Kadima Rehabilitation & Nursing at Cheswick

Inspectors wroteBased on review of facility policies, Resident Assessment Instrument (RAI) User's Manual, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization and failed to develop and implement an individualized person-centered care plan for a resident who was at risk for re-traumatization resulting in psychosocial harm for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to maintain complete and accurate documentation for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policy and documents, clinical record review, and resident and staff interviews, it was determined that the facility failed to create an environment free of accidents when a visitor/former employee entered the facility with a loaded handgun and discharged the handgun on the Third Floor Nursing Unit. This failure created an immediate jeopardy situation for all residents.

Inspectors wroteBased on review of facility documents and staff interviews, it was determined that the facility failed to provide Communication training to five of five direct care facility staff reviewed (Employees E11, E13, E14, E15 and E16).

Inspectors wroteBased on review of facility documents and staff interviews, it was determined that the facility failed to provide Resident Rights training to five of five direct care facility staff reviewed (Employees E11, E13, E14, E15 and E16).

Inspectors wroteBased on review of facility documents and staff interviews, it was determined that the facility failed to provide Abuse, Neglect, and Exploitation training to five of five direct care facility staff reviewed (Employees E11, E13, E14, E15 and E16).

Inspectors wroteBased on review of facility documents and staff interviews, it was determined that the facility failed to provide QAPI (Quality Assurance and Performance Improvement) training to four of five direct care facility staff reviewed (Employees E11, E13, E14, and E16).

Inspectors wroteBased on review of facility documents and staff interviews, it was determined that the facility failed to provide Infection Control training to five of five direct care facility staff reviewed (Employees E11, E13, E14, E15 and E16).

Inspectors wroteBased on review of facility documents and staff interviews, it was determined that the facility failed to provide Compliance and Ethics training to five of five direct care facility staff reviewed (Employees E11, E13, E14, E15 and E16).

Inspectors wroteBased on review of facility documents, and staff interviews it was determined that the facility failed to ensure that all nurse aide staff received a minimum of twelve hours of in-service education training each year for three out of three Nurse Aide (NA) Employees (Employee E13, E14, and E15)

Inspectors wroteBased on review of facility documents and staff interviews, it was determined that the facility failed to provide Behavioral Health training to five of five direct care facility staff reviewed (Employees E11, E13, E14, E15 and E16).

Inspectors wroteBased on facility policy, observation and staff interview, it was determined that the facility failed to provide a safe, clean, and comfortable environment for one of three nursing unit shower rooms. (Second floor)

Inspectors wroteBased on review of facility policy and documents, and interviews with staff, it was determined that the facility staff failed to implement policies and procedures to notify the administrator and local law enforcement in a timely manner after a visitor/former employee entered the facility with a loaded handgun and discharged the handgun on one of three nursing units (Third Floor Nursing Unit).

Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to follow a physician order for one of four residents (Resident R1).

Inspectors wroteBased on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility by failing to create a safe environment free of accidents when a visitor/former employee entered the facility with a loaded handgun and discharged the handgun on the Third Floor Nursing Unit, which created an immediate jeopardy situation for all residents.

Inspectors wroteBased on review of facility policy, clinical records, facility documents, observations, and staff interviews, it was determined the facility failed to keep residents free from hazards and provide the necessary monitoring and supervision for residents with known suicidal ideation and history of a suicide attempt for two of three residents (Resident R1, and R2).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to record food temperatures at the time of service in the main kitchen.

Inspectors wroteBased on review of facility policies, clinical records, observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions and/or goals to address the care needs of residents for two of four residents reviewed (Resident R2 and R3).

Inspectors wroteBased on review of facility policy, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide the necessary services to maintain personal hygiene for one of four residents reviewed (Resident R5).

Inspectors wroteBased on facility policy, clinical record review, and resident and staff interview, it was determined that the facility failed to procure complete physician's orders for two of three residents who receive outside services (Resident R2 and R3)

Inspectors wroteBased on review of facility policy, clinical records, facility documents, resident and staff interviews, it was determined the facility failed to keep Resident R96 free from hazards and provide the necessary monitoring and supervision for a resident with known suicidal ideation and history of a suicide attempt for one of three residents (Resident R96). This failure created an immediate jeopardy situation.

Inspectors wroteBased 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 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 R96).

Inspectors wroteBased 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. [...]

Inspectors wroteBased on a review of facility policies, observations and staff interviews it was determined that the facility failed to provide a safe, clean, comfortable environment for the residents in resident rooms [ROOM NUMBERS], Second floor dining room, and the Third floor dining room as required. (Resident room [ROOM NUMBER], Resident room [ROOM NUMBER], Second floor dining room, and Third floor dining room)

Inspectors wroteBased on review of facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for incident or accidents for two of six residents (Residents R1, R2).

Inspectors wroteBased on a review of facility policies, Four week Spring Summer (SS) cycle menu diet extension sheets and staff interviews it was determined that the facility failed to review, date. approve, and follow a preplanned cycle menu (Four week Spring Summer cycle menu, lunch meal on 3/19/25) as required.

Inspectors wroteBased on a review of facility policies, observations and staff interviews it was determined that the facility failed to provide a safe, clean, comfortable environment for the residents in residnet room [ROOM NUMBER], First floor common area, and the elevator door on the second floor nursing unit as required. ( Resident room [ROOM NUMBER], First floor common area, elevator door second floor nursing unit)

Inspectors wroteBased on a review of facility policies, manufacture instructions, observations and staff interviews it was determined that the facility failed to follow manufacture instructions for the production of sugar free pudding on 3/19/25. (sugar free pudding)

Inspectors wroteBased on a review of facility policies, observations, resident tray cards, menu diet extension sheets, and staff interviews it was determined that the facility failed to provide the approved dessert for 23 of 23 residents prescribed a Mechanical Soft diet and nine out of nine resident prescribed a puree diet for the lunch meal service on 3/19/25.

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for three of seven residents (Resident R1. R2 and R3).

Inspectors wroteBased on a review of facility policies, documents and staff interviews it was determined that the facility failed to secure a surety bond on behalf of the residents of the facility that assured the security of all personal funds of residents deposited with the facility for three months 11/24, 12/24, and 1/25 as required. (11/24, 12/24, and 1/25)

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to ensure that a Speech Therapist who provided care to residents was licensed as a Speech Therapist for three of 12 months (November, and December 2024, and January 2025)

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment by maintaining an acceptable temperature range throughout resident areas for 32 resident rooms on three of three units (First, Second, and Third Floor). Findings Include: Review of the facility policy Resident Environment dated 7/1/24, indicated the facility will provide an environment that is safe, clean, comfortable, and homelike. A homelike environment de-emphasizes the institutional character of the setting. Review of the facility policy Temperature Extremes dated 7/1/24, indicated the facility is to provide comfortable and safe temperature levels. The temperature throughout the facility shall be maintained at between 70 degrees and 82 degrees Fahrenheit (F). Review of Title 42 Code of Federal Regulations 483. [...]

Inspectors wroteBased on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four out of five residents sampled with facility-initiated transfer (Residents R41, R58, R69, R70).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of five resident hospital transfers (Resident R58, R69, R70).

Inspectors wroteBased on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for five of five residents (Resident R41, R43, R44, R59, and R77).

Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to obtain a physician order for hospice services and to ensure the coordination of hospice services (supportive services for end stage terminal illness) with facility services to meet the needs of each resident for end-of-life care for three of three residents (Resident R18, R38, and R76).

Inspectors wroteBased on facility policies, clinical record review, observation, and staff interviews, it was determined the facility failed to ensure enhanced barrier precautions were ordered and implemented for four of four residents (Resident R26, R41, R44, and R65).

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for two of three units (Second-floor, and Third-floor).

Inspectors wroteBased on review of facility policies, facility documents, clinical records, and resident and staff interviews, it was determined that the facility failed to make certain residents were free from neglect for one of three residents (Resident R53).

Inspectors wroteBased on review of facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for incident or accidents for one of six residents (Resident R70).

Inspectors wroteBased on review of resident records, admission documentation and staff interview, it was determined that the facility failed to maintain admission documentation for two of three residents (Resident R11, R67).

Inspectors wroteBased on facility policy review, clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exited to an unsupervised and unauthorized location without staff's knowledge) for one of six residents(Resident R70).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care related to oxygen equipment and management for three of four residents (Residents R33, R44 and R87).

Inspectors wroteBased on observations, and staff interview it was determined that the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to provide care for a resident requiring subcutaneous injections (insertion of medication beneath the skin) which led to an emergency room visit for one of seven residents (Resident 48).

Inspectors wroteBased on clinical record review and staff interviews it was determined the facility failed to report abnormal lab results to the ordering physician timely for one of three residents reviewed. (Resident R58) Findings Include: Review of the facility Notification of Condition Change: Physician policy dated 7/1/24, revealed a change in a resident's condition will be reported to the physician in a timely manner, including abnormal lab values. Review of Resident 58's Physician orders revealed an order dated 11/3/24, for a urine culture (test of urine to determine if there is a Urinary Tract Infection). Review of Resident 58's Laboratory report for the urinalysis revealed the report was final and was reported on 11/4/24. The results had abnormal lab values. Interview with Infection Preventionist, Employee E8 on 11/6/24, at 9:50 a.m. [...]

Inspectors wroteBased on facility policy, observations, and staff interviews it was determined that the facility failed to provide adaptive feeding devices for one of four residents (Resident R11).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for four out of five residents (Residents R41, R58, R69, R70).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to follow physician orders and notify a physician or abnormal glucose readings via a Capillary Blood Glucose (CBG) level as ordered for one of four residents (Resident R1).

Inspectors wroteBased on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that weights were monitored as ordered for one of four residents (Resident R1).

Inspectors wroteBased on facility policy, clinical record review, job description review, observation, and staff interview, it was determined the facility failed to provide care and services to meet the accepted standards of practice for four of five residents (Resident R36, R41, R76, and R84).

Inspectors wroteBased on review of facility policy, resident council group interview, resident and staff interview it was determined that the facility failed to uphold resident rights and offer residents the opportunity to vote for the November 2023 election for one of three sampled residents (Resident R6).

Inspectors wroteBased on review of facility policy, closed clinical records, resident fund account statements and staff interview it was determined that the facility failed to convey resident funds in accordance with State law and closed accounts upon death in a timely manner for one out of five closed resident records (Closed Resident Records CR246).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a physician of abnormal blood pressure for two of two residents (Resident R14 and R84).

Inspectors wroteBased on review of facility policy, documents and clinical record and staff interview, it was determined that the facility failed to protect residents from neglect for one of four residents reviewed (Resident R79).

Inspectors wroteBased on review of facility policy, clinical record review, resident and staff interviews it was determined that the facility failed to provide discharge planning for resident needs prior to discharge for one of four residents (Resident R94).

Inspectors wroteBased on a review of facility policy, clinical record review, resident interview, resident council group interview and staff interview, it was determined that the facility failed to provide care and services regarding bathing for one of four sampled residents (Resident R42).

Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop an individualized care plan to address the resident's specific nutritional concerns and preferences for one of four (Resident R67) records reviewed.

Inspectors wroteBased on review of facility policy and clinical record, observation and staff interviews it was determined that the facility failed to administer medications with a medication error rate that was less than five percent for two of five residents (Resident R36 and R84).

Inspectors wroteBased on review of facility policy and clinical record, observation and staff interviews it was determined that the facility failed it was determined that the facility failed to make certain that residents are free from significant medication errors for one of five residents (Resident R84).

Inspectors wroteBased on review of facility documents and resident clinical record and staff and resident interviews it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement for two of three residents (Resident R11 and Resident R57).

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain call bell equipment for two of five sampled residents (Resident R8 and R51).

Inspectors wroteBased on review of the facility assessment, Nurse Aide (NA) and nurse training documentation and staff interview, it was determined that the facility failed to ensure that nursing staff have annual in-service education necessary to care for residents' needs for four out of six employee records (NA Employee E1, NA Employee E2, NA Employee E13, and Licensed Practical Nurse (LPN) Employee E14).

Inspectors wroteBased on review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to determine the ability to safely self-administer medications for one of six residents reviewed (Resident R294).

Inspectors wroteBased on review of facility policies, resident interview, and staff interview it was determined the facility failed to make certain the physician orders regarding a resident's wishes regarding life sustaining treatments and the POLST (Physician Order for Life Sustaining Treatment) form were accurate for one of four residents (Resident R38).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to revise/update care plans for two of four residents to accurately reflect the current status of the residents (Residents R77 and R294).

Inspectors wroteBased on review of facility documentation and staff interview, it was determine that the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program.

Inspectors wroteBased on observation, clinical record review, staff interview, and facility policy it was determined that the facility failed to notify a physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) level as per physician's order for one out of five residents (Resident R63).

Inspectors wroteBased on review of facility policy, observations, staff and resident interviews, it was determined the facility failed to provide adequate supervision with smoking materials and keep the resident environment free of accident hazards for two of four residents (Resident R40 and R44) and failed to provide an environment free of potential accidents and hazards relating to an electric heater for one of four residents (Resident R74).

Inspectors wroteBased on review of facility policy, clinical record review, weight documentation, and staff interview it was determined that the facility failed to obtain weight monitoring documentation for one of two sampled residents (Resident R54).

Inspectors wroteBased on review of facility policy, observations, resident records and staff interview it was determined that the facility failed to discontinue the use of a enteral feed for one out two sampled residents (Resident R53).

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for two of two residents reviewed (Resident 294 and R77 ).

Inspectors wroteBased on facility policies, clinical record review and staff interview, it was determined that the facility failed to make certain the highest practicable pain management was achieved for one of four residents (Resident R50).

Inspectors wroteBased upon clinical record review, and staff interview, it was determined that the facility failed to ensure that any irregularities submitted in the medication regiment reviews (MRR) by pharmacy were acted upon for one out of five sampled residents (Resident R41).

Inspectors wroteBased on review of facility policy, clinical records and interview with staff, it was determined that the facility failed to make certain that PRN (as needed) orders for psychotropic medications are limited to 14 days for one out of five sampled residents (Resident R41).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to date multi-dose over the counter (OTC) medication bottles in two of five medication carts (1st floor, and 2 [NAME] Cart), and failed to properly secure a medication cart in one of five treatment carts (first floor).

Inspectors wroteBased on review of the facility assessment, facility in-service training and staff interview it was determined that the facility failed to update the facility assessment to include competencies, resources, and required care for residents with substance abuse concerns for six out of six residents (Residents R13, R17, R18, R40, R64, and Resident R80).

Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to prevent the potential for cross contamination during one of three resident dressing changes (Resident R50).