Pennsylvania Department of Health
CLIVEDEN NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CLIVEDEN NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 213 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


CLIVEDEN NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on an Abbreviated Survey in response to one complaint completed on March 6, 2026, it was determined that Cliveden Nursing and Rehabilitation Center was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

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) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations: Based 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 2residents reviewed (Resident R1). Findings include: Review of the March 2026 physician orders included the following diagnosis: seizures; anxiety (intense, excessive and persistent worry and fear about everyday situations);chronic obstructive pulmonary disease (COPD-a term used to describe a group of lung diseases that cause airflow blockage and breathing-related problems), and multiple sclerosis (a neurological illness that affects the brain and spinal cord). During an observation in the resident's room on March 6, 2026 at 11:00 a.m. the resident was observed lying in her bed with an abundance of items surrounding her entire room overcrowding both her and her roommate's drawers side by side each other on the left side of the resident's side of the room. The piles on both drawers were reportedly those of Resident R1 despite the items being on both drawers pilled up, leaving her roommate (Resident R2) with no room on top of her drawer. Items of Resident R1 were also observed on the floor area surrounding Resident R1's bedroom area on the heating unit, bedside table, a chair and a bedside dresser on the right side of the resident's bed, all with a number of items piled on top of each other in the room that she shares with another female resident. The items consisted of, but were not limited to stuffed animals, papers and pocketbooks. Piles of items in the resident's room were so compacted, and items that items in-between the piles could not be made out without lifting the piles of items up. During an interview with Resident R1 on March 6, 2026, at 11:00 a.m. Resident R1 reported during this survey that her room was "junky" because she has had items that have gone missing since she has been at the facility in 2021. During a visit on March 6, 2026, at 1:00 p.m. to Resident R1's room on March 6, 2026 1:00 p.m. with the Director of Nursing (DON) that she shares with her roommate, the condition of Resident R1's side of the room was discussed and observed. During a discussion with the DON on March 6, 2026, at 1:35p.m DON discussed that the resident did have hoarding behaviors. Concerns regarding Resident R2 having to be resident in a room with a description such as the above were also discussed during the above discussion. Review of the resident's current person-centered plan of care plan documents that the resident has hoarding behaviors "[name of resident] has a behavior problem of hoarding, and that the goal was for the resident to have no evidence of behavior problem hoarding by the next care plan review date but there were no interventions on the care plan outlined as to how this goal would be achieved in order for the resident to address this care area and assist the resident with the care and services that she may need (e.g behavioral health treatment; assistance with a storage area; prioritizing; assisting resident with going through the items in her room and determine which items should be thrown out, put in storage, etc, involvement of family, friends as support). During an interview with the Director of Nursing on March 6, 2026 at 12:36 p.m. the resident's plan of care for hoarding behaviors having no interventions was reviewed and discussed with the DON. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c(1) )Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Plan of Correction - To be completed: 05/04/2026

R1's care plan has been updated to reflect individualized interventions to address hoarding behaviors.

Director of Nursing or Designee will conduct Inservice training to Unit Managers regarding the importance of updating care plans so that they are detailed and individualized.

Director of Nursing or Designee will assess all current residents to determine if there are any other residents with hoarding behaviors. All noted will be appropriately planned.

Director of Nursing or Designee will conduct care plan audits audits weekly x 4 weeks then at least quarterly thereafter to ensure that the facility remains in compliance and that all residents are appropriately care planned.

Results will be reported on monthly QAPI

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations: Based 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). Findings include: Review of the facility policy, "Activities of Daily Living (ADL's) with a review date of December 2024 indicated that it was the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring that all staff, across all shifts and departments, understands the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided a are person-centered, an honor and support each resident's preferences, choices, values and beliefs. Review of Resident R2's March 2026 physician orders included the diagnoses of seizure disorder; anxiety (intense, excessive and persistent worry and fear about everyday situations); chronic obstructive pulmonary disease (COPD-a term used to describe a group of lung diseases that cause airflow blockage and breathing-related problems), and multiple sclerosis (a neurological illness that affects the brain and spinal cord). Review of the resident's significant change Minimum Data Set Assessment (MDS- periodic assessment of a resident's needs) dated January 21, 2026 documented the resident as awake, alert and oriented. During an interview with Resident R2 on March 6, 2026 at 11:00 a.m. the resident reported that she had not had a shower since May 5, 2025 due to being told that the facility no longer had a bariatric shower bed with a size that was able to accommodate her. The resident reported that she prefers to take a shower on her scheduled shower days, which are on Wednesdays and Saturdays between the hours of 3:00 p.m. through 11:00 p.m. Review of the resident's bathing record from February 5, 2026-March 6, 2026 included documentation that the resident had not had a shower at any time during the specified time period, and was only given bed baths on the days that her showers were scheduled. Review of Resident R2's person-centered plan of care included a plan of care for the resident's adl's (activites of daily living) "[resident name] has an ADL self-care performance deficit," with the goal of the resident approving/maintaining her current level of function in adl's. The interventions related to this care area included that the resident prefers showers on Wednesday and Saturday. evening, and that she requires the assistance of 1 person with bathing and showering. During a discussion with the Director of Nursing (DON) on March 6, 2026, at 1:35p.m it was discussed with the DON that the resident's bathing record documented by the resident's assigned nurse aide on the assigned shower days, did not show evidence that the resident was provided with a shower on those designated days. 28 Pa.Code 201.29(j) Resident rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Plan of Correction - To be completed: 05/04/2026

2 has been showered, and her shower days are Wednesday and Saturday.

Director of Nursing or Designee will conduct Inservice training to nursing staff clarifying that bed baths do not replace showers or tub baths., and that all residents have a right to have a shower as scheduled.

Director of Nursing or Designee will conduct shower audits for all current residents to ensure that residents are receiving their showers as scheduled.

Director of Nursing or Designee will conduct shower audits weekly x 4 weeks to ensure compliance is maintained.

Results will be reported in monthly QAPI

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