Cliveden Nursing and Rehab: Nurse Competency Gaps - PA
Inspectors arrived on a complaint investigation and pulled training records for four licensed nurses. Every one of them came up short.
None of the four, identified in inspection documents as Employees E4, E5, E6, and E7, had documentation showing they had ever been evaluated for competency in ostomy care. An ostomy is a surgically created opening in the body, typically in the abdomen, that requires consistent and careful maintenance to prevent infection, skin breakdown, and serious complications. Two of the four nurses, E4 and E5, also had no documented competency in intravenous care, which covers the insertion, monitoring, and management of IV lines used to deliver medications and fluids directly into a patient's bloodstream.
The Director of Nursing confirmed it all on August 13, 2025.
When inspectors asked to see competency documentation, the Director of Nursing said there was none. No evaluations showing the nurses had been assessed on ostomy care. No records confirming Employees E6 and E7 could demonstrate IV competency. The director did not dispute the findings.
What made the gap harder to explain away was what inspectors found when they looked for the underlying policy. There wasn't one. A review of the facility's own documentation turned up no policy related to nursing competencies at all, not a requirement that nurses be evaluated, not a process for how evaluations would be conducted, not a standard for what passing looked like. The infrastructure for tracking whether nurses could safely perform these procedures simply did not exist on paper.
Ostomy care and IV management are not elective skills in a nursing home setting. Residents who have ostomies depend on nursing staff to monitor the site, change pouching systems correctly, and recognize early signs of infection or skin damage around the stoma. Done wrong, or done by someone who has never been shown the right technique, the consequences accumulate quietly, in wound complications, in infections, in pain that residents may not be able to articulate clearly.
IV care carries its own stakes. A line placed or monitored incorrectly can introduce infection into the bloodstream, deliver medication at the wrong rate, or cause tissue damage if fluid infiltrates surrounding tissue. These are not theoretical risks. They are the reason competency verification exists.
The inspection cited four employees out of four records reviewed. That was the entire sample. Inspectors did not find one nurse in the group who had documentation on file. Whether the facility employed other licensed nurses with verified training, the report does not say. What it does say is that when regulators asked for the records, nothing came back.
The violation was tagged at a level of minimal harm or potential for actual harm, meaning inspectors did not identify a specific resident who had been injured as a result. That classification reflects what could be documented at the time of inspection, not a judgment that the gap carried no risk. Residents requiring ostomy care or IV therapy at Cliveden were being cared for by nurses whose competency in those procedures had never been formally assessed or recorded.
The Director of Nursing confirmed the deficiency. The records confirmed the deficiency. The absence of any policy confirmed that this was not a documentation lapse for a handful of employees. It was a structural gap, one where the facility had not built the systems that would have caught 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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 19, 2026 · Our methodology
CLIVEDEN NURSING AND REHABILITATION CENTER in PHILADELPHIA, PA was cited for violations during a health inspection on August 14, 2025.
Inspectors arrived on a complaint investigation and pulled training records for four licensed nurses.
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.