 19, 2024

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Minimal harm or potential for actual harm Based 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). Residents Affected - Few 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 Page 1 of 8 396133 396133 09/19/2024 Vibra Rehabilitation Center 707 Sheperdstown Rd Mechanicsburg, PA 17055

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based 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). Residents Affected - Few Findings Include: Review of facility policy, titled Abuse, Neglect and Exploitation, dated November 1, 2017, revealed Background, reference and credentials' checks should be conducted on employees prior to or at the time of employment by the Facility in accordance with applicable state and federal regulations. Review of Employee 4's (Nurse Aide) personnel file revealed a hire date of June 18, 2024. In an email correspondence with the Director of Nursing (DON) on September 18, 2024, at 10:16 AM, she stated that Employee 4's first day working in the facility was on July 3, 2024. Further review of Employee 4's personnel file revealed a Pennsylvania State Police background check wasn't conducted until July 22, 2024, there was no evidence that the nurse aide registry was verified until September 17, 2024, and there was no evidence that any reference checks were completed or attempted. Review of Employee 5's personnel file revealed a hire date of July 30, 2024. Further review of Employee 5's personnel file revealed no evidence that any reference checks were completed or attempted. During an interview with Employee 2 (Human Resources Coordinator) on September 17, 2024, at 11:52 AM, she stated that she verified the nurse aide registry for Employee 4 prior to September 17, 2024, but didn't print out the form at that time to verify the date that it was done. In a follow-up interview with Employee 2 on September 18, 2024, at 11:42 AM, she confirmed that Employees 4 and 5 did not have reference checks attempted or completed prior to their employment with the facility. During an interview with the Nursing Home Administrator (NHA) on September 19, 2024, at 11:49 AM, he confirmed that Employee 4's background check wasn't completed until after she started working at the facility and stated that the nurse aide registry was checked prior to hire, but confirmed there is no evidence of that. During this time, the NHA also confirmed that reference checks were not done for Employees 4 or 5. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 396133 Page 2 of 8 396133 09/19/2024 Vibra Rehabilitation Center 707 Sheperdstown Rd Mechanicsburg, PA 17055

F 0607 28 Pa. Code 201.19(3) Personnel policies and procedures Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 396133 Page 3 of 8 396133 09/19/2024 Vibra Rehabilitation Center 707 Sheperdstown Rd Mechanicsburg, PA 17055

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based 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). Residents Affected - Few 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. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement. 4. Document the entire investigation chronologically. A review of Resident 153's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and Diabetes Mellitus Type II (A long-term condition in which the body has trouble controlling blood sugar and using it for energy). A review of the facility's grievance log, revealed Resident 153 reported to the Director of Social Services (Employee 3) on September 12, 2024, that the Nurse Aide, Employee 8 is rude and did not want to help her [Resident 153] transfer from bed to w/c [wheelchair] so she [Resident 153] could use the bathroom. A review of the facility's form titled Employee Warning Notice, dated September 17, 2024, revealed Employee 8 was given a verbal warning. The notice described the type of offense as substandard work and rude to customers/coworkers. The warning notice continued under the description of violation Resident complaint- you [Employee 8] refused to put her shoes on prior to transfer, she almost fell-then you refused to help her up in bed and made her use the headboard to pull herself up. An interview with the Assistant Director of Nursing (Employee 1) on September 19, 2024, at 12:25 PM, revealed the facility had no witness statements or documentation by the alleged perpetrator, Employee 8, and interviewed Resident 153 on September 19, 2024, at 12:04 PM, regarding any concerns of safety or additional concerns regarding the incident and allegation made on September 12, 2024. The interview also revealed the facility did not believe the allegation to be abuse or neglect, however, admitted to having no additional investigative information for the final determination. A final interview with the Nursing Home Administrator on September 19, 2024, at approximately 12:30 PM, revealed an acknowledgement of the concern. 396133 Page 4 of 8 396133 09/19/2024 Vibra Rehabilitation Center 707 Sheperdstown Rd Mechanicsburg, PA 17055

F 0610 28 Pa. Code 201.18 (b) (1) Management Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services Residents Affected - Few 396133 Page 5 of 8 396133 09/19/2024 Vibra Rehabilitation Center 707 Sheperdstown Rd Mechanicsburg, PA 17055

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based 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 396133 Page 6 of 8 396133 09/19/2024 Vibra Rehabilitation Center 707 Sheperdstown Rd Mechanicsburg, PA 17055

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based 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). Residents Affected - Some 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. An interview with the Nursing Home Administrator on September 19, 2024, at 11:17 AM, confirmed the facility could not locate a more recent performance evaluation for Employee 6 after December 28, 2022. 28 Pa. Code 101.19 (2) Personnel policies and procedures 396133 Page 7 of 8 396133 09/19/2024 Vibra Rehabilitation Center 707 Sheperdstown Rd Mechanicsburg, PA 17055

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based 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 396133 Page 8 of 8