Kadima Rehab Cheswick: Suicide Risk Supervision Failure - PA
The finding was classified as immediate jeopardy, the most serious level of harm designation available under federal inspection rules, meaning inspectors determined the failure had already caused or was likely to cause serious injury or death.
The resident, identified in inspection records only as Resident R96, was one of three residents with similar risk profiles reviewed during the inspection. Inspectors found the failure applied to R96 specifically. The nursing home administrator confirmed it directly during an interview on October 31, at 2:15 p.m., telling inspectors the facility had failed to keep R96 free from hazards and had not provided the necessary monitoring and supervision for a resident with known suicidal ideation and a history of a suicide attempt.
That is a notable moment in any inspection record. Administrators often qualify, hedge, or dispute findings at the conclusion of a survey. Here, the administrator confirmed the failure without qualification.
The inspection was a complaint survey, meaning someone, a resident, a family member, a staff member, or a visitor, had contacted regulators before inspectors arrived. The nature of that complaint is not disclosed in the public record. What the record does show is that inspectors arrived, reviewed the facility's care planning processes, interviewed staff, and determined that a resident at known risk for self-harm had not received the level of supervision their condition required.
Suicidal ideation in a nursing home setting is not uncommon and is not untreatable. Facilities are expected to identify residents who express suicidal thoughts or who have attempted suicide, document that risk in their care plan, and then follow through on whatever supervision and intervention the care plan specifies. The breakdown at Kadima was not in identifying the risk. R96's history was known. The care plan existed. The failure was in execution.
The immediate jeopardy was lifted on October 29, at 11:14 a.m., two days before the inspection formally concluded, after inspectors verified that the facility had implemented a corrective action plan. That plan included re-educating staff on the facility's policies for handling suicidal threats, supervision protocols, and care planning for at-risk residents.
The re-education effort was substantial in scale but uneven in reach. All 113 in-house staff members received training. Of 31 agency staff working at the facility, 21 had been educated by the time inspectors reviewed the plan. The remaining 10 had not. The facility's stated solution for that gap was to require agency staff to verify their education before the start of their next scheduled shift, a process that had not yet been completed when inspectors were on site.
That detail matters. Agency staff, workers employed by a staffing company rather than the facility directly, rotate through facilities and may not have the same familiarity with a specific resident's history or care plan that a long-term employee would. A resident like R96, whose risk was documented and known, depends on every person entering that room or working that unit to understand the supervision requirements. An agency nurse or aide showing up for a shift without that knowledge represents a gap in the chain of protection.
Sixteen in-house nursing and ancillary staff were interviewed in person on October 29, between 9:37 a.m. and 10:15 a.m. All confirmed they had received education on the facility's suicide-related policies. Nine more staff were reached by phone the same morning, between 9:46 a.m. and 10:45 a.m. All nine confirmed the same. The facility's care planning policy was reviewed on October 27 and left unchanged, suggesting inspectors and facility leadership agreed the written policy itself was not the problem.
The problem was whether staff were following it.
Kadima Rehabilitation & Nursing at Cheswick sits on Saxonburg Boulevard in Cheswick, a borough northeast of Pittsburgh in Allegheny County. The facility is part of the Kadima network, which operates multiple rehabilitation and nursing facilities. The inspection was completed October 31, 2025, and the record was printed April 13, 2026.
The facility's next scheduled quality assurance meeting, as noted in the plan of correction, was set for November 18, 2025. Quality assurance meetings are the internal mechanism by which nursing homes are supposed to catch problems like this before they reach the level of an immediate jeopardy finding. Whether R96's supervision gaps were discussed in any prior QA meeting is not addressed in the inspection record.
What the record does not contain is also worth noting. There is no description of what specifically happened to R96, no account of what the lapse in supervision looked like in practice, no timeline of when the monitoring failed or for how long. Inspection records at this level of summary often omit those details, which are more fully documented in the underlying investigation notes that are not always made public. What is public is the conclusion: a resident with a known suicide attempt in their history was not adequately supervised, and inspectors determined that failure rose to the level of immediate jeopardy.
The Pennsylvania Department of Health, which conducts inspections in the state on behalf of the Centers for Medicare and Medicaid Services, cited the facility under four provisions of the Pennsylvania Code governing nursing home operations, covering the responsibility of the licensee, facility management, resident care policies, and nursing services.
Immediate jeopardy findings carry financial consequences. Facilities found in immediate jeopardy are subject to civil monetary penalties that can reach thousands of dollars per day. The specific penalty amount, if any, assessed against Kadima for this finding was not included in the publicly available inspection record.
The immediate jeopardy designation was resolved on paper on October 29. The care plan was reviewed. Staff were educated. The administrator acknowledged the failure. The agency staff gap was assigned a fix.
Resident R96 remained at the facility throughout.
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 resident, identified in inspection records only as Resident R96, was one of three residents with similar risk profiles reviewed during the inspection.
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.