Cliveden Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Cliveden Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF585Jan 12, 2023

  Based on observations, interviews with residents and staff and reviews of policies and procedures, it was determined that the facility failed to ensure the availability of information about how to file a grievance or complaint for eight of eight residents interviewed. (Residents R34, R91, R127, R114, R76, R35, R93, R53) Findings include: A review of the facility policy titled Resident Rights Grievance Social Services dated April 1, 2022 revealed that it was the policy of the facility to allow and assist residents, their representatives or family members to file grievances. The facility policy indicated that the grievance office was the social worker. […]

• No harm, potential for more than minimal, widespreadF880Jan 12, 2023

  Based on review of facility policy, facility documentation, observations, and staff interviews it was determined that the facility failed to implement proper use of personal protective equipment (PPE) for staff who were exempt from vaccination requirements and the facility failed to implement appropriate tracking and surveillance of infection for two of seven unvaccinated staff reviewed (Employee E14 and Employee E15) and infection surveillance for three of three nursing units. […]

• No harm, potential for more than minimal, widespreadF881Jan 12, 2023

  Based on a review of facility documentation, facility policies and staff interviews it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system to effectively monitor antibiotic usage for three of nine months of antibiotic stewardship program data reviewed. (April 2022 to December 2022. Findings include: A review of facility policy entitled Antimicrobial Stewardship Program last dated January 1, 2022, revealed Key objectives Establish an ASP(Antimicrobial Stewardship Program) and a system for tracking antimicrobial use to meet the requirements of participation set out by CMS. […]

• No harm, potential for more than minimal, widespreadF887Jan 12, 2023

  Based on review of clinical records and staff interviews, it was determined that the facility failed to offer and/or provide COVID -19 immunization(s) for three of five residents reviewed and the facility failed to provide staff education regarding the benefits and potential risks associated with COVID-19 vaccine. (Resident R48, 363, 149 and 132). The findings include: Review of R48's immunization records revealed no evidence that the resident received the COVID-19 vaccine(s), or the facility offered and educated about benefits and potential risk of COVID-19 vaccine(s). Review of R363's immunization records revealed no evidence that the resident received the COVID-19 vaccine(s), or the facility offered and educated about benefits and potential risk of COVID-19 vaccine(s). […]

• No harm, potential for more than minimal, widespreadF925Jan 12, 2023

  Based on observations of the physical environment, reviews of the pest control operator's reports, and interviews with resident and staff, it was determined that the facility failed to maintain an effective pest control program to ensure that the facility was free of pests for three of three nursing units and kitchen. (First floor, second floor and third floor) Findings include: Interview with Resident R363 on January 10, 2023, at 10.53 a.m. revealed that she observed mice in her room since her admission. She stated it goes underneath the dresser and the hole underneath the wall the air conditioning unit. The following observations were completed with the Nursing Home Administrator on January 11, 2023, at 1.56 p.m. […]