Kadima Cheswick: Suicide Attempt Left Undocumented - PA
The incident occurred on October 18, 2025, at Kadima Rehabilitation & Nursing at Cheswick, a long-term care facility on Saxonburg Boulevard. The resident, identified in inspection records only as Resident R96, had been living at the facility since earlier that year. Their medical record documented diagnoses of depression and adjustment disorder with depressed mood. A care plan written in August noted the resident was a suicide risk, with feelings and actions indicating suicidal ideation. The facility's own medication administration record showed staff were supposed to monitor the resident for suicidal ideation each month.
On October 18, that monitoring produced a clear finding. The nurse aide, Employee E1, witnessed R96 in crisis, actively attempting self-harm and expressing a desire to die.
Nobody documented it.
By the end of that day, across every shift, the facility's records showed Resident R96 had displayed no behavioral issues. The October medication administration record, reviewed by inspectors, contained no notation that the resident had displayed suicidal ideation. The attempted self-harm, the crying, the phone cord, the expressed wish to die — none of it appeared anywhere in the clinical record.
A registered nurse confirmed to inspectors on October 27 that no RN had assessed the resident immediately after the suicide attempt. The Director of Nursing, interviewed the same morning, described what should have occurred: a staff member stays with the resident until someone is notified, a nursing assessment is completed, the resident is placed on one-to-one monitoring or checked every fifteen minutes, and a psychiatric consult is arranged. "Safety is always number one," the Director of Nursing told inspectors.
The facility's own written policy on suicide threats, dated November 2024, required the same sequence. A staff member must remain with the resident until a nurse supervisor or charge nurse arrives. A behavioral health professional must be consulted whenever a resident suggests suicide.
None of that happened on October 18.
Resident R96 was sent to the hospital the following day. The hospital record, dated October 19, instructed the resident to follow up with psychiatry within one week. A physician order entered on October 20 stated the same thing more urgently: see psychiatry as soon as possible.
When inspectors reviewed the clinical record on October 27, nine days after the crisis and seven days after the physician's order, there was no evidence Resident R96 had been seen by a psychiatrist. The follow-up had not been arranged.
The inspection, completed October 31, 2025, cited the facility under federal tag F0742, which covers mental health treatment and services for residents with diagnosed mental disorders or psychosocial adjustment difficulties. Inspectors rated the level of harm as minimal harm or potential for actual harm. The Nursing Home Administrator and Director of Nursing both confirmed during interviews that the facility had failed to ensure appropriate treatment and services for the resident.
What the inspection record does not say is what Resident R96 experienced during those nine days, whether they were seen by psychiatry before or after inspectors left, or whether the phone cord was removed from the room.
What it does say is that on the day a resident with a documented suicide risk tried to harm themselves and told a staff member they wanted to die, the facility wrote down that nothing had happened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kadima Rehabilitation & Nursing At Cheswick from 2025-10-31 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: June 23, 2026 · Our methodology
KADIMA REHABILITATION & NURSING AT CHESWICK in CHESWICK, PA was cited for violations during a health inspection on October 31, 2025.
The incident occurred on October 18, 2025, at Kadima Rehabilitation & Nursing at Cheswick, a long-term care facility on Saxonburg Boulevard.
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.