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 195 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 two complaints, completed on January 31, 2025, 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:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based 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)

Findings include:

Review of facility's policy 'Resident Rights - Safe/Clean/Comfortable/Homelike Environment,' revised April 1, 2022, indicates that "the facility must provide a safe, clean, comfortable, and homelike environment...housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior."

Observations on January 31, 2025, at 1:00 pm, on third floor unit, in room#301, revealed a missing ceiling tile in resident's restroom, six leaking stains ceiling tiles, leaking stain down the wall in restroom.

Observation of room# 302 revealed leaking stains on ceiling tiles above resident's bed.

Observations of room# 304 revealed missing ceiling tile and three leaking stains on ceiling tiles.

Observations of room# 303 revealed leaking stains on two ceiling tiles.

Interview with Resident R5, in room# 304, bed A, revealed the missing ceiling tile between bed A and bed B, occurred "about a week ago," and no effort was observed to replace the missing tile.

28 Pa Code 201.18(a) Management

28 Pa Code 201.18(b)(1) Management

28 Pa Code 201.18(b)(3) Management

28 Pa Code 201.18(d) Management

28 Pa Code 201.29(a) Resident Rights

Plan of Correction - To be completed: 02/27/2025

1) Missing and stained ceiling tiles will be replaced in rooms 301, 302, 303 and 304.

2) House wide auditing will be conducted in resident care areas to ensure there are no missing or stained tiles. Tiles will be replaced as needed.

3) Current housekeeping staff will be re-educated on replacing stained and missing ceiling tiles and conducting routine auditing during daily cleaning routine.

4) Maint. Director or designee will do random audits weekly X4 and monthly X2 for missing and/or stained ceiling tiles and replace them as necessary. Results will be reviewed monthly in QAPI and determined if further auditing is necessary.

483.90(g)(1)(2) REQUIREMENT Resident Call System:

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.

§483.90(g) Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from-

§483.90(g)(1) Each resident's bedside; and
§483.90(g)(2) Toilet and bathing facilities.

Observations:

Based 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)

Findings include:

Review of facility policy 'Call Bells,' revised April 1, 2022, indicates that "all residents are to have access to call bells at all times, even if it is generally believed that the resident is unable to use it. Staff are expected to be as vigilant as possible in keeping the call bell within reach of the resident," and "the call system must be accessible to residents: while in their bed."

Review of Resident R6's clinical record on January 31st, 2025, revealed medical diagnosis of hemiplegia and hemiparesis (paralysis and weakness) following cerebral infarction affecting left non-dominant side, muscle wasting and atrophy, generalized muscle weakness, morbid obesity.

Observations of R6 during lunch meal service, on January 31, 2025 at 12:30 pm, revealed Resident R6 in bed with lunch tray on bedside table over Resident R6's bed.

Further observation of Resident R6 revealed resident coughing continuously while consuming meal, unable to verbalize need for assistance. Resident R6 attempted to reach for call bell which was placed on left side of bed, without success.

Interview with Licensed nurse, Employee E1, on January 31, 2025, at 12:35 pm, confirmed that Resident R6 was unable to use her left upper extremity due to hemiplegia and hemiparesis.

Interview with facility's Director of Nursing, Employee E3, on January 31, 2024, confirmed that Resident R6's call bell was to be placed on right side of bed.

28 Pa Code 211.12(d)(1)(2) Nursing services

28 Pa Code 211.10(c)(d) Resident care policies

Plan of Correction - To be completed: 02/27/2025

) Resident's care plan was updated to have call bell light on her stronger side.

2)Nursing will identify residents perceived to have a weakness or deficit on one side of the body. These residents will be referred to therapy for recommendations of care r/t the weak side regarding call bell placement and the resident's ability to use the call bell.

3) Nursing will be educated to ensure that residents call bell light is within reach of the resident and that resident can access and use.

4) Call bell audit will be completed by each unit manager weekly x 4 and monthly x 2 to ensure that call bells are always within reach of the residents and able to be accessed. Results will be reviewed monthly in QAPI and determined if further auditing is necessary.

35 P. S. § 448.809b LICENSURE Photo Id Reg:

Law amended July 11, 2022 Act 79 2022 HB 2604

(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.

(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.

Observations:

Based on observations and interview with staff, it was determined that the facility did not ensure that employees had an identification badge for two out of five employees observed (Employee E1 and E2 )

Findings include:

Review of facility policy 'Identification Badge - Pennsylvania,' revised January 3, 2022, indicates that "facility follows the established standards for identification badges of health care workers/providers according to Act 110. The employees must wear photo identification tags, when working that contain the following:

1.A recent photograph of the employee
2.Employee's first name
3.Employee's title
4.Name of the employee's health care facility or employment agency

Observation and interview with facility's maintenance assistant, Employee E2, on Friday, January 31st, 2025 at 10:00 a.m., revealed no identification badge present during tour of facility.

Observation of licensed nurse, Employee E1, on third floor unit, on January 31, 2025 at 1:00 p.m., revealed no identification badge present.

Plan of Correction - To be completed: 02/27/2025

1) E1 and E2 will be provided with ID badges.

2) Current employees will be audited to ensure they have an ID badge available to them.

3) Current employees will be re-educated on ensuring they are wearing their name badge at all times and how to obtain one if they don't have one.

4) HR director will do random audits weekly X4 and monthly X2 to ensure staff are wearing their ID badge as necessary. Results will be reviewed monthly in QAPI and determined if further auditing is necessary.

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