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

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CLIVEDEN NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 218 surveys for this facility. Please select a date to view the survey results.

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

Initial comments:
Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey, completed on June 12, 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 and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

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.

§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Plan of Correction - To be completed: 07/20/2026

Immediate corrective action: Employee involved in incident was terminated.

Housewide corrective action: No housewide correction action.

Education: Current staff will be re-educated on facility's abuse policy.

Performance Monitoring: NHA or designee will complete random interviews with 10 residents weekly x 4 weeks to ensure they feel safe and are not being abused. Results will be reviewed during the facility's monthly QAPI meeting. QA meeting will determine the need for continued auditing.

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

§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 review of facility policy, review of clinical records, observation, and interview with staff, it was determined that the facility failed to development and implement comprehensive care plans for two of 33 residents reviewed (Resident R9 and R98).

Findings Include:

Review of policy titled "Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates", revised October 1, 2024, revealed, the facility will follow a uniform process for initiating comprehensive care plans and ensuring care plans are updated to reflect the resident's status. Continued review of facility policy revealed the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's needs that are identified in the comprehensive assessment.

Review of clinical documentation revealed Resident R98 was admitted to facility on July 8, 2022, and had a diagnosis of hemiplegia and hemiparesis (paralysis or reduced ability to move or weakness of one side of the body following a stroke), critical illness polyneuropathy (an acute condition/complication of severely ill patients that causes muscle weakness and wasting), and need for assistance with personal care.

Continued review of clinical documentation revealed Resident R98 has a BIMS (Brief Interview of Mental Status) score of 13, indicating intact cognition.

Review of Resident R98's comprehensive care plan revised May 17, 2023, revealed Resident R98 is part of restorative program related to contracture (shortening and stiffening of soft tissues, such as muscles, tendons, and ligaments), with interventions for a right elbow splint and right resting hand splint.

Observation on June 10, 2026, at 10:16 a.m. revealed Resident R98 was in bed, and his/her right wrist/arm was contracted with no splint in place. A black brace was observed to be sitting on the end table.

Continued observations on June 11, 2026, at 11:13 a.m. revealed Resident R98 was in his/her wheelchair in the hallway, without the brace or splint in place on right wrist.

Interview on June 11, 2026, at 11:15 a.m. with Resident R98 revealed the resident was not wearing the brace because it "didn't work".

Interview on June 12, 2026, at 9:53 a.m. with the Director of Rehabilitation, Employee E14, revealed Resident R98 independently removes the brace sometimes.

Continued review of Resident R98's clinical records reveal no care plan was developed related to Resident R98's refusals of wearing the brace/splint.

During an interview with the Director of Nursing, Employee E2, on June 12, 2026, at 11:48 a.m. it was discussed Resident R98 lacked a care plan for refusal of brace.

Review of resident R9's clinical record revealed the resident was admitted to the facility on November 20, 2020, and has a diagnosis of Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by experiencing or witnessing a traumatic event, leading to severe anxiety, flashbacks, and emotional distress) and Dementia with agitation (a condition where individuals with dementia become restless, irritable, or aggressive due to changes in brain function, often triggered by confusion, discomfort, or environmental stressors).

Review of Resident R9's clinical record revealed no documented evidence a comprehensive care plan was developed related to dementia with agitation or post-traumatic stress disorder.

Interview on June 12, 2026, at 10:15 a.m. with Regional Nurse, Employee E8, confirmed no comprehensive care plan was developed for dementia with agitation or PTSD for Resident R9.

28 Pa Code 211.10 (a) Resident care policies.

28 Pa Code 211.10 (c) Resident care policies.

28 Pa. Code 211.12(d)(5) Nursing services.

Plan of Correction - To be completed: 07/20/2026

Immediate corrective Action: R9 and R98's care plans were updated to reflect PTSD and dementia with agitation and refusal of brace.

House wide corrective action: Current residents with a diagnosis of PTSD and dementia will be audited to ensure care plan reflects diagnosis. Current residents that utilize braces/splints will be audited to ensure care plan reflects use and/or refusal.

Education: Nursing administration staff will be re-educated on the facility's policy for comprehensive care planning.

Performance Monitoring: DON or designee will complete weekly audits x 4 weeks of new admissions to ensure PTSD and dementia diagnosis are reflected in the care plan. DON or designee will complete weekly audits of residents with splint/brace orders to ensure refusals are reflected in the care plan.

The results of the audits will be reviewed during the facilities monthly QAPI meeting. The QA committee will determine the need for continued monthly auditing.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:
Based on review of facility policy, review of clinical records, observation, and interview with staff, it was determined that the facility failed to ensure the resident environment was free of accident/hazards for two of 33 residents reviewed (Residents R32 and R51).

Findings Incldue:

Review of Resident R51's clinical records revealed Resident R51 was admitted to the facility on June 20, 2023 and has diagnoses of marasmic kwashiorkor (a severe, life-threatening type of malnutrition), atherosclerosis of native arteries of bilateral legs (build up of plaque or fatty deposits inside the arteries of both legs), difficulty in walking, and muscle weakness.

Continued review of Resident R51's clinical record revealed the resident has a BIMS (Brief Interview for Mental Status) score of 9, indicating moderate impairment of cognition.

Review of facility documentation submitted to state survey agency revealed on September 24, 2025, Resident R51 had a fall in his/her wheelchair while being transported in a van by contract transport company coming back from an appointment. When the van driver, Employee E11, came to a stop, Resident R51 tipped backward and hit the back of his/her head. Resident R51 remained strapped in the wheelchair as it tipped backwards.

Continued review of facility documentation revealed a statement by van driver, Employee E11, dated September 24, 2025, that revealed the employee may have forgotten to put the front straps on the resident's wheelchair to hold it in place when securing Resident R51 into the van. Van Driver, Employee E11, reported that as the van proceeded through a light on a hill, Resident R51's chair was pulled backwards by the back straps. Resident R51 subsequently fell backwards, hitting his/her head.

Review of Resident R51's clinical record revealed a nursing progress note dated September 24, 2025, that upon a physical assessment (after returning to the facility after the above noted incident) Resident R51 was noted with a lump to the back of the head with a small amount of bleeding. Resident R51 was subsequently transferred to the hospital for evaluation.

Review of incident report completed by the transport company dated September 24, 2025, revealed upon a review of video footage from the van interior, it was determined and confirmed that Van Driver, Employee E11, failed to properly secure Resident R51 in the van. Per the incident report, Resident R51 was initially strapped in by the van driver "x2 versus x4".

Interview with Director of Nursing, Employee E2, on June 12, 2026, at approximately 11:00 a.m. confirmed the above incident with Resident R51.

Review of the facility policy titled, "Administering Medications" revised October 2025 revealed medications shall be administered in a safe and timely manner, and as prescribed. If a drug is withheld, refused or given at a time other than the scheduled time, staff should document in the electronic health record per protocol. The resident's responsible party, if applicable, and Attending Physician will be made aware.

Continued review of facility "Administering Medications" revealed residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.

Review of resident R32's clinical record revealed that the resident was admitted to the facility on February 7, 2026, and had a diagnosis of muscle weakness, anxiety disorder (a group of mental health conditions defined by intense, excessive, and persistent worry or fear about everyday situations), major depressive disorder (a serious mental health condition causing persistent sadness, hopelessness, and a loss of interest in activities), hyperlipidemia (high levels of fats in the blood), and Type 2 Diabetes (a chronic condition where your body either resists the effects of insulin or doesn't produce enough of it to maintain normal glucose levels).

Observations on June 9, 2026, at 10:00 a.m. during a tour of the second-floor nursing unit revealed Resident R32 had medications left in a plastic cup at the bedside.

Observations on June 9, 2026, at 10:05 a.m. with Unit Manager, Employee E4, confirmed Resident R51 had a clear, plastic cup that contained 6 pills at bedside. Unit Manager, Employee E4, confirmed Resident R32 does not self-administer medications, and the medications should not have been left at bedside.

28 Pa. Code 201.14 (a) Responsibility of licensee.

28 Pa. Code 211.10 (d) Resident Care Policies.

28 Pa. Code 211.12 (d)(5) Nursing Services.

Plan of Correction - To be completed: 07/20/2026

Immediate corrective Action: Transport company employee has not returned back to this facility after the incident.

The van that was used for this transport was new and had different securing procedures than what the driver was accustomed to with the old van. The Ambulance Company reinserviced with their driver the importance of proper securing of wheelchairs for this new van. (4 straps instead of 2)

Facility will ensure that transportation companies that service the facility implement appropriate education to thier employees regarding transport safety, during initiation of contract.

Medications were administered to R32.

House wide corrective action: Current residents' rooms will be audited to ensure medications are not left at bedside.

Education: Current licensed nursing staff will be re-educated to ensure medications are not left at the bedside.

Performance Monitoring: DON or designee will complete weekly audits x 4 weeks of 10 residents' room to ensure medications are not left at the bedside.

The results of the audits will be reviewed during the facilities monthly QAPI meeting. The QA committee will determine the need for continued monthly auditing.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Plan of Correction - To be completed: 07/20/2026

Immediate Corrective Action: Weights were obtained for R3, R9 and R14.

House wide Corrective Action: Current residents will be audited to ensure a current weight has been obtained and reviewed for the month of June.

Policy/Education: Licensed nurses and CNAs will be re-educated on facility's weight policy.

Performance Monitoring: The dietician or designee will complete weekly audits of resident's requiring re-weights to ensure weights are obtained as requested.

The results of the audits will be reviewed during the facility's monthly QAPI meeting. The QA committee will determine the need for continued monthly auditing.

483.40 REQUIREMENT Behavioral Health Services:

§483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.

Observations:
Based on review of facility policy, review of clinical records, observations, and staff and resident interviews it was determined that the facility failed to ensure residents received necessary behavioral health services for one of 33 residents reviewed (Resident R36).

Findings Include:

Review of facility policy on consultations, review date June 2026, revealed residents should receive necessary medical services as ordered by the attending physician or designee. Per the facility policy, all consultations must be ordered by the attending physician or designee. The nurse will initiate consultation per facility practice and consultant services will be provided in the facility when possible.

Further review of facility policy on consultations revealed nursing staff will document all actions in the medical record including a consultation order, date and time resident went to appointment, recommendations and follow up, and communication with resident and resident representative.

Review of Resident R36's clinical record revealed the resident was admitted to the facility on December 8, 2025, and had a diagnosis of major depressive disorder (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things), anxiety disorder (intense, excessive, persistent worry or fear), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).

Review of Resident R36's admission Minimum Data Set (MDS federally mandated resident assessment and care screening) dated December 18, 2025, revealed section D0150 (Resident Mood Interview) A. Little interest or pleasure in doing things was coded "yes", B. Feeling down, depressed, or hopeless was coded "yes", C. Trouble falling or staying asleep, or sleeping too much was coded "yes", D. Feeling tired or having little energywas coded "yes".

Resident R36's clinical record revealed a physician order for bupropion 100 milligrams (mg) one time per day for major depressive disorder, that was ordered December 8, 2025, and discontinued April 29, 2026. Further, the physician ordered Trazodone on April 29, 2026, for major depressive disorder.

Continued review of Resident R36's clinical record revealed a physician order dated December 8, 2025, for "Psychiatry consult Evaluation, Treatment, and Follow-up as Recommended".

Review of Resident R36's clinical record revealed the psychiatry consult ordered December 8, 2025, was not fulfilled until May 8, 2026.

Review of Resident R36's clinical record revealed a psych note dated May 8, 2026, that revealed Resident R36 was seen for complaint of low mood.

Observation on June 10, 2026, at 10:49 a.m. revealed that Resident R36 appeared sad and non-engaging with interview.

Interview with Regional nurse, Employee E8, conducted on June 12, 2026, at 11:35 a.m. confirmed that there was an order dated December 8, 2025, to obtain a psychiatry consultation for Resident R51. Regional nurse, Employee E8, further confirmed Resident R36 was not seen by psych until May 8, 2026 (5 months after the consult was ordered).

28 Pa. Code 201.14 (a) Responsibility of licensee.

28 Pa. Code 201.21 (c) Use of outside resources.

28 Pa. Code 211.12 (d)(5) Nursing services.

Plan of Correction - To be completed: 07/20/2026

Immediate Corrective Action: R36 continues with psych services as ordered.

Housewide Corrective Action: Current resident's on psychotropic medication will be audited to ensure pysch services are in place.

Education: Nursing administration will be re-educated on ensuring psych services are initiated as ordered.

Performance Monitoring:  DON or designee will audit new admissions weekly to assess the need for psych services to ensure consultation is placed timely. The results of the audits will be reviewed during the facility's monthly QAPI meeting. The QA committee will determine the need for continued monthly auditing.

483.20(f)(5),483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations:
Based on review of clinical records and staff interviewit was determined that the facility failed ensure clinical records were maintained with complete and accurate documentation for one of 33 residents reviewed (Resident R132).

Findings Include:

Review of Resident R132's clinical record revealed the resident was admitted to the facility on August 15, 2023.

Interview on June 9, 2026, with Resident R132 revealed the resident stated he/she was upset due to not having their wound treatment completed last Saturday and Thursday. Resident R132 stated that he/she is supposed to receive wound treatment three times a week and he has not been.Observation of the dressing on Resident R132's right leg revealed a dressing dated June 8, 2026. The dressing was soiled with blood that soaked through to the resident's sheets.

Review of Resident R132's clinical record revealed a physician order datedMarch 26, 2026, to cleanse right posterior calf with wounder cleanser, apply calcium alginate, ABD (highly absorbent, multi-layer dressing), and wrap with kling. The physician order dated March 26, 2026, also indicated to Cleanse left posterior calf with wounder cleanser, apply calcium alginate, ABD, and wrap with kling (type of gauze).

Review of Resident R132's treatment administration record for June 2026, revealed the order for wound care was not signed out as completed June 4 and June 6.

Interview on June 12, 2026, at 1:11 p.m. with the wound care nurse, Employee E7 revealed that he/she completed wound care treatment for Resident R132 on June 4, 2026, but confirmed it was not documented. The wound care nurse, Employee E7, could not confirm or explain why Resident R132's treatment was not signed out on June 6, 2026.

28 Pa. Code 211.5(f) Clinical records

28 PA. Code 211.10 (d) Resident care policies

Plan of Correction - To be completed: 07/20/2026

Immediate Corrective Action: Late documentation was completed for R132's treatment orders for 6/4 and 6/7.

Housewide Corrective Action: A 30 day look back of current residents with wounds will be audited to ensure treatments were signed out.

Education: Wound nurse and licensed nurses will be re-educated on ensuring wound care treatments are documented upon completion.

Performance Monitoring:  DON or designee will complete weekly audit of 10 residents x 4 weeks to ensure wound care treatments have been signed out. The results of the audits will be reviewed during the facility's monthly QAPI meeting. The QA committee will determine the need for continued monthly auditing.

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