Cliveden Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interviews with staff and review of facility policy it was determined that the facility failed to ensure that food items were stored prepared and served according to professional standards.

Inspectors wroteBased on interviews and the review of clinical records, it was determined that the facility failed to ensure that a person-centered plan of care was developed for a resident who the facility documented as hoarding items in her room for 1 out of 2 residents reviewed (Resident R1).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that a resident received showers as scheduled for one of two residents reviewed (Resident R2).

Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility failed to ensure that residents were free from misappropriation of personal property when narcotic medications were stolen/diverted for two of two clinical records reviewed. (Resident R1 and Resident R2).

Inspectors wroteBased on facility policy, interviews, and record reviews, the facility failed to conduct a thorough investigation into an allegation of drug misappropriation and to protect residents from misappropriation of controlled substances for two of two residents reviewed. (Residents R1 and R2)

Inspectors wroteBased on a review of medical records and staff interviews it was determined that the facility failed to develop and implement care plans for two of eight residents reviewed regarding intravenous (IV) and ostomy care. (Resident R7 and R8.)

Inspectors wroteBased on review of facility documentation and staff interview, it was determined that the facility failed to ensure that licensed nursing staff had the proper competencies including intravenous (IV) care and ostomy care for four of four licensed nurse training records reviewed (Employees E4, E5, E6 & E7).

Inspectors wroteBased on observations, and staff and resident interviews. it was determined that the facility failed to maintain a comfortable environment for one of three nursing units observed (3rd floor lounge). Findings Include: A tour of the facility was conducted on June 26, 2025, at approximately 10:30 a.m. with Maintenance Director, Employee E3, to monitor the temperatures of the building and resident care areas. Temperatures taken by Maintenance Director, Employee E3, on June 26, 2025, at 11:15 a.m. in the 3rd floor multipurpose room revealed temperatures reached up to 84 degrees. Temperature of the room felt hot, humid, and uncomfortable. Observations on June 26, 2025, at 11:15 a.m. in the 3rd floor multipurpose room revealed about 20 residents were gathered in the room and were being supervised by nurse aide, Employee E4. [...]

Inspectors wroteBased on review of facility policy, facility documentation, review of clinical records, and staff interviews, it was determined that the facility failed to conduct a complete and thorough investigation related to abuse/neglect and misappropriation of resident property for three of four residents reviewed (Resident R303, R90 and R108.). Findings Include: Review of facility policy Abuse, reviewed December 2024, revealed misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. It is the policy of the facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. [...]

Inspectors wroteBased on review of facility policy, facility documentation, and staff interviews it was determined that the facility failed to implement appropriate tracking and surveillance of infection for five of five months of infection surveillance data reviewed. (January 2025 through May 2025) Findings Include: Review of facility policy Surveillance, June 2025, revealed The ongoing, systematic collection, analysis, and interpreta1ion of health data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know. The Infection Preventionist will monitor new infections and antibiotic. The Infection Preventionist is encouraged to map out the HAI onto a facility map monthly to rule out concerns/ patterns with care givers. The surveillance sheet will capture the following information : [...]

Inspectors wroteBased on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system that includes antibiotic use protocols and a system to effectively monitor antibiotic usage for 10 of 10 months of antibiotic stewardship program data reviewed. (January 2025, February 2025, March 2025, April 2025, and May 2025). Findings Include: A review of CDC (Centers for Disease Control and Prevention) guidelines, The core element of Antibiotic Stewardship for Nursing Homes, revealed that Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. 1. [...]

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to offer and/or provide the influenza and pneumococcal immunization for three of five residents reviewed (Resident R117, R295, R32, R62, and R95).

Inspectors wroteBased staff interviews, review of facility policy and the review of the clinical record, it was determined that the facility failed to ensure that a resident received proper notification for a room change, and failed to ensure that the resident had the opportunity to refuse a room change for 1 out of 29 residents reviewed (Resident R11).

Inspectors wroteBased on observations, resident and staff interviews, it was determined that facility failed maintain a safe, clean comfortable and home like environment for residents of one of three nursing units. (Third floor) Findings Include: Observation of Third floor nursing unit on June 10, 2025, at 9:45 AM revealed there was a strong odor of urine throughout the South unit hallway. Observation of Third floor nursing unit on June 10, 2025, at 9:52 AM revealed there was a strong odor of urine throughout the [NAME] unit hallway. Interview with the Licensed Practical Nurse, Employee E23, on June 9, 2025, at 9:52 AM confirmed that there was strong odor of urine on both hallways. Employee E3 stated it could be from staff changing the residents. A follow up tour of the south hallway on June 10, 2025, at 10:00 AM revealed that there were no residents receiving incontinence care. [...]

Inspectors wroteBased on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital for 3 of 29 residents reviewed (Residents R83, R137 and R118). Findings Include: Clinical record review for Resident R83 revealed progress notes, dated October 15, 2024, at 11:18 a.m. and 1:06 p.m. which indicated that the resident had increased abdominal girth and no bowel movement in 72 hours (three days) and was ordered by the physician to be transferred to a local hospital for evaluation. Clinical record review for Resident R137 revealed a progress note, dated May 1, 2025, ay 11:12 p.m. which indicated that the resident had abnormal labs and was ordered by the physician to be transferred to a local hospital for evaluation. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to follow up dental consults related to recommendations for dentures, for 1 out of 29 residents reviewed (Resident R97).

Inspectors wroteBased on clinical record reviews and interviews with residents and staff, it was determined that the facility failed to assist a resident to obtain an audiologist consult for hearing aides, for one of 29 residents reviewed (Resident R117).

Inspectors wroteBased on interviews with residents, review of facility policy and review of clinical records, it was determined that the facility failed to ensure that a device to prevent contractures was applied as order by the physician for one out of 29 residents reviewed (Resident R97)

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff and resident interviews, it was determined that the facility failed to provide necessary respiratory care consistent with professional standards of practice for one of three residents reviewed for tracheostomy (Resident R127). Findings Include: Review of facility policy Tracheostomy Care revised October 4, 2024, revealed it is the policy of the facility to establish standards for the care and maintenance of tracheostomy tubes. Per the policy, trach care sohuld be performed daily and as needed for dressing soilage. This includes removal of drain/dressing sponge and cleasing around stoma site and trach plate. [...]

Inspectors wroteBased on review of facility documentation, review of personnel files and interviews with staff, it was determined that the facility failed to assure that nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs for three of five personnel files of newly hired staff reviewed (Employees E8, E9 and E10).

Inspectors wroteBased on a review of facility documentation and interviews with staff, it was determined that the facility failed to complete performance reviews for three of three nurse aides personnel files reviewed related to performance reviews as required (Employees E11, E12 and E13).

Inspectors wroteBased on observation, staff interviews and review of manufacturers' guidelines, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards of practice for two of four medication carts observed. (Third floor east and south medication carts). Findings Include: Review of manufacturer's guidelines for Humalog Insulin (insulin lispro) (medication used to treat high blood sugar levels) revealed that Humalog must be discarded 28 days after opening. Review of manufacturer's guidelines for Lantus Insulin(insulin glargine) revealed that the medication must be discarded 28 days after opening. Review of manufacturer's guidelines for Novolin Insulin revealed that the medication must be discarded 28 days after opening. [...]

Inspectors wroteBased on clinical records and staff interview. it was determined that the facility failed to ensure that a resident with out dentures was assess for speech rehabilitation services for 1 out of 29 residents reviewed (Resident R97).

Inspectors wroteBased on review of facility documentation and interviews with staff, it was determined that the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies, as required.

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to ensure assessments accurately reflected the resident's status for four of 29 residents reviewed (Resident R127, R133, R128, and R142). Findings Include: Review of the Centers for Medicare and Medicaid Services (CMS) Long Term Care RAI Manual dated October 2019 revealed the resident Minimum Data Set (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) included Section C: Cognitive Status which is used to determine the resident's attention, orientation, and ability to registry and recall information. Review of Resident R128's clinical record revealed a quarterly MDS dated [DATE]. Review of Resident R133's clinical record revealed an admission MDS dated [DATE]. Review of Section C: [...]

Inspectors wroteBased on observations, interview with residents and staff, and review of facility policy, it was determined that the facility did not ensure to provide safe, homelike environment for four out of five rooms observed (Room's 301, 302, 303, 304)

Inspectors wroteBased on observation's, interview with resident and staff, it was determined that the facility failed to ensure that a call device was accessible to one out of nine residents observed (Resident R6)

Inspectors wroteBased on observation and interviews with residents and facility staff, it was determined that the facility failed to provide care and services to enhance residents' dignity related to serving meals on disposable paperware, serving residents meals timely on one of three dining rooms (Third floor dining room) and no catheter dignity bag for one of 28 Residents reviewed (Resident R244).

Inspectors wroteBased on observations and interviews with residents and staff, it was determined that the facility failed to provide a drawer or cabinet in the resident's room that can be locked for storage of the resident valuable items for two of 35 residents reviewed.

Inspectors wroteBased on personnel records and interview with staff, it was determined that the facility did not provide requested evidence of competency trainings for licensed nursing staff for four of four employees records review. (Employees E9, E18, E20, and E21)

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility did not provide requested evidence of yearly performance reviews for nurse aides.

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that a resident was allowed to participate in decisions regarding medical appointment requests for one of twenty-eight residents reviewed. (Resident 135). Findings Include: Interview with Resident R135 on August 27, 2024 at 9:52 a.m. revealed the resident had concerns with seeing outside physicians which she had mentioned multiple times and no one ever followed through with giving her an answer or scheduling any appointments with her. Review of Resident R135's clinical record revealed on August 1, 2024 there was an Interdisciplinary Progress Note that stated, Care Conference scheduled on 8/1/24. IDT (Interdisciplinary Team) visited with resident by bedside. Resident had concerns for nursing and the in-house physician. [...]

Inspectors wroteBased on the tour of facility, observations and interviews with staff, it was determined the facility failed to ensure State Department of Health information was posted visible in a prominent place to residents in two out of three of the units. (Second Floor and Third Floor)

Inspectors wroteBased on observation, staff interview, review of clinical record, it was determined that the facility failed to maintain privacy related to personal privacy during tracheostomy care and sensitive patient health information during medication administration for three of 28 residents reviewed (Resident R9, Resident R121, and Resident R97).

Inspectors wroteBased on observations, review of facility policy, review of facility records, and interviews with residents and staff, it was determined that the facility failed to ensure that grievance forms were accessible for residents who wish to file a grivance anonymously and there was no grievance box availble on two of three nursing floors (First and Third floor). Findings Include: Review of facility policy titled, Grievance Program dated April 1, 2022 states, Purpose: To promote an environment and culture open to feedback positive and or negative from residents, family members, employees, physicians, and any other visitors. [...]

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility did not ensure that resident assessments accurately reflected resident status related to discharge for one of three closed records reviewed (Resident R141).

Inspectors wroteBased on review of facility policies, review of clinical records, and staff interviews, it was determined at the facility failed to develop a baseline care plan that includes the instructions needed to provide effective and person-centered care within 48 hours of admission for respiratory care, pressure ulcer, catheter, and pain for three of twenty-eight residents reviewed (Residennt R130, Resident R138 and Resident R444).

Inspectors wroteBased on review of facility policy, review of clinical records, and interviews with staff it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for three of twenty-eight residents reviewed. (Residents R31, R55, R97) Findings Include: Review of facility policy titled Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates dated April 1, 2022 states, Policy Statement- Facility will follow a uniform process for initiating the baseline care plan upon admission, The Comprehensive care plan upon CAA completion, and ensure care plans are updated to reflect the resident's status. Further review of the policy states, Ongoing updates to care plans- Nursing staff will update the care plan related to physician's orders and/or changes in care needs. [...]

Inspectors wroteBased on a review of clinical records, review of facility policy, and interviews with residents and staff, it was determined the facility failed obtain a physican order for tracheostomy care and suctioning for one resident and failed to notify the physician after one resident missed medication doses for two out of 28 residents reviewed. (Resident R 97 and Resident R138)

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and interviews with staff, it was determined that the facility failed to ensure that physician orders were followed regarding oxygen administration for two of two residents observed on oxygen. (Resident R4 and R31) Findings Include: Review of facility policy titled, Oxygen Administration with a policy date of December 4, 2023 state, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. Steps in the Procedure: Wash and dry your hands thoroughly. [...]

Inspectors wroteBased on review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to maintain ongoing communication between the facility and a dialysis provider for three of eight dialysis residents reviewed (Residents R44, R133 and R28).

Inspectors wroteBased on review of clinical records, it was determined that the facility failed to provide pharmaceutical services to assure the acquiring and administering of medications to meet the residents need of one resident for one of twenty-eight residents reviewed. (Resident R138)

Inspectors wroteBased on a review of clinical records and facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for three of 36 residents clinical records reviewed (Resident R18 and R35). Findings Include: Review of the Pharmacy Services: Drug Regimen Review Policy dated October 24, 2022, revealed, the pharmacist will report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports will be acted upon. Review of Resident R18's clinical record revealed that resident was admitted on [DATE], with diagnoses including anxiety. A review of Resident R18's pharmacy progress notes revealed the following note: August 6, 2024 - Medication Regimen Reviewed. Recommendations made. SeeMedication Regimen Review Report. [...]

Inspectors wroteBased on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employees E4).

Inspectors wroteBased on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature for three of eight residents interviewed (Residents R52, R236 and R6).

Inspectors wroteBased on a review of facility documents and resident clinical records and interviews with staff and residents, it was determined that the facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for three of nine residents reviewed (Resident R56).

Inspectors wroteBased on the review of facility observations and interviews with resident and staff, it was determined that the facility failed to ensure a safe, functional, sanitary environment on three of three nursing units observed. (1st , 2nd, 3rd floor nursing units)

Inspectors wroteBased on interviews with staff and residents, review of the facility tray audit form, and the completion of a lunch test tray, it was determined that the facility failed to provide food and drinks that were served at appetizing temperatures on one of three nursing units (2nd floor nursing unit).

Inspectors wroteBased on observations, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure dignity for residents related to the use of plastic utensils during the lunch time meal (Resident R1, R2, R3, R4, R5, R6), and for one resident who required assistance with feeding from nursing staff (Resident R6), for 6 out of 6 residents reviewed.

Inspectors wroteBased on observations, residents and staff interviews and review of clinical records, it was determined that the facility failed to ensure a clean, safe, comfortable homelike environment for 1 out of 3 nursing units (3rd floor nursing unit).

Inspectors wroteBased on observations, reviews of policies and procedures and interviews with residents and staff, it was determined that the facility failed to developed a plan of care for refusal of medication for one of seven residents with mood and behavioral needs. Resident R35)

Inspectors wroteBased on interviews with residents, review of facility policy and staff and review of clinical records, it was determined that the facility failed to ensure that one resident participated in the restorative care nursing program to maintain, improve, or prevent avoidable decline in range of motion and mobility for one out of 34 residents reviewed (Resident R44).

Inspectors wroteBased on observation, clinical record review and staff interview, it was determined that the facility failed to ensure that physician orders were followed related to the size of an indewelling urinary cathter for one of one residents reviewed with a urinary catheter.

Inspectors wroteA review of the skills training and competency records for the nursing staff, staff interview, review of facility policies and facility assessment, it was determined that appropriate competencies and skills sets were not provided for the nursing staff related to dementia management and behavioral health care.

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility did not ensure that the consultant pharmacist's recommendations were implemented in a timely manner for two of five records reviewed (Residents R30 and R46).

Inspectors wroteBased on review of clinical records, observations and resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 30 residents reviewed (R22, R91).

Inspectors wroteBased on observation, review of facility policy and procedures and interview with staff, it was determined that the facility failed to maintain proper infection control practices related to signage outside of a room for a residen with a transmission based precaution and during tracheostomy care for one of one resident with a tracheostomy. (Resident R109).

Inspectors wroteBased on observation and interviews with staff, it was determined that the facility failed to maintain a safe, sanitary, and comfortable environment for residents in one of three nursing units. (3rd floor)

Inspectors wroteBased on observation, interviews with resident and staff, it was determined that the facility failed to equip corridors with safe handrails, for one of one nursing unit. (3rd floor nursing unit).

Inspectors wroteBased on observation, review of facility policy and interviews with staff, it was determined that the facility did not ensure that hairnets were available and properly utilized in the kitchen during preparation of the luncheon meal.