Kadima Rehabilitation & Nursing At Cheswick

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resolved. The facility's MDS/RAI/Care Planning policy was reviewed on 10/27/25, and no changes were made. 113/113 in-house staff and the facility utilizes one staffing agency. 21/31 agency staff were educated.

During in-person interviews completed on 10/29/25, from 9:37 a.m. to 10:15 a.m. 16 in-house staff members (nursing and ancillary) confirmed they were educated on the facility policy and procedures for suicidal threats, supervision, and care plans of residents. During phone interviews completed on 10/29/25, from 9:46 a.m. to 10:45 a.m. 9 staff members confirmed they were educated on suicide risks, supervision, and care planning. Facility will ensure all agency staff members verify education prior to the start of their next scheduled shift. The facility's next scheduled QA is 11/18/2025. The Immediate Jeopardy was lifted on 10/29/25, at 11:14 a.m. when the action plan implementation was verified. During an interview on 10/31/25, at 2:15 p.m. the NHA confirmed the facility failed to keep a resident free from hazards and provide the necessary monitoring and supervision for a resident with known suicidal ideation and history of suicide attempt for one of three residents (Resident Resident R96). This failure created an immediate jeopardy situation. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

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Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/31/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Kadima Rehabilitation & Nursing at Cheswick

3876 Saxonburg Boulevard Cheswick, PA 15024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records and facility policy review, and staff interview, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services for one of three residents (Resident Resident R96).Based on clinical records and facility policy review, and staff interview, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services for one of three residents (Resident Resident R96).Findings include: Review of facility policy Suicide Threats dated 11/24, indicated resident suicide threats must be taken seriously and immediately reported to the nurse supervisor charge nurse. A staff member must remain with the resident until the nurse supervisor/charge nurse arrives to examine the resident. A behavioral health professional consult is indicated whenever the resident suggests suicide. Review of the clinical record indicated Resident Resident R96 was admitted to the facility

on [DATE REDACTED]. Review of Resident Resident R96's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/5/25, revealed diagnoses of depression and adjustment disorder with depressed mood. Section D0150. Resident Mood Interview revealed the resident had felt down, depressed, or hopeless nearly every day. Residents Resident R96 care plan dated 8/13/25, indicated the resident was a suicide risk as evidence by feelings/actions which indicate suicidal ideation. Information the facility submitted to the Department of Health revealed on 10/18/25, Nurse Aide (NA), Employee E1 entered Resident Resident R96's room to complete care, and the resident was attempting to wrap their telephone cord around their neck and expressing suicidal ideation. Resident Resident R96 expressed wanting to die, was upset and crying. Review of Resident Resident R96's October Medication Administration Record revealed the facility monitors Resident Resident R96 for suicidal ideations. Review of documentation on 10/18/25, failed to include documentation that the resident displayed suicidal ideations. The facility documented no, the resident did not display any behavioral issues on any shift on 10/18/25. Review of Resident Resident R96's hospital record dated 10/19/25, instructed the residents to follow up with psychiatry within one week. Review of Resident Resident R96 physician order dated 10/20/25, stated to see psychiatry as soon as possible. Review of Resident Resident R96 clinical record on 10/27/25, failed to include evidence the resident was seen by psychiatry as ordered. During an interview on 10/27/25, at 10:48 a.m.

Registered Nurse, Employee E2 confirmed a RN failed to assess the resident immediately after suicide attempt on 10/18/25. During an interview on 10/27/25, at 11:05 a.m. the Director of Nursing stated if someone expresses suicidal ideation, a staff member should stay with the resident until someone is notified. Safety is always number one, nursing skin and pain assessment should be conducted, and the resident is monitored either 1:1 or Q15 minutes check after assessed. Psych should be consulted. During

an interview on 10/27/25, at 11:08 a.m. the Nursing Home Administrator and Director of Nursing confirmed

the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services for one of three residents (Resident Resident R96). 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(3)(5) Nursing services.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/31/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Kadima Rehabilitation & Nursing at Cheswick

3876 Saxonburg Boulevard Cheswick, PA 15024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or potential for actual harm

Based on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of four quarterly meetings (Quarter Three of 2025). Findings Include: The facility Quality Assurance/Performance Improvement policy dated 9/4/25, indicated the facility will conduct quality assurance/improvement and assessment committee meeting at least quarterly to identify areas of service that are non-complaint, or with potential for improvement. Review of Quality assurance and Performance Improvement sign in sheets and attendance records for Quarter Three of 2025, failed to reveal the Infection Preventionist, Director of Nursing, and Medical Director were in attendance. During an interview on 10/31/25, at 12:59 p.m. the Nursing Home Administrator confirmed that

the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all

the required committee members for one of four quarterly meetings (Quarter three of 2025), as required. 28 Pa Code: 201.18(e)(1)(2)(3)(4) Management.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet