Philadelphia, PA

Cliveden Nursing And Rehabilitation Center

2-star overall rating with 2-star inspections with 22 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

6400 Greene Street, Philadelphia, PA

(215) 844-6400

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

180

Certified beds

Average residents

161

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Bedrock Care

Operator or chain grouping

Approved since

1991-07-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

10 facilities

Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.22

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.96

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.38

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.56

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.18

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.28

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.22

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.23

CMS adjusted RN staffing hours

Adjusted total hours

3.63

CMS adjusted total nurse staffing hours

Case-mix index

1.34

Higher values indicate more complex resident acuity

RN turnover

75%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

49%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,803

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

19.06

Composite VBP score used to determine payment impact.

Payment multiplier

0.9821

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0.26

Baseline 22.35% · Performance 21.95% · Measure score 0.26 · Achievement 0 · Improvement 0.26

Healthcare-associated infections

1.33

Baseline 7.41% · Performance 7.44% · Measure score 1.33 · Achievement 1.33 · Improvement 0

Total nurse turnover

3.69

Performance 48.61% · Measure score 3.69 · Achievement 3.69 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

2.34

Baseline 2.63 hours · Performance 3.52 hours · Measure score 2.34 · Achievement 1.57 · Improvement 2.34

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.27%	10.72% 0.5 pts worse	No Different than the National Rate · Eligible stays 69 · Observed rate 13.04% · Lower 95% interval 7.53%
Discharge to community	48.48%	50.57% 2.1 pts worse	No Different than the National Rate · Eligible stays 63 · Observed rate 38.1% · Lower 95% interval 34.11%
Medicare spending per beneficiary	0.78	1.02 0.2 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 63 · Denominator 63
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 63
Discharge self-care score	51.16%	53.69% 2.5 pts worse	Numerator 22 · Denominator 43
Discharge mobility score	34.88%	50.94% 16.1 pts worse	Numerator 15 · Denominator 43
Pressure ulcers or injuries, new or worsened	3.17%	2.29% 0.9 pts worse	Numerator 2 · Denominator 63 · Adjusted rate 2.62%
Healthcare-associated infections requiring hospitalization	7.44%	7.12% 0.3 pts worse	No Different than the National Rate · Eligible stays 53 · Observed rate 9.43% · Lower 95% interval 4.03%
Staff COVID-19 vaccination coverage	45.73%	8.2% 37.5 pts better	Numerator 91 · Denominator 199
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	46.51%	56.45% 9.9 pts worse	Numerator 20 · Denominator 43
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 26 · Denominator 26
Resident COVID-19 vaccinations up to date	0%	25.2% 25.2 pts worse	Numerator 0 · Denominator 29

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.1	1.7 0.4 pts worse	1.9 0.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.5 · Expected 2.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.4	1.2 0.8 pts better	1.8 1.4 pts better	Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.5 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	15.5%	86.9% 71.4 pts worse	93.4% 77.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 18.9% · Q3 11.6% · Q4 12.1% · 4Q avg 15.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	21.6%	93.5% 71.9 pts worse	95.5% 73.9 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 21.6%
Percentage of long-stay residents experiencing one or more falls with major injury	2.7%	3.2% 0.5 pts better	3.3% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.1% · Q3 3.3% · Q4 3.0% · 4Q avg 2.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	5.3%	6.5% 1.2 pts better	11.4% 6.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 5.6% · Q4 13.4% · 4Q avg 5.3%
Percentage of long-stay residents who lose too much weight	5.0%	6.5% 1.5 pts better	5.4% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 4.2% · Q3 2.6% · Q4 7.2% · 4Q avg 5.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	14.1%	19.9% 5.8 pts better	19.6% 5.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 15.4% · Q3 16.4% · Q4 16.7% · 4Q avg 14.1%
Percentage of long-stay residents who received an antipsychotic medication	4.4%	18.7% 14.3 pts better	16.7% 12.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 5.7% · Q3 3.3% · Q4 4.2% · 4Q avg 4.4% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	23.1%	19.6% 3.5 pts worse	16.3% 6.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 27.1% · Q3 12.5% · Q4 37.5% · 4Q avg 23.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	18.0%	18.3% 0.3 pts better	14.9% 3.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 15.4% · Q3 6.3% · Q4 40.5% · 4Q avg 18.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.8%	0.9% 0.1 pts better	1.0% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.7% · Q3 0.7% · Q4 0.5% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.7% 1.7 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	26.2%	26.4% 0.2 pts better	19.8% 6.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.9% · Q2 22.4% · Q3 32.7% · Q4 30.2% · 4Q avg 26.2%
Percentage of long-stay residents with pressure ulcers	6.4%	5.3% 1.1 pts worse	5.1% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 6.4% · Q3 3.7% · Q4 7.4% · 4Q avg 6.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	7.2%	68.9% 61.7 pts worse	81.7% 74.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 7.4% · Q3 4.7% · Q4 8.0% · 4Q avg 7.2%
Percentage of short-stay residents who had an outpatient emergency department visit	3.5%	9.8% 6.3 pts better	12.0% 8.5 pts better	Short Stay · 20240701-20250630 · Adjusted 3.5% · Observed 3.9% · Expected 12.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.4%	1.5% 0.9 pts worse	1.6% 0.8 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.8% · Q3 3.6% · Q4 1.2% · 4Q avg 2.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	5.6%	68.7% 63.1 pts worse	79.7% 74.1 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 5.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	32.9%	23.1% 9.8 pts worse	23.9% 9 pts worse	Short Stay · 20240701-20250630 · Adjusted 32.9% · Observed 37.3% · Expected 27.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-13 · Fire 2025-06-13

22 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 2 Health 2024-08-30 · Fire 2024-08-30

23 health deficiencies

Top issue: Resident Rights (7 deficiencies)

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 3 Health 2023-11-17 · Fire 2023-11-17

14 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-06-13

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-08-01

E · Potential for more than minimal harm 2024-08-30

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-10-29

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-02

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2025-10-01

D · Potential for more than minimal harm 2025-09-02

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-10-01

D · Potential for more than minimal harm 2025-08-14

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-10-01

D · Potential for more than minimal harm 2025-08-14

F726 · Nursing and Physician Services Deficiencies

Health

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.

Corrected 2025-10-01

D · Potential for more than minimal harm 2025-06-26

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Not marked corrected

E · Potential for more than minimal harm 2025-06-13

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-08-01

E · Potential for more than minimal harm 2025-06-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-01

E · Potential for more than minimal harm 2025-06-13

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2025-08-01

E · Potential for more than minimal harm 2025-06-13

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-06-13

F559 · Resident Rights Deficiencies

Health

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-06-13

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-06-13

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-06-13

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-06-13

F685 · Quality of Life and Care Deficiencies

Health

Assist a resident in gaining access to vision and hearing services.

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-06-13

F688 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-06-13

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-06-13

F726 · Nursing and Physician Services Deficiencies

Health

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.

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-06-13

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-06-13

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-06-13

F825 · Quality of Life and Care Deficiencies

Health

Provide or get specialized rehabilitative services as required for a resident.

Corrected 2025-08-01

C · Minimal harm 2025-06-13

F838 · Administration Deficiencies

Health

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.

Corrected 2025-08-01

B · Minimal harm 2025-06-13

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-08-01

E · Potential for more than minimal harm 2025-01-31

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-01-31

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2025-02-27

E · Potential for more than minimal harm 2024-08-30

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-10-14

E · Potential for more than minimal harm 2024-08-30

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-10-14

E · Potential for more than minimal harm 2024-08-30

F726 · Nursing and Physician Services Deficiencies

Health

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.

Corrected 2024-10-14

E · Potential for more than minimal harm 2024-08-30

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2024-10-14

E · Potential for more than minimal harm 2024-08-30

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-10-14