Deficiency Records for Cliveden Nursing and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Cliveden Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-26 | 2024-01-16 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-26 | 2024-01-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-17 | 2024-01-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-11-17 | 2024-01-16 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-11-17 | 2024-01-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-11-17 | 2024-01-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-17 | 2024-01-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-17 | 2024-01-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-11-17 | 2024-01-16 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2023-11-17 | 2024-01-16 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-11-17 | 2024-01-16 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-11-17 | 2024-01-16 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-27 | 2023-10-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-15 | 2023-04-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-04 | 2023-02-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-12 | 2023-02-20 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-01-12 | 2023-02-20 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-01-12 | 2023-02-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-01-12 | 2023-02-20 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-01-12 | 2023-02-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-12 | 2023-02-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-01-12 | 2023-02-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-01-12 | 2023-02-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-12 | 2023-02-20 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-01-12 | 2023-02-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-12 | 2023-02-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-12 | 2023-02-20 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-01-12 | 2023-02-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-12 | 2023-02-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-01-12 | 2023-02-20 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-12 | 2023-02-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-12 | 2023-02-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-01-12 | 2023-02-20 | N |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2023-01-12 | 2023-02-20 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-01-12 | 2023-02-20 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-01-12 | 2023-02-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-12 | 2023-02-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-01-12 | 2023-02-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-12 | 2023-02-20 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-01-12 | 2023-02-20 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-01-12 | 2023-02-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-01-12 | 2023-02-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-12 | 2023-02-20 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-01-12 | 2023-02-20 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-05 | 2023-01-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-06 | 2022-06-17 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-06 | 2022-06-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-06 | 2022-06-17 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-03-04 | 2022-04-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-04 | 2022-04-07 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-03-04 | 2022-04-07 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-03-04 | 2022-04-07 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-03-04 | 2022-04-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-04 | 2022-04-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-04 | 2022-04-07 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-03-04 | 2022-04-07 | Y |
| Provide or obtain dental services for each resident. | Health | 2022-03-04 | 2022-04-07 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-31 | 2022-03-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-30 | 2022-01-12 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-11-30 | 2022-01-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-10 | 2021-12-10 | Y |
