Health inspection·June 13, 2025

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Based staff interviews, review of facility policy and the review of the clinical record, it was determined that the facility failed to ensure that a resident received proper notification for a room change, and failed to ensure that the resident had the opportunity to refuse a room change for 1 out of 29 residents reviewed (Resident R11). Findings include: Review of the facility policy, Room Change/Roommate Assignment, dated April 1, 2022 indicated that changes in room or roommate assignment shall be made when the facility deems it necessary or when the resident requests the change. Changes in room or roommate assignment shall be made when the facility deems it necessary or when the resident requests the change. The policy also stated that prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents or their representatives (sponsors)) will be given advance notice of such change. Continued review of the policy indicated that he notice of a change in room or roommate assignment may be oral or in writing, or both, and will include the reason(s) for such change. Review of the June 2025 physician orders for Resident R11 included the following diagnoses epilepsy; hypertension (high blood pressure) and muscle weakness. During an interview Resident R11 on June 10, 2025 at 10:30 a.m. the resident reported he was told that he had to move from the st floor because the first floor was only for short term residents. The resident reported that he told the facility that he did not want to move. I told them that I did not want to move. Review of the resident's clinical record revealed a Roommate Change-Advanced Notification form dated April 23, 2025 indicating that on the above referenced date, the resident was moved from the1st floor to the 3rd floor on April 23, 2025 and that the reason for the room change was switch from skilled unit to long-term care unit. Review of a nursing note dated April 23, 2025 at 1:04 p.m. indicated that the resident was transferred from the 1st floor to the 3rd floor on the above referenced date. Review of the clinical record did not show evidence that the resident received advanced notice of the room changed (prior to April 23, 2025) and instead, was notified the same day that the room change occurred. Review of the clinical record also did not show evidence that the resident was allowed Page 1 of 24 395852 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0559 the opportunity to refuse the room change to the 3rd floor. Level of Harm - Minimal harm or potential for actual harm During a discussion with the Director of Nursing on June 13, 2025 at 12:15 p.m. , it was discussed that there was no evidence in the clinical record that the resident received advanced notice of his room change that occurred on April 23, 2025, and there was no evidence that the resident was provided with the right to refuse the room change to the 3rd floor. Residents Affected - Few The facility failed to ensure prior written notification was provided to Resident R11 and failed to ensure that the resident was provided with the opportunity to refuse the room change. 28 Pa. Code 201.14(a) Responsibility of licensee 29 Pa. Code 201.29(d) Resident rights 29 Pa. Code 201.29(j) Resident rights 395852 Page 2 of 24 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0584 Level of Harm - Minimal harm or potential for actual harm 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. Based on observations, resident and staff interviews, it was determined that facility failed maintain a safe, clean comfortable and home like environment for residents of one of three nursing units. (Third floor) Residents Affected - Few Findings Include: Observation of Third floor nursing unit on June 10, 2025, at 9:45 AM revealed there was a strong odor of urine throughout the South unit hallway. Observation of Third floor nursing unit on June 10, 2025, at 9:52 AM revealed there was a strong odor of urine throughout the [NAME] unit hallway. Interview with the Licensed Practical Nurse, Employee E23, on June 9, 2025, at 9:52 AM confirmed that there was strong odor of urine on both hallways. Employee E3 stated it could be from staff changing the residents. A follow up tour of the south hallway on June 10, 2025, at 10:00 AM revealed that there were no residents receiving incontinence care. Observation of Third floor nursing unit on June12, 2025, at 10:41 AM revealed there was strong odor of on the [NAME] hallway. Observation of the Third-floor dining room on June11, 2025, at 10:35 AM revealed that there was trash on the floor, liquid spill on the floor and table. There were breakfast trays sitting on the table. Residents were observed sitting in the dining room and watching TV at the time of the observation. Interview with the Housekeeping Director, Employee E24, on June 12, 2025, at 10:52 AM confirmed that there was strong odor on the third-floor hallway. He stated facility cleaned the rooms, but the odor still kept coming. He stated staff sprayed the hallway but it only lasted for 15 min and the odor comes back. 28 Pa Code: 201.14 (a) Responsibility of licensee. 395852 Page 3 of 24 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, facility documentation, review of clinical records, and staff interviews, it was determined that the facility failed to conduct a complete and thorough investigation related to abuse/neglect and misappropriation of resident property for three of four residents reviewed (Resident R303, R90 and R108.). Residents Affected - Some Findings Include: Review of facility policy Abuse, reviewed December 2024, revealed misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. It is the policy of the facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. Investigation regarding misappropriation should consist of, but not limited to, an interview with any witnesses to the incident, a search of resident room (with resident permission), interviews with the resident's roommate, family members, and visitors, a root-cause analysis of all circumstances surrounding the incident. Review of Resident R303's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 5, 2025, revealed the resident was cognitively intact, assessed by a Brief Interview for Mental Status (BIMS) score of 15. Review of documentation submitted to the Survey State Agency on February 20, 2025, revealed that Resident R303 reported that on February 15, 2025, nurse aide, Employee E16, allegedly stole $100 from the resident's purse while the nurse aide was in the room to provide care. Resident R303 subsequently provided the Nursing Home Administrator, Employee E1, with a copy of the receipt for the money Resident R303 withdrew from the ATM. Review of facility documentation revealed a statement dated February 20, 2025, by nurse aide, Employee E16, who denied stealing Resident R303's money. Nurse aide, Employee E16, was subsequently suspended pending an investigation. Interview on June 12, 2025, at 12:07 p.m. with the Director of Nursing, Employee E2, revealed no investigation was available for the allegations of misappropriation of resident's property. Review of facility documentation revealed no evidence that the facility obtained interviews with any witnesses to the incident, a search of the resident room (with resident permission), interview with family members or visitors, or interviews with resident's roommate or residents under the care of the same nurse aide in question. Interview on June 12, 2025, at 2:00 p.m. with the Nursing Home Administrator, Employee E1, revealed the statement by nurse aide, Employee E16, was all that was available for the investigation of misappropriation for Resident R303's allegedly stolen money. Review of the June 2025 physician orders for Resident R90 included the following diagnoses: dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities); muscle weakness and lack of coordination. 395852 Page 4 of 24 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the resident's Quarterly Minimum Data Set Assessment (MDS-periodic assessment of a resident's needs) dated September 13, 2024 indicated that the resident was severely cognitively impaired. Review of a reportable incident submitted to the State Survey Agency on October 16, 2024 indicated that on October 15, 2024 at approximately 3:30 p.m. Resident R90 fell out of her wheelchair in the hallway outside her room and was found lying on her left side. Continued review of the resident's fall report indicated that the resident was found on the floor in the hallway lying on her left side, and that the resident was unable to provide a description of what happened. Review of the fall report provided by the facility did not show evidence that the facility conducted a complete and through investigation (e.g. interviews with any staff members or residents who may have been present; no information on who found the resident on the floor )to rule out abuse/neglect. During an interview on June 12, 2025, at 12:07 p.m. with the Director of Nursing, Employee E2, revealed no investigation was available for the above referenced incident. Review of the June 2025 physician orders for Resident R108 included the following diagnoses: osteoarthritis of the knee; lack of coordination; morbid obesity; muscle weakness and difficulty walking. Review of the resident's Quarterly Minimum Data Set Assessment (MDS-periodic assessment of a resident's needs) for the resident dated October 28, 2024 indicated that the resident was awake, alert and oriented. Review of a reportable incident submitted to the State Survey Agency on October 30, 2024 indicated that on October 29, 2024, the resident sustained a fall while transferring from her bed to the wheelchair while using a mechanical lift with two nurse aides. Continued review of the reportable incident indicated that the sling broke during the transfer causing the resident to slide down in the sling and onto the floor. The resident was subsequently sent out to the hospital and treated for a left thumb sprain. The reportable incident also indicated that staff were interviewed, resident were interviewed, and that abuse was ruled out, and staff was able to confirm that the sling was connected correctly to the lift. Review of the information related to the investigation that was provided by the facility did not show evidence of a complete and through investigation to rule out abuse/neglect. The facility could not produce any interviwed regarding the incident from the nurse aides, other nursing staff, or the resident. It was also unknow if the facility investigated to ensure that the sling that the reportedly two nurse aides were utilizing during the transfer was the correct sling size for the resident's weight. During an interview on June 12, 2025, at 12:07 p.m. with the Director of Nursing, Employee E2, revealed no investigation was available for the above referenced incident. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.29 (a) Resident rights. 395852 Page 5 of 24 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital for 3 of 29 residents reviewed (Residents R83, R137 and R118). Findings Include: Clinical record review for Resident R83 revealed progress notes, dated October 15, 2024, at 11:18 a.m. and 1:06 p.m. which indicated that the resident had increased abdominal girth and no bowel movement in 72 hours (three days) and was ordered by the physician to be transferred to a local hospital for evaluation. Clinical record review for Resident R137 revealed a progress note, dated May 1, 2025, ay 11:12 p.m. which indicated that the resident had abnormal labs and was ordered by the physician to be transferred to a local hospital for evaluation. Review of Resident R118's clinical record revealed a nursing progress note dated January 19, 2025, that indicated the resident had an unwitnessed fall and sustained a hematoma (collection of blood that pools outside of blood vessels) to the head. Resident R118 was subsequently transferred to the local hospital for evaluation. Further review revealed that there was no indication that the Office of the State Long-Term Care Ombudsman was notified of the above facility-initiated emergency transfers for Residents R83, R137 and R118. Interview on June 12, 2025, at 9:26 p.m. Employee E3, Regional Nurse, confirmed that the Office of the State Long-Term Care Ombudsman was not notified in a timely manner as required of facility-initiated emergency transfers and discharges. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management 395852 Page 6 of 24 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure assessments accurately reflected the resident's status for four of 29 residents reviewed (Resident R127, R133, R128, and R142). Residents Affected - Some Findings Include: Review of the Centers for Medicare and Medicaid Services (CMS) Long Term Care RAI Manual dated October 2019 revealed the resident Minimum Data Set (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) included Section C: Cognitive Status which is used to determine the resident's attention, orientation, and ability to registry and recall information. Review of Resident R128's clinical record revealed a quarterly MDS dated [DATE]. Review of Resident R133's clinical record revealed an admission MDS dated [DATE]. Review of Section C: Cognitive Pattern for each above-mentioned residents' MDS, revealed section C0100 should brief interview for mental status [BIMS] (C0200-C0500) be conducted revealed this question was marked with a dash and left unanswered. Subsequently, the BIMS assessment was not conducted. Interview on June 12, 2025, with the Registered Nurse Assessment Coordinator (RNAC) confirmed BIMS assessments should have been done for Resident R128 and R133 but were unable to be completed timely for the MDS. Therefore, Section C of the MDS needed to be coded as no information. Review of Resident R127's comprehensive MDS dated [DATE], revealed the resident was admitted to the facility on [DATE], was determined cognitively intact, and had diagnoses of respiratory failure (definition) and tracheostomy status (definition). Review of Resident R127's comprehensive care plan dated April 24, 2025, revealed the resident had a tracheostomy related to impaired breathing mechanics. Interventions included to suction as needed. Continued review of Resident 127's comprehensive MDS dated [DATE], Section O revealed the facility was required to check off treatments, procedures, or programs that were received by the resident. Review of Section O - Special Treatments, Procedures, Programs revealed the facility failed to check off suctioning and tracheostomy care under the respiratory treatment category. Review of Resident R142's clinical record revealed a nursing note dated March 14, 2025, that the resident had a planned discharge home and was picked up by a friend. Resident R142 was noted to have received prescriptions and discharge instructions. Review of Resident R142's MDS dated [DATE], revealed section A2105. Discharge Status was marked incorrectly and indicated that Resident R142 was discharged to a short-term hospital. 28 Pa. Code 201.14 (a) Responsibility of licensee. 395852 Page 7 of 24 395852 06/13/2025 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 clinical record review and staff interview, it was determined that the facility failed to follow up dental consults related to recommendations for dentures, for 1 out of 29 residents reviewed (Resident R97). Residents Affected - Few Findings include: Review of the facility policy, Dental Services, with a date of April 1, 2022 indicated that the facility has a contract with a dentist who comes to the facility and provides dental services on a monthly basis. Continued review of the policy indicated that a designated staff member is responsible for assisting the resident/family in making dental appointments and transportation arrangements as necessary. Review of the June 2025 physician orders for Resident R97 included the diagnosis of dysphagia (difficulty swallowing). During an interview with Resident R97 on June 11, 2025 at 1:00 p.m. the resident reported that he has been trying to get help from the facility with getting new upper dentures, and that he has a hard time chewing his food properly due to no longer having his upper dentures. The resident reported that his teeth were thrown away on his food tray by staff, and that he was notified by the facility that Medicaid will not pay for replacement dentures. Residnet R97 was observed with no upper dentures/teeth in his mouth during the above referenced interview. Review of an onsite dental consultation visit dated April 4, 2025, indicated that the resident was seen for a visit by the dentist and reported patient claims that the facility lost his denture. Continued review of the dental consult asked for the facility to approve front upper dentures. Please approve FU. Review of the resident's clinical record did not include any evidence that the facility followed with the recommendations. Review of an onsite dental consultation visit dated April 15, 2025 indicated that the resident told the dentist that he is still waiting or his upper dentures and that staff [NAME] the dentures out. Pt stated he's waiting for his upper denture. He said the staff [sic] it out. Continued review of the dental consult indicated that the resident reported to the dentist that he was not able to eat without his teeth. Pt said he is not able to eat without his teeth. Review of the resident's clinical record did not include any evidence that the facility followed with the recommendations from the above referenced dental visit. During an interview with the Unit Manger (Employee E20) on June 13, 2025 at 10:54 a.m. the above-referenced dental consults were reviewed with the unit manager. The unit manager reported that after residents are seen by the dentist, the dentist provides the dental consults to the nurse, and the nurse writes a note in the clinical record regarding the dental consults. It was discussed with unit manager that there was nothing in the clinical record to indicate that anything was followed up with in regards to the resident's 2 dental visits. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services 28. Pa Code 211.15 Dental services 395852 Page 8 of 24 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on clinical record reviews and interviews with residents and staff, it was determined that the facility failed to assist a resident to obtain an audiologist consult for hearing aides, for one of 29 residents reviewed (Resident R117). Residents Affected - Few Findings include: Interview on June 10, 2025, at 11:27 a.m. Resident R117 stated that he had difficulty hearing and needed hearing aids. Resident R117 stated that he was evaluated by a doctor for hearing loss, but that he has not received his hearing aides yet. Clinical record review for Resident R117 revealed an Ear Nose and Throat (ENT) Consultation Report, dated June 18, 2024, which indicated that the resident had suspected hearing loss, and recommended an audiology (branch of medicine focused on hearing) and hearing aide evaluation. Further review of Resident R117's clinical record revealed that there was no documentation available for review at the time of the survey to indicate if the resident received the audiology and hearing aid evaluations that were recommended by the ENT specialist. Interview on June 12, 2025, at 9:26 a.m. Employee E3, Regional Nurse, confirmed that Resident R117 did not receive the audiology evaluation as recommended. 28 Pa Code 201.18(a)(1) Management 28 Pa Code 211.12(d)(3)(5) Nursing services 395852 Page 9 of 24 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on interviews with residents, review of facility policy and review of clinical records, it was determined that the facility failed to ensure that a device to prevent contractures was applied as order by the physician for one out of 29 residents reviewed (Resident R97) Findings include: Review of the June 2025 physician orders for Resident R97 included the following diagnosis: heart failure (occurs when the heart muscles don't pump blood as well as they should); diabetes (a disease characterized by high blood sugar levels); and dysphagia (difficulty swallowing). Continued review of June 2025 physician orders included a physician order with a start date of February 16, 2023 for RUE (right upper extremity) elbow extension splint and resting hand splint on in a.m. and off in p.m. with skin checks prior to donning (putting on) and post doffing (removing) every morning and at bedtime. Review of the resident's person-centered plan of care included a plan of care dated February 19, 2023 stating that the resident required restorative programs related to contracture management so that the resident would be able to maintain his current activities of daily living ability. The interventions outlined in the care plan associated with this goal included the resident participating in restorative programs to the best of his ability, in addition to wearing a right wrist support brace. During an interview with the resident on June 11, 2025 at 1:12 p.m. the resident was observed without any splints on. When asked if he wore a splints on his right hand/elbow the resident reported, I used to wear something on this hand (pointing to his right hand) but they took it. I don't know why. During an interview with the unit manger (Employee E20) on June 11, 2025 at 1:27 p.m. the physician's order for the splint were reviewed with the unit manager in the resident's electronic clinical record. The unit manager acknowledged that splint has not been applied to the resident. Review of the resident's Treatment Administration Record (TAR) and Medication Administration Record (MAR) did not show evidence that the splint was applied, as ordered, at anytime during June 1, 2025 through June 11, 2025. During an interview with the occupational therapist (Employee E21), on June 13, 2025 at 12:07 p.m., the occupational therapist reported that the resident does require the use of the right write and hand splint for the management of his tone. 28 Pa Code 211.12 (a)(c)(d)(5) Nursing services 28 Pa. Code: 211.5(f) Clinical records 395852 Page 10 of 24 395852 06/13/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, observations, and staff and resident interviews, it was determined that the facility failed to provide necessary respiratory care consistent with professional standards of practice for one of three residents reviewed for tracheostomy (Resident R127). Residents Affected - Few Findings Include: Review of facility policy Tracheostomy Care revised October 4, 2024, revealed it is the policy of the facility to establish standards for the care and maintenance of tracheostomy tubes. Per the policy, trach care sohuld be performed daily and as needed for dressing soilage. This includes removal of drain/dressing sponge and cleasing around stoma site and trach plate. Review of Resident R127's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 27, 2025, revealed the resident was admitted to the facility on [DATE], was determined cognitively intact, and had diagnoses of respiratory failure (when the respiratory system fails to maintain normal levels of oxygen and carbon dioxide in the blood) and tracheostomy status (surgical hole in the windpipe that helps with breathing with the use of a medical tracheostomy tube). Review of Resident R127's comprehensive care plan dated April 24, 2025, revealed the resident had a tracheostomy related to impaired breathing mechanics. Interventions included to ensure trach ties were secured at all times, suction as needed, monitor/document for signs ands symptoms in change of status, and to use universal precautions as appropriate. Observations June 11, 2025, at 10:45 a.m. confirmed Resident R127 had a tracheostomy and used a cap (a device that covers the opening of the tracheostomy tube, forcing the patient to breathe through the nose and mouth) on the end of the trach. Interview with Resident R127 on June 11, 2025, at 10:45 a.m. the resident reported tracheostomy care is not done daily by nursing staff. Review of Resident R127's clinical record revealed a physician order dated June 10, 2025, that the resident was ordered a #8 shiley cuffless dxLT (size and type of tracheostomy). Continued review of Resident R127's entire clinical record revealed no documented evidence the resident had physician orders or a comprehensive care plan for the daily care of the tracheostomy or orders/interventions for management of the cap used for the tracheostomy. Interview and observation on June 11, 2025, at 2:12 p.m. with Registered Nurse, Employee E18, revealed Resident R127 was wearing a #6 shiley cuffless tracheostomy tube and that the physician order was incorrect. Further interview on June 11, 2025, at 2:12 p.m. with Registered Nurse, Employee E18, confirmed Resident R127 did not have physician orders or documentation for the daily care/cleaning of the tracheostomy and no physician order for the management and use of the cap on the tracheostomy 28 Pa. Code 211.10 (c) Resident care policies. 395852 Page 11 of 24 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0695 28 Pa. Code 211.12 (d)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395852 Page 12 of 24 395852 06/13/2025 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 - Few 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 review of facility documentation, review of personnel files and interviews with staff, it was determined that the facility failed to assure that nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs for three of five personnel files of newly hired staff reviewed (Employees E8, E9 and E10). Findings include: Review of the facility's job description for nurse aides revealed that nurse aide staff are responsible for providing direct personal care to residents, including performing restorative nursing and rehabilitative procedures, serving meals trays, assisting residents with feeding, assisting residents with transferring, lifting and ambulating, and providing incontinence and skin care. Review of the facility's job description for licensed practical nurses (LPNs) revealed that LPNs are responsible for providing direct nursing care to residents, including administration of medications, treatments and direct care according to physician orders. Review of facility documentation of newly hired staff revealed that Employee E8 was hired by the facility on April 29, 2025, as a nurse aide; Employee E9 was hired by the facility on April 29, 2025, as a nurse aide; and Employee E10 was hired by the facility on April 29, 2025, as an LPN. Review of Employees E8, E9 and E10's personnel files revealed no evidence that the employees received any skills competency evaluations to ensure competency of hands-on skills and techniques necessary to care for residents' needs. Interview on June 11, 2025, at 1:25 p.m. the Director of Nursing confirmed that no hands-on skills evaluations for Employees E8, E9 and E10 were available for review at the time of the survey. 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(b) Staff development 395852 Page 13 of 24 395852 06/13/2025 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 a review of facility documentation and interviews with staff, it was determined that the facility failed to complete performance reviews for three of three nurse aides personnel files reviewed related to performance reviews as required (Employees E11, E12 and E13). Residents Affected - Few Findings include: Review of facility documentation pertaining to current employees, revealed that Employee E11 was hired by the facility as a nurse aide on July 14, 1996; Employee E12 was hired as a nurse aide on September 15, 1988; and Employee E13 was hired as a nurse aide on November 26, 2007. Interview on June 11, 2025, at 10:03 a.m. Employee E5, HR Director, revealed that the facility had not completed any performance reviews for any staff, including Employees E11, E12 and E13. 28 Pa. Code 201.19(2) Personnel policies and procedures 395852 Page 14 of 24 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and review of manufacturers' guidelines, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards of practice for two of four medication carts observed. (Third floor east and south medication carts). Findings Include: Review of manufacturer's guidelines for Humalog Insulin (insulin lispro) (medication used to treat high blood sugar levels) revealed that Humalog must be discarded 28 days after opening. Review of manufacturer's guidelines for Lantus Insulin(insulin glargine) revealed that the medication must be discarded 28 days after opening. Review of manufacturer's guidelines for Novolin Insulin revealed that the medication must be discarded 28 days after opening. Review of manufacturer's guidelines for Novolog Insulin (insulin aspart) revealed that the medication must be discarded 28 days after opening. Unopened vials should be refrigerated unit use. Observation on [DATE], at 9:52 a.m. of the second-floor south medication cart with Licensed Practical Nurse, Employee E25, revealed open and undated vials of 2 Novolin vials, 3 Lantus vials and 5 lispro vials. There was also one vial of expired Lispro and one vials of expired Novolin in the cart. These observations were confirmed by Employee E25. Observation on [DATE], at 10:00 a.m. of the second-floor east medication cart with Licensed Practical Nurse, Employee E23, revealed open and undated one NovoLog vial, 2 Lantus vials and one Aspart vial in the cart. There were also numerous unidentified loose pills behind the medication containers on the top drawer. These observations were confirmed by Employee E23. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395852 Page 15 of 24 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records and staff interview. it was determined that the facility failed to ensure that a resident with out dentures was assess for speech rehabilitation services for 1 out of 29 residents reviewed (Resident R97). Residents Affected - Few Findings include: Review of the June 2025 physician orders for Resident R97 included the diagnosis of dysphagia (difficulty swallowing). During an interview with Resident R97 on June 11, 2025 at 1:00 p.m. the resident reported that he has been trying to get help from the facility with getting new upper dentures, and that he has a hard time chewing his food properly due to no longer having his upper dentures. The resident reported that his teeth were thrown away on his food tray by staff, and that he was notified by the facility that Medicaid will not pay for replacement dentures. Residnet R97 was observed with no upper dentures/teeth in his mouth during the above referenced interview. Review of an onsite dental consultation visit dated April 15, 2025 indicated that the resident told the dentist that he is still waiting or his upper dentures and that staff [NAME] the dentures out. Pt stated he's waiting for his upper denture. He said the staff [sic] it out. Continued review of the dental consult indicated that the resident reported to the dentist that he was not able to eat without his teeth. Pt said he is not able to eat without his teeth. Review of the resident's clinical record did not include any evidence that the facility referred resident to speech therapy due to the resident stating to the dentist that he was having trouble eating without his upper dentures. During an interview with the Director of Rehabilitation (Employee E21) on June 13, 2025 at 12:07 p.m. the Director of Rehab reported that there was no evidence that the speech therapist assessed the resident after any of his dental visits in April 2025 at any time in April 2005 through the current month of June 2025. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services 28. Pa Code 211.15 Dental services 395852 Page 16 of 24 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0838 Level of Harm - Potential for minimal harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on review of facility documentation and interviews with staff, it was determined that the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies, as required. Findings include: Review of facility documentation, Facility Matrix, dated June 10, 2025, revealed that the facility had a census of 144 residents. Continued review revealed that 58 residents required dementia care, 12 residents required care of pressure ulcers, 11 residents required indwelling catheter care, 5 residents required dialysis, 4 residents required hospice, 4 residents required intravenous therapy, 7 residents required feeding tube care, 3 residents required tracheostomy care, 6 residents required transmission based precautions, and 2 residents required trauma-informed care. The Facility Assessment was requested by State Agents on June 10, 2025, at 10:21 a.m. and again on June 11, 2025, at 1:30 p.m. Interview on June 11, 2025, at 1:31 p.m. the Nursing Home Administrator revealed that the Facility Assessment was not available for review at the time of the survey. 28 Pa. Code 201.14(a) Responsibility of licensee 395852 Page 17 of 24 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, facility documentation, and staff interviews it was determined that the facility failed to implement appropriate tracking and surveillance of infection for five of five months of infection surveillance data reviewed. (January 2025 through May 2025) Residents Affected - Some Findings Include: Review of facility policy Surveillance, June 2025, revealed The ongoing, systematic collection, analysis, and interpreta1ion of health data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know. The Infection Preventionist will monitor new infections and antibiotic. The Infection Preventionist is encouraged to map out the HAI onto a facility map monthly to rule out concerns/ patterns with care givers. The surveillance sheet will capture the following information : o Name o Room o Unit o Indication where acquired o CAI = community-acquired infection o HAI = hospital-acquired infection o NHAI = nursing home-acquired infection o Other Nosocomial = acquired in another health care setting o New infections/ ABT use o Signs/ Symptoms o Onset Date o Type of Infection o Antibiotic (HAI and community acquired) o Prescribing Physician o Dose 395852 Page 18 of 24 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0880 o Start and End date Level of Harm - Minimal harm or potential for actual harm o Total Days o X-Ray/ Labs Results Residents Affected - Some o Cultures o Organism identified o Date of Culture (if applicable) o Cultures ordered during stay o Cultures results during stay o ESBL, Cdiff, MRSA, VRE, CRE o Indicate Diagnostic Tool Used o Whether criteria were met A request was made to Director of Nursing, Employee E2 for infection tracking of the facility on June 10, 2025. Review of facility infection tracking for the month of January 2025 revealed that the facility had 11 infections for the month of January 2025. 10 of those infections were facility acquired. The tracking did not include signs and symptoms or stop dates for the antibiotics. Review of January 2025 pharmacy order report revealed that the facility had 15 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Review of facility infection tracking for the month of February 2025 revealed that the 2nd floor had 2 infections for the month of February. Both of those infections were facility acquired. The tracking did not include signs and symptoms or stop dates for the antibiotics. There was no tracking available for 3rd floor. Review of February 2025 pharmacy order report revealed that the facility had 5 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Review of facility infection tracking for the month of March 2025 revealed that the 3rd floor had 3 infections for the month of March 2025. All three of those infections were facility acquired. The tracking did not include signs and symptoms or stop dates for the antibiotics. Review of February 2025 pharmacy order report revealed that the facility had 5 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Review of March 2025 pharmacy order report revealed that the facility had 14 residents/infections with antibiotics ordered which was not consistent with facility tracking form. 395852 Page 19 of 24 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of facility infection tracking for the month of April 2025 revealed that the facility had 5 infections for the month of April. 3 of those infections were facility acquired. The tracking did not include signs and symptoms or stop dates for the antibiotics. Review of April 2025 pharmacy order report revealed that the facility had 13 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Review of facility documentation revealed that no infection tracking for were available for May 2025. Review of May 2025 pharmacy order report revealed that the facility had 12 residents/infections with antibiotics ordered which was not consistent with facility tracking form Interview with Employee E2, Director of Nursing on June 11, 2025, at 2 p.m. confirmed that the facility did not have complete infection surveillance including the tracking of signs and symptoms. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395852 Page 20 of 24 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm 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 that includes antibiotic use protocols and a system to effectively monitor antibiotic usage for 10 of 10 months of antibiotic stewardship program data reviewed. (January 2025, February 2025, March 2025, April 2025, and May 2025). Residents Affected - Some Findings Include: A review of CDC (Centers for Disease Control and Prevention) guidelines, The core element of Antibiotic Stewardship for Nursing Homes, revealed that Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. 1. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.2 The Centers for Disease Control and Prevention (CDC) recommends that all acute care hospitals implement an antibiotic stewardship program (ASP) and outlined the seven core elements which are necessary for implementing successful ASPs.2 CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether feedback is effective in changing prescribing behaviors. Integrate the dispensing and consultant pharmacists into the clinical care team as key partners in supporting antibiotic stewardship in nursing homes. Pharmacists can provide assistance in ensuring antibiotics are ordered appropriately, reviewing culture data, and developing antibiotic monitoring and infection management guidance in collaboration with nursing and clinical leaders. Identify clinical situations which may be driving inappropriate courses of antibiotics such as asymptomatic bacteriuria or urinary tract infection prophylaxis and implement specific interventions to improve use. Perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians. Track the amount of antibiotic used in your nursing home to review patterns of use and determine the impact of new stewardship interventions. Some antibiotic use measures (e.g., prevalence surveys) provide a snap-shot of information; while others, like nursing home initiated antibiotic starts and days of therapy (DOT) are calculated and tracked on an ongoing basis. Selecting which antibiotic use measure to track should be based on the type of practice intervention being implemented. Interventions designed to shorten the duration of antibiotic courses, or discontinue antibiotics based on post-prescription review (i.e., antibiotic time-out), may not necessarily change the rate of antibiotic starts, but would decrease the antibiotic DOT. 395852 Page 21 of 24 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of facility policy, Antimicrobial Stewardship Program, dated February 2025 revealed that Since antimicrobials are frequently over or inappropriately prescribed, a concerted effort to decrease or eliminate inappropriate use can make a big impact on resident safety and the reduction of adverse events. Antimicrobial stewardship consists of coordinated interventions aimed at treating infections while promoting appropriate antimicrobial use. The practice of antimicrobial stewardship requires commitment, leadership, communication, and actions informed by best practice guidelines and defined protocols. In compliance with the current Centers for Medicare and Medicaid Services (CMS} Requirements of Participation for infection control in long-term care facilities, this Antimicrobial Stewardship Policy outlines how the facility will address this important health care issue. Actions Prescription record keeping. Dose, duration, route, and indication of every antimicrobial prescription MUST be documented in the medical record for every resident, regardless of prior prescriptions or documentation elsewhere (e .g., in medical record of a discharging facility). Notation of this information should be made on the day that an in-house prescription is written or on the day that a resident returns to the facility on an antimicrobial prescribed elsewhere. Records will be reviewed monthly to assess compliance with this require ent swell as prescription appropriateness for the individual resident, site, and type of infection. Assessment of residents suspected of having an infection. Provider will utilize the Pennsylvania Patient Safety Reporting (PA-PSRS} Criteria when considering initiation of antimicrobials for suspected infections including; urinary tract infections, respiratory tract infections, gastrointestinal infections, skin and soft tissue infections and device related blood stream infections. Antimicrobial time-out. At 72 hours after antimicrobial initiation or first dose in the facility, each resident will be reassessed for consideration o l antimicrobial need, duration, selection, and de-escalation potential. At this time, laboratory testing results, response to therapy, resident condition, and facility needs (e . , outbreak situation) will be considered. Completion of an antimicrobial time out must be recorded in the resident record. 395852 Page 22 of 24 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0881 Level of Harm - Minimal harm or potential for actual harm Review of facility antibiotic stewardship/surveillance data provided by the facility during the survey revealed that the facility only completed 10 resident infection review from January 2025 to June 2025. Review of January 2025 pharmacy order report revealed that the facility had 15 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Residents Affected - Some Review of February 2025 pharmacy order report revealed that the facility had 5 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Review of March 2025 pharmacy order report revealed that the facility had 14 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Review of April 2025 pharmacy order report revealed that the facility had 13 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Review of May 2025 pharmacy order report revealed that the facility had 12 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Interview with Employee E2, Director of Nursing on June 11, 2025, at 2 p.m. confirmed that the confirmed that the facility antibiotic stewardship program did not include use protocols for antibiotics, did not include complete review of facility antibiotic orders to determine the appropriateness of the antibiotics and a system to effectively monitor antibiotic usage and a tracking of symptoms. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395852 Page 23 of 24 395852 06/13/2025 Cliveden Nursing and Rehabilitation Center 6400 Greene Street Philadelphia, PA 19119

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 staff interviews, it was determined that the facility failed to offer and/or provide the influenza and pneumococcal immunization for three of five residents reviewed (Resident R117, R295, R32, R62, and R95). Residents Affected - Some The findings include: Review of the clinical record for Resident R117 revealed the resident was admitted to the facility on [DATE]. Resident was [AGE] years old. Review of R117's immunization records revealed no evidence that the resident received the pneumococcal vaccine, or the facility offered the pneumococcal vaccine. Facility did not offer or administer influenza vaccine. Review of the clinical record for Resident R295 revealed that the resident was [AGE] years old. Review of R295's immunization records revealed no evidence that the resident received the pneumococcal vaccine, or the facility offered the pneumococcal vaccine. Review of the clinical record for Resident R32 revealed that the resident was [AGE] years old. Review of R32's immunization records revealed no evidence that the resident received the pneumococcal vaccine, or the facility offered the pneumococcal vaccine. Review of the clinical record for Resident R62 revealed the resident was admitted to the facility on [DATE]. Resident was [AGE] years old. Review of R62's immunization records revealed no evidence that the resident received the pneumococcal vaccine, or the facility offered the pneumococcal vaccine. Facility did not offer or administer influenza vaccine. Review of the clinical record for Resident R95 revealed that the resident was [AGE] years old. Review of R95's immunization records revealed no evidence that the resident received the pneumococcal vaccine, or the facility offered the pneumococcal vaccine. 28 Pa Code: 201.14 (a ) Responsibility of licensee 28 Pa Code: 201.12 (d)(1) Nursing services 395852 Page 24 of 24