Cliveden Nursing: Care Plan Failures for IV, Ostomy - PA
One resident, identified in inspection records only as R7, had been living at the facility with a colostomy, a surgically created opening in the abdomen that requires consistent, careful daily attention. He told inspectors on August 13 that he was getting colostomy care every day. His medical file had no comprehensive care plan for any of it.
The second resident, R8, had an intravenous line delivering medication to prevent infection in his wounds. He confirmed this himself when inspectors spoke with him that same morning. His file also had no care plan addressing the IV.
The Director of Nursing, interviewed that afternoon, confirmed both gaps.
A care plan is the document that tells staff what a resident needs, how to provide it, and when. Without one, the people responsible for a resident's treatment have no written guide for what they're doing, no recorded timetable, and no way to measure whether the care is working or falling short. For a colostomy, that means no documented protocol for how the stoma site should be cleaned, monitored, or assessed for complications. For an IV line delivering infection-prevention medication, it means no written record of what staff should watch for, how long the treatment should run, or what changes in the resident's condition should prompt a call to a physician.
Inspectors cited the facility under a federal standard requiring nursing homes to develop and implement care plans that meet each resident's needs, with specific timetables and measurable actions. The deficiency was tagged at a level indicating minimal harm or potential for actual harm, and was listed as affecting a small number of residents.
The inspection was a complaint survey, meaning someone had raised a concern about care at Cliveden before inspectors arrived. The survey was completed August 14, 2025.
Cliveden Nursing and Rehabilitation Center sits at 6400 Greene Street in the Germantown neighborhood of Philadelphia. Inspectors reviewed eight residents' records during this survey and found the care plan failures in two of them, both men receiving treatments that carry real clinical risk if not properly managed.
A colostomy requires ongoing monitoring of the stoma, the surrounding skin, and the output itself. Changes in color, odor, or consistency can signal infection or other complications. An IV line, particularly one delivering antibiotics or other infection-fighting medication, requires attention to the insertion site, the infusion rate, and the resident's response to the drug. These are not incidental parts of a resident's day. For R7 and R8, they were central to why each man was there.
Neither resident's file reflected that.
The Director of Nursing did not dispute the finding. In the interview recorded by inspectors at 1:20 p.m. on August 13, she confirmed that no care plan existed for R7's colostomy care and no care plan existed for R8's IV care.
What that means in practice is that any nurse or aide who walked into either man's room to provide care was doing so without a facility-approved written plan telling them what to do, how to do it, or what to watch for. Whether the care those residents actually received was adequate is not something the inspection record addresses. What it documents is the absence of the system that should have been guiding it.
R7 told inspectors his colostomy care came every day. R8 told inspectors his IV was there to protect his wounds from infection. Both men knew what they were receiving. The facility, on paper, had not gotten around to planning for it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cliveden Nursing and Rehabilitation Center from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 4, 2026 · Our methodology
CLIVEDEN NURSING AND REHABILITATION CENTER in PHILADELPHIA, PA was cited for violations during a health inspection on August 14, 2025.
He told inspectors on August 13 that he was getting colostomy care every day.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.