Inspection Reports for
Cliveden Convalescent Center
6400 Greene St, Philadelphia, PA 19119, USA, PA, 19119
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
20.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
332% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
11% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 2, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of narcotic medications for two residents at the facility.
Complaint Details
The complaint investigation was substantiated with findings that narcotic medications were missing for two residents. The investigation revealed manipulation of narcotic count sheets by an agency nurse who was placed on a Do Not Return list. The facility's investigation lacked documentation of inventory reconciliation, medication counts, and waste documentation.
Findings
The facility failed to protect residents from misappropriation of controlled substances when narcotic medications were stolen or diverted for two residents. The investigation identified an agency nurse responsible for manipulating narcotic count sheets, resulting in missing medications. The facility conducted an incomplete investigation and revised policies to prevent future occurrences.
Deficiencies (2)
F 0602: Protect each resident from the wrongful use of the resident's belongings or money. The facility failed to prevent misappropriation of narcotic medications for two residents.
F 0610: Respond appropriately to all alleged violations. The facility failed to conduct a thorough investigation into the drug misappropriation allegation and did not document critical elements of the investigation.
Report Facts
Missing medications: 10
Missing medications: 9
Medication carts audited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E2 | Director of Nursing | Reported findings of the investigation and confirmed education and policy revisions |
| Employee E3 | Licensed Nurse | Identified medication discrepancy and conducted narcotic counts |
| Employee E4 | Licensed Nurse (Agency) | Manipulated narcotic count sheets leading to missing medications; placed on Do Not Return list |
| Employee E5 | Nursing Supervisor | Provided written statement regarding medication counts during shift |
| Employee E1 | Nursing Home Administrator | Provided completed background check after request |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Aug 14, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with nursing care regulations, including care planning and nursing staff competencies.
Findings
The facility failed to develop and implement complete care plans for residents requiring intravenous and ostomy care. Additionally, the facility did not ensure licensed nursing staff had documented competencies in IV and ostomy care.
Deficiencies (2)
F 0656: The facility failed to develop and implement care plans for two residents regarding intravenous and ostomy care. No comprehensive care plans were found for Resident R7's colostomy or Resident R8's IV care.
F 0726: The facility failed to ensure licensed nursing staff had proper competencies in intravenous and ostomy care. Four licensed nurses lacked documented competency evaluations for these skills.
Inspection Report
Routine
Census: 20
Deficiencies: 1
Date: Jun 26, 2025
Visit Reason
The inspection was conducted to monitor the temperatures of the building and resident care areas and to ensure the nursing home area is safe, easy to use, clean, and comfortable for residents, staff, and the public.
Findings
The facility failed to maintain a comfortable environment in the 3rd floor lounge where temperatures reached up to 84 degrees, causing discomfort among residents. Several residents were observed without beverages despite the warm conditions.
Deficiencies (1)
F 0921: The facility failed to maintain a comfortable environment in the 3rd floor multipurpose room where temperatures reached 84 degrees, causing discomfort to residents. Residents were observed without water or beverages despite the warm and humid conditions.
Report Facts
Residents present: 20
Temperature: 84
Residents without beverages: 16
Inspection Report
Complaint Investigation
Deficiencies: 17
Date: Jun 13, 2025
Visit Reason
The inspection was conducted to investigate multiple complaints regarding resident rights violations, inadequate care, infection control, and other regulatory compliance issues at Cliveden Nursing and Rehabilitation Center.
Complaint Details
The inspection was complaint-driven, investigating multiple allegations including failure to provide resident rights, inadequate care, improper infection control, and failure to follow up on medical and dental needs.
Findings
The facility was found deficient in multiple areas including failure to provide proper notification and opportunity to refuse room changes, inadequate environmental cleanliness, incomplete investigations of abuse and neglect allegations, failure to notify the Ombudsman of emergency transfers, inaccurate resident assessments, failure to follow up on dental and hearing care, failure to apply prescribed medical devices, inadequate respiratory care, lack of staff competency evaluations and performance reviews, improper medication storage and labeling, incomplete infection surveillance and antibiotic stewardship, and failure to provide required vaccinations.
Deficiencies (17)
F 0559: The facility failed to ensure a resident received proper notification and opportunity to refuse a room change on April 23, 2025.
F 0584: The facility failed to maintain a safe, clean, and homelike environment due to strong urine odor and unsanitary conditions on the third floor.
F 0610: The facility failed to conduct complete investigations of abuse, neglect, and misappropriation allegations for three residents.
F 0628: The facility failed to notify the State Long-Term Care Ombudsman of emergency hospital transfers for three residents.
F 0641: The facility failed to ensure accurate resident assessments for four residents, including incomplete cognitive and treatment documentation.
F 0684: The facility failed to follow up on dental consult recommendations for dentures for one resident.
F 0685: The facility failed to assist a resident in obtaining audiology evaluation and hearing aids as recommended.
F 0688: The facility failed to apply a prescribed elbow extension and hand splint for contracture prevention for one resident.
F 0695: The facility failed to provide necessary respiratory care and documentation for a resident with a tracheostomy.
F 0726: The facility failed to ensure nursing staff competency evaluations for three newly hired employees.
F 0730: The facility failed to complete performance reviews for three nurse aides.
F 0761: The facility failed to ensure all drugs and biologicals were labeled and stored properly on two medication carts.
F 0825: The facility failed to ensure a resident without dentures was assessed for speech rehabilitation services.
F 0838: The facility failed to conduct and document a facility-wide assessment to determine resources necessary to care for residents during day-to-day operations and emergencies.
F 0880: The facility failed to implement appropriate infection tracking and surveillance for five months, lacking signs, symptoms, and antibiotic stop dates.
F 0881: The facility failed to maintain an effective antibiotic stewardship program including protocols and monitoring for 10 months.
F 0883: The facility failed to offer and/or provide influenza and pneumococcal vaccinations to five residents reviewed.
Report Facts
Residents reviewed: 29
Facility census: 144
Residents requiring dementia care: 58
Residents requiring pressure ulcer care: 12
Residents requiring indwelling catheter care: 11
Residents requiring dialysis: 5
Residents requiring hospice: 4
Residents requiring intravenous therapy: 4
Residents requiring feeding tube care: 7
Residents requiring tracheostomy care: 3
Residents requiring transmission based precautions: 6
Residents requiring trauma-informed care: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E1 | Nursing Home Administrator | Named in investigation of misappropriation and emergency transfer notification |
| Employee E2 | Director of Nursing | Named in multiple interviews regarding investigations, infection control, and antibiotic stewardship |
| Employee E3 | Regional Nurse | Interviewed regarding odor issues and audiology consult |
| Employee E5 | HR Director | Interviewed regarding lack of performance reviews |
| Employee E8 | Nurse Aide | New hire lacking competency evaluation |
| Employee E9 | Nurse Aide | New hire lacking competency evaluation |
| Employee E10 | Licensed Practical Nurse | New hire lacking competency evaluation |
| Employee E11 | Nurse Aide | No performance review available |
| Employee E12 | Nurse Aide | No performance review available |
| Employee E13 | Nurse Aide | No performance review available |
| Employee E18 | Registered Nurse | Interviewed regarding tracheostomy care |
| Employee E20 | Unit Manager | Interviewed regarding dental consult follow-up and splint application |
| Employee E21 | Occupational Therapist / Director of Rehabilitation | Interviewed regarding splint use and speech therapy referral |
| Employee E23 | Licensed Practical Nurse | Interviewed regarding medication cart observations and odor issues |
| Employee E24 | Housekeeping Director | Interviewed regarding odor issues |
| Employee E25 | Licensed Practical Nurse | Interviewed regarding medication cart observations |
| Employee E16 | Nurse Aide | Named in misappropriation allegation |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 31, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations regarding resident safety, environment, and care, including ensuring a safe, clean, and homelike environment and verifying the availability of working call systems in resident bathrooms and bathing areas.
Findings
The facility failed to maintain a safe, homelike environment due to missing and leaking ceiling tiles in multiple resident rooms. Additionally, the facility did not ensure that a call device was accessible to one resident with hemiplegia, impacting their ability to summon assistance.
Deficiencies (2)
F 0584: The facility did not provide a safe, homelike environment for four out of five rooms observed, with missing ceiling tiles and leaking stains in rooms 301, 302, 303, and 304.
F 0919: The facility failed to ensure a working call system was accessible to one out of nine residents observed, Resident R6, who was unable to use the call bell due to hemiplegia and hemiparesis.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E1 | Licensed nurse | Confirmed Resident R6 was unable to use left upper extremity due to hemiplegia and hemiparesis. |
| Employee E3 | Director of Nursing | Confirmed Resident R6's call bell was to be placed on right side of bed. |
Inspection Report
Annual Inspection
Census: 28
Deficiencies: 18
Date: Aug 30, 2024
Visit Reason
Annual inspection survey of Cliveden Nursing and Rehabilitation Center to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including resident dignity during meal service, privacy violations, missing grievance procedures, incomplete care plans, medication administration errors, unqualified dietary director, food safety and palatability issues, and failure to ensure resident capacity for arbitration agreements.
Deficiencies (18)
F 0550: The facility failed to provide dignified meal service including timely serving and use of dignity bags for catheter bags for some residents.
F 0552: The facility failed to ensure one resident was allowed to participate in decisions regarding medical appointment requests.
F 0574: The facility failed to post State Department of Health information visibly in two of three units.
F 0583: The facility failed to maintain privacy during tracheostomy care and medication administration for three residents.
F 0584: The facility failed to provide locked storage for residents' valuables and did not address missing items complaints adequately.
F 0585: The facility failed to ensure grievance forms were accessible for anonymous filing and lacked grievance logs prior to June 2024.
F 0641: The facility failed to ensure accurate resident discharge assessments; one resident's discharge status was coded incorrectly.
F 0655: The facility failed to develop baseline care plans within 48 hours of admission for respiratory care, pressure ulcers, catheter, and pain for three residents.
F 0657: The facility failed to update care plans to reflect current resident needs for three residents, including oxygen therapy and dementia care.
F 0684: The facility failed to obtain physician orders for tracheostomy suctioning and failed to notify the physician after missed medication doses for two residents.
F 0695: The facility failed to maintain ongoing communication with dialysis providers for three residents receiving dialysis.
F 0726: The facility failed to provide requested competency training documentation for licensed nursing staff.
F 0730: The facility failed to provide evidence of yearly performance reviews for nurse aides.
F 0755: The facility failed to provide pharmaceutical services to assure medication acquisition and administration for one resident.
F 0801: The facility failed to employ a qualified director of food and nutrition services.
F 0804: The facility failed to provide food and drink that was palatable and served at proper temperatures for several residents.
F 0812: The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional food safety standards.
F 0847: The facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement for one resident.
Report Facts
Residents reviewed: 28
Residents affected: 3
Residents affected: 4
Residents affected: 8
Residents affected: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E9 | Licensed Nurse | Named in catheter dignity bag and oxygen administration findings |
| Employee E18 | Licensed Nurse | Named in medication administration privacy and competency training findings |
| Employee E2 | Director of Nursing | Named in multiple interviews related to care plan, privacy, and medication findings |
| Employee E4 | Food Service Director | Named in food safety, palatability, and qualification deficiencies |
| Employee E1 | Nursing Home Administrator | Named in interviews regarding grievance logs, competency training, and dietary qualifications |
Inspection Report
Routine
Deficiencies: 3
Date: May 8, 2024
Visit Reason
The inspection was conducted to assess the safety, functionality, sanitation, and comfort of the nursing home environment across three nursing units.
Findings
The facility failed to maintain a safe, functional, and sanitary environment on all three nursing units observed, with issues including detached heating baseboards, missing covers, strong odors, dirty floor mats, improperly stored basins, and dusty equipment.
Deficiencies (3)
F 0921: The facility failed to ensure a safe, functional, sanitary environment on three nursing units, including detached heating baseboards, missing baseboards, and strong urine odor in resident rooms.
Basins were improperly stored in resident rooms, left on top of sinks and dressers instead of the bottom shelf as required.
Third floor rooms had dirty floor mats with large stains and ripped edges, dusty and unsanitary CPAP machines, broken dresser shelves, and dirty bathroom floor edges.
Report Facts
Housekeeping staff count: 17
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Dec 26, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident dignity, nursing services, and food service quality at Cliveden Nursing and Rehabilitation Center.
Findings
The facility failed to ensure residents' dignity by using plastic utensils during meals due to a shortage of silverware and delayed feeding assistance for a dependent resident. Additionally, the facility served food and beverages at temperatures below the facility's standards, resulting in residents reporting consistently cold meals.
Deficiencies (2)
F 0550: The facility failed to honor residents' dignity by providing plastic utensils during lunch meals and delayed feeding assistance for a resident dependent on staff for eating.
F 0804: The facility failed to serve food and drinks at safe and appetizing temperatures, with hot items served below the minimum temperature standard, resulting in resident complaints of cold food.
Report Facts
Temperature of hot black coffee: 117
Temperature of green beans: 126
Residents observed with plastic utensils: 6
Minutes delay feeding Resident R6: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E6 | Regional Dietary Director | Reported shortage of silverware causing use of plastic utensils |
| Employee E4 | 3rd floor licensed nurse | Identified residents requiring assistance with eating |
| Employee E5 | Nursing assistant | Observed feeding Resident R7 and delayed feeding Resident R6 |
Inspection Report
Routine
Deficiencies: 2
Date: Nov 17, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, and restorative services at Cliveden Nursing and Rehabilitation Center.
Findings
The facility failed to maintain a clean, safe, and homelike environment on the 3rd floor nursing unit due to a resident's poor hygiene and odor. Additionally, the facility did not ensure that a resident participated in the restorative care nursing program to maintain range of motion and mobility as required.
Deficiencies (2)
F 0584: The facility failed to ensure a clean, safe, and homelike environment on the 3rd floor nursing unit due to a resident's poor hygiene and persistent urine odor affecting the unit.
F 0688: The facility failed to ensure that one resident participated in the restorative care nursing program to maintain range of motion and mobility, as splinting devices were not applied as ordered.
Report Facts
Residents reviewed: 34
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| 3rd floor Unit manager | Reported resident refusal of care and odor issue on 3rd floor | |
| licensed nursing staff (Employee E6) | Reported resident did not have splints and no physician order for splints | |
| Director of Rehabilitation | Confirmed resident has restorative care program requiring splints |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Nov 17, 2023
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements and evaluate the quality of care and safety at Cliveden Nursing and Rehabilitation Center.
Findings
The facility was found to have multiple deficiencies including failure to maintain a clean and safe environment, inadequate care plans for medication refusal, failure to ensure restorative care compliance, improper catheter care, lack of staff training in dementia and behavioral health, delayed pharmacist recommendation implementation, incomplete clinical records, improper infection control practices, unsafe physical environment, and broken handrails in corridors.
Deficiencies (10)
F 0584: The facility failed to ensure a clean, safe, comfortable homelike environment on the 3rd floor nursing unit, evidenced by persistent urine odor and poor resident hygiene.
F 0656: The facility failed to develop and implement a complete care plan addressing medication refusal for a resident with mood and behavioral needs.
F 0688: The facility failed to ensure a resident participated in the restorative care nursing program, neglecting to apply prescribed splints to maintain range of motion.
F 0690: The facility failed to follow physician orders regarding the size of an indwelling urinary catheter for a resident.
F 0726: The facility failed to provide appropriate dementia management and behavioral health training and competencies for nursing staff.
F 0756: The facility failed to ensure timely implementation of consultant pharmacist recommendations for two residents.
F 0842: The facility failed to maintain complete and accurate clinical records for residents.
F 0880: The facility failed to maintain proper infection control practices during tracheostomy care and failed to post required isolation signage for a resident with a transmissible infection.
F 0921: The facility failed to maintain a safe, sanitary, and comfortable environment, including damaged walls and peeling baseboards in resident rooms on the 3rd floor.
F 0924: The facility failed to equip corridors with firmly secured handrails, with a broken handrail presenting sharp edges on the 3rd floor.
Report Facts
Residents living in facility: 154
Residents with dementia care needs: 61
Medication refusals: 15
Pharmacist recommendations not implemented timely: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| 3rd floor Unit Manager | Reported Resident R16 refused care and had overwhelming odor | |
| Licensed Nurse Employee E9 | Confirmed discrepancies in catheter size, environmental damages, and handrail condition | |
| Director of Nursing | Confirmed lack of dementia and behavioral health training and delayed pharmacist recommendation responses | |
| Licensed Nurse Employee E4 | Observed performing tracheostomy care with improper infection control practices | |
| Nurse Aide Employee E10 | Confirmed resident infection transmission risk and PPE requirements |
Inspection Report
Deficiencies: 1
Date: Sep 27, 2023
Visit Reason
The inspection was conducted to evaluate compliance with dietary service regulations, specifically regarding food procurement, storage, preparation, and serving in accordance with professional standards.
Findings
The facility failed to ensure that hairnets were available and properly utilized by dietary staff during meal preparation. Observations and interviews confirmed insufficient hairnet supply and improper hair covering by staff, violating sanitary conditions for food preparation.
Deficiencies (1)
F 0812: The facility did not ensure hairnets were available and properly used in the kitchen during meal preparation. Dietary staff were observed without hairnets or with hair improperly secured, and no hairnet supply was found in the food preparation area.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 15, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding incomplete documentation in a resident's clinical record related to a leave of absence for Resident R1.
Complaint Details
The complaint investigation found that the facility did not document the Power of Attorney's directive to suspend Resident R1's leave of absence trips with his sister. The finding was substantiated with interviews and record review.
Findings
The facility failed to ensure complete documentation in Resident R1's clinical record concerning the suspension of leave of absence trips with the resident's sister as directed by the resident's Power of Attorney. Interviews and record reviews confirmed the lack of documentation despite the POA's directive.
Deficiencies (1)
28 Pa. Code 211.12(c), 211.12(d)(1), 211.12(d)(2), and 211.12(d)(5) Nursing service. The facility did not maintain complete documentation in Resident R1's clinical record regarding the suspension of leave of absence trips as directed by the resident's Power of Attorney.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E4 | Director of Nursing and Licensed nurse | Interviewed regarding Resident R1's leave of absence and documentation issues. |
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