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Complaint Investigation

Kadima Rehabilitation & Nursing At Cheswick

October 31, 2025 · Cheswick, PA · 3876 Saxonburg Boulevard
Citations 3
CMS Rating 1/5
Beds 121
Provider ID 395538
Healthcare Facility
Kadima Rehabilitation & Nursing At Cheswick
Cheswick, PA  ·  View full profile →
Inspection Summary

KADIMA REHABILITATION & NURSING AT CHESWICK in CHESWICK, PA — inspection on October 31, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies
Immediate Jeopardy

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 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/31/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Kadima Rehabilitation & Nursing at Cheswick

3876 Saxonburg Boulevard Cheswick, PA 15024

SUMMARY STATEMENT OF DEFICIENCIES

Review of the clinical record indicated Resident R96 was admitted to the facility on [DATE].

Review of 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 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 R96's room to complete care, and the resident was attempting to wrap their telephone cord around their neck and expressing suicidal ideation.

Resident R96 expressed wanting to die, was upset and crying.

Review of Resident R96's October Medication Administration Record revealed the facility monitors 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 R96's hospital record dated 10/19/25, instructed the residents to follow up with psychiatry within one week.

Review of Resident R96 physician order dated 10/20/25, stated to see psychiatry as soon as possible.

Review of 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 R96). 28 Pa.

Code 201.18(b)(1) Management.28 Pa.

Code 211.12(d)(3)(5) Nursing services.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/31/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Kadima Rehabilitation & Nursing at Cheswick

3876 Saxonburg Boulevard Cheswick, PA 15024

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CHESWICK, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from KADIMA REHABILITATION & NURSING AT CHESWICK or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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