Health inspection·August 30, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation and interviews with residents and facility staff, it was determined that the facility failed to provide care and services to enhance residents' dignity related to serving meals on disposable paperware, serving residents meals timely on one of three dining rooms (Third floor dining room) and no catheter dignity bag for one of 28 Residents reviewed (Resident R244). Findings include: Observations during the initial tour of the facility on August 27, 2024, at 10:50 a.m. in Resident R244's room revealed that resident had an indwelling foley catheter in place and that the urine collection bag attached to the catheter was hanging from the side of the bed not covered with a dignity bag exposing a clear plastic bag with a amber colored fluid inside of it. The urine collection bag was clearly visible through the doorway hallway. Interview with the Licensed nurse, Employee E9, on August 27, 2024, at 11:15 a.m. confirmed that Resident R100's catheter bag, which was hanging on the side of her bed, was visible from the doorway and was not covered. During further interview with Employee E9, she stated that the urine collection bag should be in a dignity bag, or the privacy curtain should be drawn. Dining observation was made on the third floor in the dining room on August 27, 2024 starting at 12:18 p.m. There were 22 residents present and seated in the dining room waiting on their mails. At 12:23 p.m. the first food truck arrived on only 12 of the 22 residents were served their meals. At one table 4 were served and 2 were missing their meals. At the second table four were served and one was missing their meal. At the third table 3 were served and two were missing their meals. At the fourth table 3 were served and 1 was missing their meal. There were also 2 residents seated alongside the wall not served with their tray tables in front of them. When asked about the timing of the meals, the nurse aide Employee E12 stated that she would prefer that all residents' trays in the dining room are brought up at the same time but it hasn't been. Employee E12 stated the second food truck usually does not arrive till closer to 1:00 p.m. Continued observation revealed the second truck came up to the dining room at 12:55 p.m. Nurse aide Employee E13 began passing on the food to the remaining residents, and she did not take the food of the trays when placing them in front of the residents. Resident R7 who needed feeding assistance was served his food tray at 12:58 p.m. but did not receive the assistance for eating until 1:09 p.m. due to nurse aides Employee E12 and E13 feeding two other residents first. Observations during the lunch meal on August 28, 2024, at 12:25 p.m. in the third-floor dining room revealed facility staff delivering trays to the residents who were sitting at tables in the dining room. Further observation revealed clear plastic disposable cups with lids on multiple trays Page 1 of 29 395852 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some containing applesauce and a yellow pudding like substance which was being served to many residents. Further observation revealed that the residents were not offered clothing protectors and several residents had food spilled on their clothing and that they ate their food from the trays for the entire meal. Interview with the Administrator on August 30, 2024, at 12:10 p.m. confirmed that in the dining room staff would be expected to offer clothing protectors and to remove the meal from the tray when serving in the dining room. 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 201.29(a) Resident rights 395852 Page 2 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that a resident was allowed to participate in decisions regarding medical appointment requests for one of twenty-eight residents reviewed. (Resident 135). Residents Affected - Few Findings Include: Interview with Resident R135 on August 27, 2024 at 9:52 a.m. revealed the resident had concerns with seeing outside physicians which she had mentioned multiple times and no one ever followed through with giving her an answer or scheduling any appointments with her. Review of Resident R135's clinical record revealed on August 1, 2024 there was an Interdisciplinary Progress Note that stated, Care Conference scheduled on 8/1/24. IDT (Interdisciplinary Team) visited with resident by bedside. Resident had concerns for nursing and the in-house physician. Resident wishes to get vitamin supplements D-3, to get print out of all their medications getting. Requesting to see the cardiologist specialist at (hospital). Wanting to get a MRI x-ray to check why not using legs. Requested to be updated when they had a virus several months ago. Aware of the POLST code status. Interview with the Director of Nursing Employee E2 on August 30, 2024 at 2:12 p.m. revealed the physician was aware of the requests made by Resident 135 but had not yet followed up on them. 28 Pa Code 201.18(b)(2) Management 28 Pa Code 211.12(d)(1) Nursing services 395852 Page 3 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0574 The resident has the right to receive notices in a format and a language he or she understands. Level of Harm - Minimal harm or potential for actual harm Based on the tour of facility, observations and interviews with staff, it was determined the facility failed to ensure State Department of Health information was posted visible in a prominent place to residents in two out of three of the units. (Second Floor and Third Floor) Residents Affected - Few Findings include: On August 28, 2024 at approximately 11:11 a.m. a tour of the facility with Social Worker, Employee E14 and it was determined that only one of three units had the State Department of Health contact information posted and visible for residents and/or family. The first floor has a paper printed State Department of Health signs with small print that were posted in a glass case before you entered unit one. The printed paper we posted high in the glass case which would make it non-visible for residents who were wheelchair bound. A tour of the second-floor nursing unit revealed no printed State Department of Health signs located on the unit. A tour of the third-floor nursing unit revealed no printed State Department of Health signs located on the unit. Social Worker Employee E14 confirmed the facility failed to ensure that the process for filing a complaint and the State Department of Health Hotline number was posted as required. 28 Pa. Code 201.20(a) Resident rights. 395852 Page 4 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, review of clinical record, it was determined that the facility failed to maintain privacy related to personal privacy during tracheostomy care and sensitive patient health information during medication administration for three of 28 residents reviewed (Resident R9, Resident R121, and Resident R97). Residents Affected - Few Findings include: Medication administration observation with Licensed nurse, Employee E18 conducted on August 28, 2024, at 9:05 am revealed that after preparing the morning medications for Resident R9 Employee E18 went inside Resident R9's room to give her medications. Further observation revealed that Employee E18 left her laptop open with the laptop facing the hallway with Resident R9's medical information visible. Further medication administration observation with Employee E18, revealed that, during medication administration for Resident R121, after preparing the morning medications for Resident R121, Employee E18 went inside Resident R121s room to give him his medications. Further observation revealed that Employee E18 left her laptop open with the laptop facing the hallway with Resident R121s medical information visible. Interview with Employee E18 conducted after the medication administration observation confirmed that the laptop was left open unattended while she went inside Resident R9 and Resident R121. Tracheostomy care observation for Resident R97 with Licensed nurse, Employee E17 conducted on August 30, 2024, at 8:50 am revealed that Resident R97 was in a single room. Further, there was no privacy curtain around Resident R97's bed. Further observation revealed that after Licensed nurse, Employee E17 finished setting up the dressing kit and the dressing supplies, Employee E17 started to perform the tracheostomy care on Resident R97. Further observation revealed that the door to the resident's room was left open the entire time nurse was performing trach care with Resident R97 visible from the hallway. Interview with Licensed nurse, Employee E17 conducted after the tracheostomy care was completed, confirmed that the door was left open during the tracheostomy care. Interview with Employee E2 conducted on August 30, 2024, at 9:38 a.m. revealed that the facility did not have a policy for privacy. 28 Pa. Code 210.29(i) Resident rights 28 Pa. Code 211.12(d)(3) Nursing services 395852 Page 5 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews with residents and staff, it was determined that the facility failed to provide a drawer or cabinet in the resident's room that can be locked for storage of the resident valuable items for two of 35 residents reviewed. Findings include: Review of facility policy, Inventory of Resident Personal Belongings/ Property, revised July 1, 2023, revealed that, Money, jewelry, or collectibles should be kept in a lock drawer. If a resident doesn't have a key, one will be provided. Observations during the initial tour of the second-floor nursing unit on August 27, 2024, at 11:30 a.m. in room [ROOM NUMBER], bed A revealed a wardrobe with a silver hasp, but no lock and the top drawer on the chest next to her bed had a lock. Interview with Resident R77, who lives in room [ROOM NUMBER], Bed A, revealed that she was missing almost all of her tops, and that they told her that they would lock them in her wardrobe so that they would be safe, but she did not have a lock for the wardrobe. She further stated people steal everything, and that she did not have the key for her locking top drawer where she could store valuables. Observations during the initial tour of the second-floor nursing unit on August 27, 2024, at 11:35 a.m. in room [ROOM NUMBER], bed A revealed that the top drawer on the chest next to her bed had a lock. Interview with Resident R51, who lives in room [ROOM NUMBER], Bed A, revealed that she was missing a lot of clothing, including T-Shirts, sweatshirts and sweat pants, and soaps and sprays that her family had brought her. She said that she did not have a key to her locked drawer to keep her valuables. Interview with the Unit Manager, Employee E7, on the second-floor nursing unit on August 27, 2024, at 11:45 a.m. confirmed that these residents did not have keys to their locked drawers to protect their valuables. Interviews with residents during Resident Council on August 29, 2024 at 10:00 a.m. revealed residents had complaints about money being stolen from their rooms and clothing items being taken to be laundered and never being returned. Resident R55 stated at 10:20 a.m. that the evening before she had approximately $20.00 to $30.00 dollars stolen from her during the night shift. She reported that she told the nurse on shift about the stolen money, but nothing has yet to be done. Resident R55 also stated that she had a family member buy her fifteen pairs of socks a few months ago due to none of her socks coming back in the laundry. Resident R55 stated that at this point she does not currently have any socks. Resident R55 showed the surveyor her shoes and stated she did not have any socks on which was observed. Review of the facility grievance log from the last six months revealed no grievance completed for Resident R55. Resident R89 stated at 10:23 a.m. during resident council that he has had clothing stolen and nothing has been done about it. Resident R89 stated that his sister bought new clothes a few weeks ago to replace clothing that has been missing. Resident R89 stated that he reported the clothing being stolen six weeks including jeans from his room. Resident R89 stated that his sister now does his 395852 Page 6 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some laundry so that his items will not be stolen or not returned. Review of the facility grievances for the last six months revealed no grievances completed for Resident R89. At 10:40 a.m. Resident R98 stated that he had clothing taken to the laundry and a lot of them had not been returned. Resident R98 stated that a lot of the items were labeled with his name and still were not returned. When asked if the resident mentioned this to staff he stated, I mention it to everyone I see because I want my stuff back. Resident R98 stated that this has been going on for several weeks. Review of the facility grievance log revealed no grievance form completed for Resident R98. Review of the facility grievances revealed Resident R31's family filed grievance on July 20, 2024 in regards to missing clothing and missing a virtual assistance device. The Findings and Disposition of the form revealed, Room was searched for missing belongings and condition of room. [virtual assistance device] was not found after searching both sides of room. Recreation therapy loaned one to the daughter to program its intentions. Review of Resident R31's clinical record revealed no inventory sheets had been completed for the resident since his admission on [DATE]. There was no evidence that Resident R31's item would be replaced or that the family would be reimbursed for the item. There was also no evidence of the facility completing a new inventory sheet for the resident. 28 Pa. Code 204.5 (f) Resident Rooms. 395852 Page 7 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observations, review of facility policy, review of facility records, and interviews with residents and staff, it was determined that the facility failed to ensure that grievance forms were accessible for residents who wish to file a grivance anonymously and there was no grievance box availble on two of three nursing floors (First and Third floor). Findings Include: Review of facility policy titled, Grievance Program dated April 1, 2022 states, Purpose: To promote an environment and culture open to feedback positive and or negative from residents, family members, employees, physicians, and any other visitors. Both positive and negative comments from these individuals helps to provide information which will be incorporated into policies, procedures, and practices within the organization that focus on creating a culture of excellence through identification and resolution within continuous quality improvement. Right to file Grievances: residents and visitors have the right to present concerns/grievances on behalf of himself or herself or others to the staff or administrator of the facility either verbally or in writing, to governmental officials, or to any other persons; to file grievance anonymously; to receive a written decision related to the grievance filed, if requested; to recommend changes in policies and services to facility personnel; and to join with other residents or individuals within or outside the facility to work for improvements in resident care, and be free of restraint, interference, coercion, discrimination, or reprisal. Review of the facility Resident Concern Report revealed that there was no place to check off that the form was being filled out anonymously. A tour of the facility was taken on August 28, 2024 at 11:11 a.m. with Social Worker Employee E14. A tour of facility revealed that there were no grievance forms located throughout the facility that were accessible for residents to obtain anonymously. The tour of the facility also revealed there was no grievance box on the first or third floor nursing units allowing residents to turn in anonymous grievances. The grievance box located on the social workers office on the second floor is high up on the door, not allowing for residents who are wheelchair bound to turn in grievance forms anonymously. Interview with Social Worker Employee E14 on August 28, 2024 at 11:15 a.m. revealed that residents must obtain a copy of the Resident Concern Report from a social worker or from a nurse at the nurses station currently. Resident Concern Reports are located on the door of the social workers office on the second floor, but this is in the administration office, where there is a sign stating residents are not welcome to enter. Further interview with the Social Worker Employee E14 revealed there are no grievance logs that are accessible prior to June 2024 due the facility not keeping a log of facility grievances. Interview with Nursing Home Administrator Employee E1 on August 28, 2024 at 12:24 p.m. confirmed there is no facility grievance log available prior to June 2024. Employee E1 stated that the previous Nursing Home Administrator was not keeping a log of grievances each month. Employee E1 stated that there were some grievance forms available for January 2024 through May 2024, but the facility may be missing some due to a process not being in place for filing them. Interviews held during resident council on August 29, 2024 at 10:00 a.m. revealed residents stated 395852 Page 8 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0585 that they did not know how to file a grievance form including Residents R55. Level of Harm - Minimal harm or potential for actual harm Interviews held during resident council on August 29, 2024 at 10:00 a.m. revealed several residents stated that they did not have any resolve to grievances formed regarding missing clothing items including Residents R55, R89, and R98. Residents Affected - Few Resident R55 stated at 10:20 a.m. that the evening before she had approximately $20.00 to $30.00 dollars stolen from her during the night shift. She reported that she told the nurse on shift about the stolen money, but nothing has yet to be done. Resident R55 also stated that she had a family member buy her fifteen pairs of socks a few months ago due to none of her socks coming back in the laundry. Resident R55 stated that at this point she does not currently have any socks. Resident R55 showed the surveyor her shoes and stated she did not have any socks on which was observed. Review of the facility grievance log from the last six months revealed no grievance completed for Resident R55. Resident R89 stated at 10:23 a.m. during resident council that he has had clothing stolen and nothing has been done about it. Resident R89 stated that his sister bought new clothes a few weeks ago to replace clothing that has been missing. Resident R89 stated that he reported the clothing being stolen six weeks including jeans from his room. Resident R89 stated that his sister now does his laundry so that his items will not be stolen or not returned. Review of the facility grievances for the last six months revealed no grievances completed for Resident R89. At 10:40 a.m. Resident R98 stated that he had clothing taken to the laundry and a lot of them had not been returned. Resident R98 stated that a lot of the items were labeled with his name and still were not returned. When asked if the resident mentioned this to staff he stated, I mention it to everyone I see because I want my stuff back. Resident R98 stated that this has been going on for several weeks. Review of the facility grievance log revealed no grievance form completed for Resident R98. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.29(a)(i) Resident rights 395852 Page 9 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview with staff, it was determined that the facility did not ensure that resident assessments accurately reflected resident status related to discharge for one of three closed records reviewed (Resident R141). Residents Affected - Few Findings include: Review of clinical documentation revealed that Resident R141 was admitted to the facility on [DATE], and discharged from the facility on June 11, 2024. A nursing note written on June 11, at 8:11 p.m. stated, Resident discharged . Left facility at about 5pm via medical transport with family. All scripts and personal belongings were taken by family prior to discharge. Home care services referral in place. The resident's discharge instructions, signed by licensed nurse, Employee E15, on June 11, 2024 included referral for homecare physical therapy and occupational therapy services. Review of the resident's discharge MDS (Minimum Data Set, a periodic evaluation of resident needs), section A2105, Discharge Status, signed on June 14, 2024, by the Registered Nurse Assessment Coordinator, Employee E16, stated that the resident was discharged to a short-term general hospital. Interview with employee E16, on August 29, 2024, at 1:30 p.m. revealed that the resident had been discharged to his home by staff, and that the assessment had been coded in error. 28 Pa Code 211.5(f) Clinical records 395852 Page 10 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, review of clinical records, and staff interviews, it was determined at the facility failed to develop a baseline care plan that includes the instructions needed to provide effective and person-centered care within 48 hours of admission for respiratory care, pressure ulcer, catheter, and pain for three of twenty-eight residents reviewed (Residennt R130, Resident R138 and Resident R444). Findings include: Review facility policy for baseline care plan, comprehensive care plan, and ongoing care plan updates dated April 1/20/22. Reveal that under section Policy Statement: Bedrock Care will follow a uniform process for initiating the baseline care plan upon admission, the Comprehensive Care Plan upon CAA completion and ensuring care plans are updated to reflect the resident's status. Under subsection baseline care plan. The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. The baseline care plan will: #1. Be developed within 48 hours of a residence admission; #a. The admitting nurse will initiate baseline care plan in facility electronic health record utilizing the nursing admission assessment and the admission Used Defined Assessment (UDA's), orders, and clinical knowledge of the resident. #2. Include the minimum health care information necessary to properly care for your resident, including but not limited to; #a. Initial goals based on admission orders, #b. Physician orders, #c. Dietary orders, #d. Therapy services, #e. social services, and #f. PASARR recommendations if applicable. The facility will provide the resident and the representative with the summary of the baseline care plan when requested. That includes, but not limited to, the initial goals of the resident, and a summary of the resident's medications and dietary instructions. This written summary of the baseline care plan must be provided to the resident and or the representative by completion of the comprehensive care plan. Review of Resident R130's clinical record revealed that Resident R130 was admitted to the facility on [DATE], with diagnoses of Chronic Kidney Disease (A long standing disease of the kidneys leading to renal failure), Burn of unspecified body region, Severe Protein Calorie Malnutrition, Sepsis (is a life threatening emergency that happens when the body's response to an infection damages vital organs and often causes death). Further review of Resident R130's clinical record revealed a physician's order obtained August 16, 2024 to insert Foley Catheter to promote sacrum wound healing. Further review of Resident R130's clinical record revealed that there was no baseline care plan for the unrinary catheter developed within 48 hours of Resident R130's admission. Review of Resident R138's clinical record revealed that Resident R138 was admitted to the facility on [DATE] with diagnoses of Extradural and Subdural Abscess, Dorsalgia (Dorsalgia is a collective name given to a group of conditions that produce moderate to intense pain in the muscles, nerves, bones, joints, or other structures associated with the spinal column of the body.), Osteomyelitis of the vertebra (lumbar region) and infective myositis (Infectious myositis is a rare infection of the skeletal muscles caused by a variety of pathogens, including bacteria, fungi, viruses, and parasites.) of unspecified left leg, Opioid Abuse. 395852 Page 11 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of Resident R138'd clinical record revealed a physician's order for: Oxycodone oral tablet 10 milligrams, give 10 milligrams by mouth every six hours as needed for pain-ordered August 19, 2024, Roxicodone 10 milligram tablet, give 2 tablets by mouth every six hours as needed for pain for 10 days-ordered August 7, 2024, Ibuprofen oral tablets 600 milligrams, give one tablet by mouth three times a day for pain for 10 days-ordered August 7, 2024, Gabapentin Oral capsule 400 milligrams, give 2 capsules by mouth every eight hours for a neuropathy for 360 days-order date August 7, 2024, Acetaminophen Tablet 325 milligrams. Give 2 tablets by mouth every eight hours for pain, for 10 days- ordered August 7, 2024, Lidocaine external patch 5% applied to affected area topically in the morning for pain and remove per schedule-ordered August 8, 2024. Further review of Resident R138's clinical record revealed that there was no baseline care plan for pain management developed within 48 hours of Resident R138's admission. Review of Resident R444's clinical record revealed that Resident R444 was admitted to the facility on [DATE], with diagnoses of Anoxic brain damage, Type 2 diabetes mellitus. Pressure ulcer, Tracheostomy Status (tracheostomy in place) Review of Resident R444's clinical record revealed a physician's order for: Santyl external ointment, 250 units per gram, apply to sacrum topically every day shift for wound. Cleanse sacrum with NS (normal saline), pat dry apply Santyl ointment adaptic bordered dressing-ordered August 23, 2024, Santyl external ointment, 250 unit per gram apply to sacrum topically as needed for wound. Cleanse Sacrum with NS (normal saline), pat dry apply Santyl ointment, adaptic border dressing-order date August 22, 2024, #8 Shiley Cuffed/Non-Fenestrated trach every shift -Start Date-August 22, 2024, Oxygen humidification: O2 5 liters via trach collar, 28% humidification every shift 5L-Start Date- August 22, 2024, Suction trach PRN every shift-Start Date-August 22, 2024 Further review of Resident R444's clinical record revealed that there was no baseline care plan for wound-care, pressure ulcer or skin breakdown developed within 48 hours of Resident R444's admission. 28 Pa. Code 211.10(d) Resident care policies 395852 Page 12 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, and interviews with staff it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for three of twenty-eight residents reviewed. (Residents R31, R55, R97) Findings Include: Review of facility policy titled Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates dated April 1, 2022 states, Policy Statement- Facility will follow a uniform process for initiating the baseline care plan upon admission, The Comprehensive care plan upon CAA completion, and ensure care plans are updated to reflect the resident's status. Further review of the policy states, Ongoing updates to care plans- Nursing staff will update the care plan related to physician's orders and/or changes in care needs. The nursing staff will initiate and/or update acute care plans for the resident as they are warranted. Resident R31 was observed on August 27, 2024 at 11:01 a.m. with oxygen on. Review of Resident R31's care plan revealed there was no current care in place for oxygen therapy. Review of Resident R31's current physician orders revealed an order for oxygen therapy that was initiated on September 30, 2023. An interview held with the Director of Nursing, Employee E2 on August 30, 2024 at 12:02 p.m. confirmed Resident R31's current care plan did not have oxygen therapy included. Employee E2 provided a document that showed Resident R31 did have a care plan in place for Oxygen therapy but the focus was checked off as resolved/cancelled. Review of Resident R55's clinical record revealed the resident had a diagnosis of Dementia. Review of the resident's care plan revealed the resident did not have a care plan focus in place for the Dementia (progressive degenerative disease of the brain) diagnosis. An interview with the Director of Nursing Employee E2 at 10:29 a.m. confirmed that Resident R55 did not have a current care plan focus in place for Dementia care. Review of the clinical record for resident R97 revealed that he was admitted to the facility on [DATE], and had diagnoses including, but not limited to, acute and chronic respiratory failure, aphasia (inability to process speech), anoxic brain damage (caused by going for an extended period of time without oxygen), and encounter for attention to gastrostomy (an opening made into the stomach through the abdominal wall, in this case for the purpose of inserting a tube to assist with feeding). Review of the resident's care plan revealed that it included instructions for both every shift Jevity 1.5 (a type of nutrition made to go through a gastrostomy tube) @65 mL x12 hrs TV = 780 mL via PEG Which was ordered May 16, 2024, and ISOSOURCE (another type of tube feed formula) 1.5 x20 hrs total volume=1,200 mL via PEG, which was ordered on May 11, 2024. According to review of the resident's physician orders, the isosource had been discontinued on May 16, 2024. During an interview on August 30, 2024 at 11:00 a.m., the Director of Nursing, Employee E2, confirmed that only the Jevity order was active and that the care plan should have been revised to remove 395852 Page 13 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0657 the isosource instrutions. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(5) Nursing Services. Residents Affected - Few 395852 Page 14 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, review of facility policy, and interviews with residents and staff, it was determined the facility failed obtain a physican order for tracheostomy care and suctioning for one resident and failed to notify the physician after one resident missed medication doses for two out of 28 residents reviewed. (Resident R 97 and Resident R138) Residents Affected - Few Findings include: Tracheostomy care observation for Resident R97 with Employee E17 conducted on August 30, 2024, at 8:50 am revealed that Employee E17 performed tracheostomy care dressing of tracheostomy site with normal saline, replaced the disposable inner cannula and suctioned Resident R97. Review of Resident R97's clinical record revealed that there was no physician's order to suction Resident R97. Interview with Director of Nursing, Employee E2 conducted on August 30, 2024, at 9:38 a.m. confirmed that there were no orders for suctioning. Employee E2 further stated that she will have an order for suctioning put in. Review of Resident R138's clinical record revealed that Resident R138 was admitted to the facility on [DATE] with diagnoses of Extradural and Subdural Abscess, Dorsalgia (Dorsalgia is a collective name given to a group of conditions that produce moderate to intense pain in the muscles, nerves, bones, joints, or other structures associated with the spinal column of the body.), Osteomyelitis of the vertebra (lumbar region) and infective myositis (Infectious myositis is a rare infection of the skeletal muscles caused by a variety of pathogens, including bacteria, fungi, viruses, and parasites) of unspecified left leg, Opioid Abuse. Further review of Resident 138's clinical record revealed the following physician's order : Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously one time a day for Infection for 32 Days-Start Date-08/08/2024-D/C Date-08/10/2024 Daptomycin- Sodium Chloride Intravenous Solution 500-0.9 MG/50ML- % Use 475 mg intravenously one time a day for Infection for 32 Days-Start Date-08/11/2024-D/C Date-08/19/2024 Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously at bedtime for Infection for 32 Days-Start Date-08/19/2024-D/C Date- 08/20/2024 Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously at bedtime for Infection for 32 Days-Start Date-08/21/2024 Reviews of Resident R138's MAR (medication administration record) for August 2024 revealed that on August 10, 2024, the MAR was coded 5; on August 12. 2024, the MAR was coded 9; on August 18, 2024, the MAR was coded 9; on August 19, 2024, the MAR was coded 9; on August 25, 2024, the MAR was coded 5 and on August 27, 2024, the MAR was coded 9. 395852 Page 15 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the MAR Code Chart revealed that 5 was for Hold/see progress note and 9 was for Other/see progress notes. Review of Resident R138's progress notes revealed the following notes: On August 26, 2024, 6:16 NOT GIVEN: Resident AAOx4, able to make needs known. Waiting on Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML, from pharmacy. Resident did not receive ABT I.V. There was no documented evidence that the physician was made aware that Daptomycin was not administered to Resident R138. Review of MAR revealed that the MAR was coded as given. On August 25, 2024, 12:57 NOT GIVEN: Resident AAOx4, able to make needs known. Waiting on Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML, from pharmacy. Resident did not receive ABT I.V. Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML. There was no documented evidence that the physician was made aware that Daptomycin was not administered to Resident R138. On August 25, 2024, 22:04 NOT GIVEN: Resident AAOx4, able to make needs known. Pharmacy was called and notified about ABT on Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML, from pharmacy. Pharmacy said it will arrive tomorrow by Noon. Resident did not receive ABT I.V. Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML on shift. There was no documented evidence that the physician was made aware that Daptomycin was not administered to Resident R138. On August 25, 2024, 6:24 NOT GIVEN: Resident continues on I.V. ABT, no s/s of adverse reaction, afebrile during this shift. RUE PICC site in place, no s/s of infection, bleeding. Resident denies pain/discomfort during this shift. Resident didn't receive I.V. awaiting pharmacy to delivery later today, DON (director of nursing) made aware. There was no documented evidence that the physician was made aware that Daptomycin was not administered to Resident R138. There was no documented evidence that the physician was made aware that Daptomycin was not administered to Resident R138. On August 25, 2024, NOT GIVEN: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously at bedtime for Infection for 32 Days Awaiting pharmacy to delivery. There was no documented evidence that the physician was made aware that Daptomycin was not administered to Resident R138. August 19, 2024, 21:23 NOT GIVEN: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously at bedtime for Infection for 32 Days not administered, waiting pharmacy delivery, supervisor informed. There was no documented evidence that the physician was made aware that Daptomycin was not administered to Resident R138. August 18, 2024, 11:21 NOT GIVEN: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously one time a day for Infection for 32 Days Medication unavailable, waiting on pharmacy. There was no documented evidence that the physician was made aware that Daptomycin was not administered to Resident R138. August 12, 2024, 9:56 NOT GIVEN: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously one time a day for Infection for 32 Days pending delivery. There was no documented evidence that the physician was made aware that Daptomycin was not administered to Resident R138. 28 Pa. Code 211.9(d) Pharmacy services 395852 Page 16 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0684 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395852 Page 17 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, review of clinical records, observations, and interviews with staff, it was determined that the facility failed to ensure that physician orders were followed regarding oxygen administration for two of two residents observed on oxygen. (Resident R4 and R31) Residents Affected - Few Findings Include: Review of facility policy titled, Oxygen Administration with a policy date of December 4, 2023 state, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. Steps in the Procedure: Wash and dry your hands thoroughly. Remove all potentially flammable items from the immediate area where the oxygen is to be administered. Check the tubing connected to the oxygen cylinder to assure that it is free or kinks. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. Observation on August 27, 2024 at 9:55 a.m. revealed Resident R4's oxygen was administered and was set at 5 liters. Review of the resident's clinical record revealed an order for continuous oxygen at a rate of 2 liters. Review of Resident R4's clinical record revealed the resident was re-admitted to the facility August 27, 2022 with the following diagnoses: cerebral palsy (a group of conditions that affect movement and posture caused by brain damage before birth), pneumonia (an infection of the air sacs in one of both lungs), asthma (a condition in which the airways narrow and swell) . Interview and observation of Resident R4's oxygen with licensed nurse Employee E9 on August 27, 2024 at 12:04 p.m. revealed Resident R4's oxygen was set wrong and the licensed nurse Employee E9 reset the level to 2 liters. Observation on August 27, 2024 at 10:10 a.m. revealed Resident R31's oxygen was administered and was set at 1 liter. Review of the resident's clinical record revealed an order for continuous oxygen at a rate of 3 liters. Interview and observation of Resident R31's oxygen with licensed nurse Employee E8 at 12:18 p.m. revealed Resident R31's oxygen was set wrong and the licensed nurse Employee E31 reset the level to 3 Liters. 28 Pa. Code 211.12(d)(1)(2) Nursing Services 395852 Page 18 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to maintain ongoing communication between the facility and a dialysis provider for three of eight dialysis residents reviewed (Residents R44, R133 and R28). Residents Affected - Few Findings include: A review of the Dialysis Policy dated April 1, 2022, revealed that the facility will utilize the Dialysis Communication form each time a resident attends dialysis as a tool to relay pertinent information regarding the resident's condition and coordinate care and services with the dialysis provider. Review of Resident R33's clinical record revealed that the resident was admitted on [DATE], with diagnoses including but not limited to end stage renal disease (condition where the kidney reaches advanced state of loss of function). Further review of Resident 33's clinical record revealed that the resident has dialysis treatments three times per week on Monday, Wednesday and Friday at 5:15 a.m. at a dialysis center. A review of Resident R33's dialysis communication book revealed that on four dates (June 26, 2024, July 12, 2024, August 19, 2024, and August 23, 2024) had no documented communication from the dialysis center. Further review revealed that on the August 16, 2024, log page there was no documentation from the facility nurse after the resident returned from dialysis. An interview on August 29, 2024, at 12:50 p.m. with the Licensed Nurse, Employee E9, confirmed the above findings, acknowledging that the log sheets should be completed each time the resident goes to dialysis, and that the dialysis center should be completing the middle section of the report, and the nurse on duty when the resident returns should complete the bottom section. 28 Pa. Code: 211.10(c) Resident care policies 28 Pa Code 211.5(f)(ix) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395852 Page 19 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on personnel records and interview with staff, it was determined that the facility did not provide requested evidence of competency trainings for licensed nursing staff for four of four employees records review. (Employees E9, E18, E20, and E21) Findings include: On August 29, 2024, at 2:15 p.m., the surveyor requested skills competency evaluations for Licensed Nurses, Employees E9, E18, E20, and E21. The requested skills were to related to medication administration, oxygen administration, care of gastrostomies and administration of nutrition, tracheostomy care, wound care, and abuse prevention and reporting. In an interview on August 30, 2024, at 10:30 a.m. with the Nursing Home Administrator, Employee E1, stated that the facility was unable to supply the surveyor with all of the requested skills competencies for the nurses, stating that they didn't have them. 28 Pa. Code: 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 395852 Page 20 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and interview with staff, it was determined that the facility did not provide requested evidence of yearly performance reviews for nurse aides. Residents Affected - Some Findings include: On August 29, 2024, at 12:39 p.m., an email was sent to the Nursing Home Administrator, Employee E1 requesting evidence of yearly performance reviews for nurse aides. During an interview on August 30, 2024, at 10:15 a.m. the Director of Nursing, Employee E2 stated that there were no yearly reviews for the nurse aides. 28 Pa. Code: 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 395852 Page 21 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, it was determined that the facility failed to provide pharmaceutical services to assure the acquiring and administering of medications to meet the residents need of one resident for one of twenty-eight residents reviewed. (Resident R138) Findings include: Review of Resident R138's clinical record revealed that Resident R138 was admitted to the facility on [DATE] with diagnoses of Extradural and Subdural Abscess, Dorsalgia (Dorsalgia is a collective name given to a group of conditions that produce moderate to intense pain in the muscles, nerves, bones, joints, or other structures associated with the spinal column of the body.), Osteomyelitis of the vertebra (lumbar region) and infective myositis (Infectious myositis is a rare infection of the skeletal muscles caused by a variety of pathogens, including bacteria, fungi, viruses, and parasites.)of unspecified left leg, Opioid Abuse. Further review of Resident 138's clinical record revealed the following physician's order for Daptomycin: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously one time a day for Infection for 32 Days-Start Date-08/08/2024-D/C Date-08/10/2024 Daptomycin- Sodium Chloride Intravenous Solution 500-0.9 MG/50ML- % Use 475 mg intravenously one time a day for Infection for 32 Days-Start Date-08/11/2024-D/C Date-08/19/2024 Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously at bedtime for Infection for 32 Days-Start Date-08/19/2024-D/C Date- 08/20/2024 Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously at bedtime for Infection for 32 Days-Start Date-08/21/2024 Reviews of Resident R138's MAR (medication administration record) for August 2024 revealed that on August 10, 2024, the MAR was coded 5; on August 12. 2024, the MAR was coded 9; on August 18, 2024, the MAR was coded 9; on August 19, 2024, the MAR was coded 9; on August 25, 2024, the MAR was coded 5 and on August 27, 2024, the MAR was coded 9. Review of the MAR Code Chart revealed that 5 was for Hold/see progress note and 9 was for Other/see progress notes. Review of Resident R138's progress notes revealed the following notes: On August 27, 2024, NOT GIVEN: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously at bedtime for Infection for 32 Days. Attempted to call pharmacy several times, spoke with Dr. [NAME]. Medication was not delivered overnight. On call pharmacy told me to call back after 8am to speak with pharmacist, they are not available right now. 395852 Page 22 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On August 26, 2024, 6:16 NOT GIVEN: Resident AAOx4, able to make needs known. Waiting on Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML, from pharmacy. Resident did not receive ABT I.V. On August 25, 2024, 12:57 NOT GIVEN: Resident AAOx4, able to make needs known. Waiting on Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML, from pharmacy. Resident did not receive ABT I.V. Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML. On August 25, 2024, 22:04 NOT GIVEN: Resident AAOx4, able to make needs known. Pharmacy was called and notified about ABT on Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML, from pharmacy. Pharmacy said it will arrive tomorrow by Noon. Resident did not receive ABT I.V. Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML on shift. On August 25, 2024, 6:24 NOT GIVEN: Resident continues on I.V. ABT, no s/s of adverse reaction, afebrile during this shift. RUE PICC site in place, no s/s of infection, bleeding. Resident denies pain/discomfort during this shift. Resident didn't receive I.V. awaiting pharmacy to delivery later today, DON (director of nursing) made aware. On August 25, 2024, NOT GIVEN: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously at bedtime for Infection for 32 Days Awaiting pharmacy to delivery. August 19, 2024, 21:23 NOT GIVEN: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously at bedtime for Infection for 32 Days not administered, waiting pharmacy delivery, supervisor informed. August 18, 2024, 11:21 NOT GIVEN: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously one time a day for Infection for 32 Days Medication unavailable, waiting on pharmacy. August 12, 2024, 9:56 NOT GIVEN: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-% Use 475 mg intravenously one time a day for Infection for 32 Days pending delivery. 28 Pa. Code 211.9(d) Pharmacy services 395852 Page 23 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for three of 36 residents clinical records reviewed (Resident R18 and R35). Findings Include: Review of the Pharmacy Services: Drug Regimen Review Policy dated October 24, 2022, revealed, the pharmacist will report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports will be acted upon. Review of Resident R18's clinical record revealed that resident was admitted on [DATE], with diagnoses including anxiety. A review of Resident R18's pharmacy progress notes revealed the following note: August 6, 2024 - Medication Regimen Reviewed. Recommendations made. SeeMedication Regimen Review Report. Further review of Resident R18's clinical record revealed no further pharmacy notes or recommendations related to the August 6, 2024, recommendation. Interview with the Director of Nursing on August 30, 2024, at 11:15 p.m. confirmed that there was no further documentation available for review for the related to the August 6, 2024, recommendation. Review of Resident R35's clinical record revealed that resident was admitted on [DATE], with diagnoses including depression and post-traumatic stress disorder. A review of Resident R35's pharmacy progress notes revealed the following note: July 16, 2024 - Medication Regimen Reviewed. Recommendations made. See Medication Regimen Review Report. Further review of Resident R35's clinical record revealed no further pharmacy notes or recommendations related to the July 16, 2024, recommendation. Interview with the Director of Nursing on August 30, 2024, at 11:15 p.m. confirmed that there was no further documentation available for review for the related to the July 16, 2024, recommendation. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 395852 Page 24 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employees E4). Residents Affected - Few Findings include: An interview on August 27, 2024, at 9:30 a.m. with Employee E4, Food Service Director (FSD), revealed that her responsibilities included oversight of ordering, receiving, storing, preparation and service of food. Further interview with the FSD confirmed that she was not currently a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; or had an associate's or higher degree in food service management or hospitality from an accredited institution; and that she had not received frequently scheduled consultations from a qualified dietitian. A review of Employee E4's credentials revealed that Employee E4 did not meet the statutory qualifications of a director of food and nutrition services. During an interview on August 30, 2024, at 10:30 a.m. with the Administrator, the FSD's personnel file was reviewed, and her qualifications were discussed which revealed she had been working at the facility for over a year and was not a Certified Dietary Manager or Certified Food Manager. The Administrator confirmed that the FSD had not completed these requirements. The Nursing Home Administrator was unable to provide evidence that the FSD was Certified, and therefore unqualified to direct the dietary department. 28 Pa. Code 211.6(c)(d) Dietary services 28 Pa Code 201.18(e)(1)(6) Management 395852 Page 25 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature for three of eight residents interviewed (Residents R52, R236 and R6). Residents Affected - Few Findings include: A review of Test Tray form revealed that the standard temperature range for Entrée, Starch and Vegetable was 135° F, and milk and cold beverage were 45° F. Interview on the second floor with Resident R52 on August 27, 2024, at 10:40 AM revealed that the food is not great, and not aways warm enough, and too many eggs, and has not been getting her milk. Interview on the second floor with Resident R136 on August 27, 2024, at 10:45 AM, at 10:55 AM revealed that for the past four to five days he was not getting coffee, no milk and no ice cream listed on his ticket, and for breakfast he is only getting one yogurt, and the food is not always hot when he is served. Interview on the second floor with Resident R77 on August 27, 2024, at 10:50 AM revealed that she does not like the food, it is of poor quality, no variety, that especially the vegetables are overcooked and mushy, and that the food is not always warm enough. Interview on the second floor with Resident R132 on August 27, 2024, at 10:55 AM revealed that the resident had issues with meals and was tired of complaining, he also said that he should be getting double portions and that his food is not always warm. Observations during a test tray conducted with Employee E3, Food Service Director, on August 28, 2024, at 12:20 PM revealed that the chicken was 116.8 degrees, the potatoes were 114.5 degrees, the broccoli was 108 degrees, the milk was 50 degrees, and the hot tea was 116.6 degrees. Tasting revealed that the hot food was too cool and the hot water was not warm enough to steep the tea. An interview with the Dietary Staff, Employee E4, on August 28, 2024, at 12:20 PM confirmed that the hot foods and hot water were too cool to be palatable. Interviews with residents during Resident Council on August 29, 2024 at 10:00 a.m. revealed residents had complaints about the food palatability at the facility. The following resident described the food as cold when it was supposed to be hot, having bad texture, and not being offered alternatives: Resident R1, R14, R44, R98. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.6(f) Dietary services 395852 Page 26 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: An initial tour of the Food Service Department was conducted on August 27, 2024, at 9:30 a.m. with Employee E4, Food Service Director (FSD), which revealed the following: Observation in the receiving area revealed trash including paper and plastic on the ground near the door and dumpster. Observation in the walk-in refrigerator revealed a dark substance on the walls and an accumulation of dirt and dust on the floor, especially in the corners. Observation in the hot food production area revealed a prep table with the undershelf setting directly on the ground, the shelf was pitted with rust colored stains and there was no way to clean under it without moving it. Further observations revealed the outsides of the convection oven and reach-in refrigerator were covered with a layer of grease and grime, and the door gaskets were torn on the right door of the reach in refrigerator. The interior of the convection ovens were also covered in a build-up of dark colored baked on coating of burned food. Observations of the dish machine revealed a build-up of light brownish substance in the corners of the top of the machine. Interview with FSD on August 27, 2024, at 9:45 a.m., confirmed the above findings. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management 395852 Page 27 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility documents and resident clinical records and interviews with staff and residents, it was determined that the facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for three of nine residents reviewed (Resident R56). Residents Affected - Few Findings include: Review of Attachment 19, Binding Arbitration Agreement, found on page 72 of the facilities admission Agreement revealed, The Arbitration Agreement was explained to the Resident, his/her Resident Representative, or Guardian with legal authority to enter into the Arbitration Agreement in the case of a Resident without capacity signing below, in a form and manner that he or she understands, including in a language the Resident and his/her Resident Representative signing below understand. Interview on August 29, 2024, at 1:15 p.m., with the Administrator, who was on the phone with the admission Director, who was home on a medical leave, revealed that the admission Director stated that all arbitration agreements were always signed as part of the admission agreement, and no resident had refused to sign the arbitration agreement. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of admission record indicated Resident R56 was admitted to the facility on [DATE]. Review of Resident R56's Minimum Data Set (MDS - a periodic assessment of care needs) dated August 6, 2023, indicated the diagnoses of stroke and dementia (progressive degenerative disease of the brain). The resident was assessed with a BIMS (Brief Interview of Mental Status) score of 3 - severe impairment of cognition. Review of Resident R56's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated that he signed the document (typed in script) on admission on [DATE]. Interview on May 16, 2024, at 2:05 p.m. with the Nursing Home Administrator confirmed that this resident had a low BIMS score, indicating severe cognitive impairment, and should not have been signing admissions documents including the binding arbitration agreement as he did not have the capacity to understand the terms of a binding arbitration agreement. 395852 Page 28 of 29 395852 08/30/2024 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0847 28 Pa. Code: 201.14(a)(c)(d)(e) Responsibility of licensee. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395852 Page 29 of 29