Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT CHESWICK
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

KADIMA REHABILITATION & NURSING AT CHESWICK
Inspection Results For:

There are 306 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


KADIMA REHABILITATION & NURSING AT CHESWICK - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated survey in response to seven complaints, one incident completed on March 4, 2026, it was determined that Kadima Rehabilitation and Nursing at Cheswick was not in compliance with the following requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

�483.60(i) Food safety requirements.
The facility must -

�483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

�483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based 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.

Findings include:

A review of the facility's food temperature log on 3/4/26, at 12:15 p.m. revealed that there was no documented evidence that the holding food temperatures were obtained at the time of of during service for breakfast and lunch to ensure that the food maintained safe internal temperatures. In an interview during this observation period, Dietary Manager Employee E7 stated confirmed that there were no recorded temperatures for breakfast or lunch and they should have been recorded.

28 Pa. Code 201.14(a)Responsibility of licensee.
28 Pa. Code 201.18(b)(3) Management.

Plan of Correction - To be completed: 04/06/2026

All residents received appropriate care and services to meet their needs on 3/04/26 and there was no direct correlation to an individual resident. Dietary Manager immediately inserviced all staff present on 3/04/26 regarding completing and recording holding food temperature logs for each meal. Dietary Manager will complete inservice by 3/27/26 for all dietary staff on holding food temperature log completion and recording for each meal. Dietary Manager will audit holding food temperature logs for completion of all meals daily for two weeks, then monthly for three months. Results of the audits will be reviewed at Quarterly QAPI committee meeting

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

�483.21(b) Comprehensive Care Plans
�483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at �483.10(c)(2) and �483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under �483.24, �483.25 or �483.40; and
(ii) Any services that would otherwise be required under �483.24, �483.25 or �483.40 but are not provided due to the resident's exercise of rights under �483.10, including the right to refuse treatment under �483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
�483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based 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).

Findings include:

Review of the facility policy "MDS/RAI/Care Planning" last reviewed on 11/1/25, indicated the care planning process provides a tool for an interdisciplinary approach to the care of the residents. The care plan will be assessed at least quarterly and reviewed by the interdisciplinary team.

Review of the clinical record revealed that Resident R2 was admitted to the facility on 1/14/26.

Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/21/26, indicated the diagnosis of diabetes (high sugar in the blood), anxiety and chronic pain.

Review of Resident R2's physician orders dated 1/14/26, indicated Methadone (used to treat chronic pain and opioid use disorder) HCl Oral Concentrate 10 milligrams/milliliter (MG/ML) give 8 ml by mouth two times a day for chronic back pain.

Review of Physician Initial Comprehensive Visit dated 1/16/26, indicated resident R2 goes to methadone clinic outpatient for script (prescription).

Review of Resident R2's current care plan initiated on 1/19/26, indicated pain related to diagnosis of chronic pain, the care plan failed to include any information regarding Resident R2's use of methadone or methadone clinic appointments.

Review of the clinical record revealed that Resident R3 was admitted to the facility on 12/7/25.

Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/13/25, indicated the diagnosis of arthritis (swelling and tenderness of joints), anxiety and chronic pain.

Review of nursing progress note dated 12/8/25, indicated resident left via wheelchair with nurse escort at baseline condition to appointment.

Review of physician order dated 12/8/25, indicated resident to dose every Monday at clinic and to receive six take home doses in lunchbox to be administered by facility staff.

Review of Resident R3's current care plan initiated on 12/8/25, failed to include any information regarding Resident R3's use of methadone or methadone clinic appointments.

During an interview completed on 4/4/26, at 2:10 p.m. the Director of Nursing confirmed the care plans for Resident R2 and Resident R3 did not include any information concerning the use of methadone or the methadone clinic appointments and stated, "I just updated them now" and 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).

28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 201.18 (b)(1) Management.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Plan of Correction - To be completed: 04/06/2026

On 3/04/2026, Director of Nursing reviewed and updated the careplans for Residents R2 and R3. The Director of Nursing or designee reviewed one week of prior admissions to ensure resident centered careplans were completed for all residents in house receiving methadone. All interdisciplinary team members will be educated by 4/06/26 by Director of Nursing or designee on person centered careplans and specified,individualized interventions to address the care needs of residents. Director of Nursing or designee will audit twenty four hour reports for new admissions daily for two weeks, then three times weekly for one week, then monthly thereafter to ensure compliance with comprehensive careplans. Results will be reported at quarterly QAPI committee meeting.

483.25 REQUIREMENT Quality of Care:

� 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based 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)

Findings include:

Review of the facility policy "Transfer to Appointment Outside the Facility" last reviewed 11/1/25, indicated verify that a physician order for appointment/consult is present. Arrange for transportation as appropriate. Arrange for escort as appropriate.

Review of the clinical record revealed that Resident R2 was admitted to the facility on 1/14/26.

Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/21/26, indicated the diagnosis of diabetes (high sugar in the blood), anxiety and chronic pain.

Review of Resident R2's physician orders dated 1/14/26, indicated Methadone (used to treat chronic pain and opioid use disorder) HCl Oral Concentrate 10 milligrams/milliliter (MG/ML) give 8 ml by mouth two times a day for chronic back pain.

Review of Physician Initial Comprehensive Visit dated 1/16/26, indicated resident R2 goes to methadone clinic outpatient for script (prescription).

Review of physician order dated 1/25/26, indicated Methadone Oral Concentrate 10 MG/ML (Methadone HCl) Give 8 ml by mouth two times a day every Mon, Tue, Wed, Fri, Sat, Sun for back pain control Thursday A.M dose given at clinic and give 8 ml by mouth at bedtime every Thu for back pain control Thursday A.M dose given at clinic. The order failed to include:
- name of methadone clinic.
- address of methadone clinic.
- methadone clinic contact phone number.
- time of methadone clinic appointment.
- transportation service information.
- the need for an escort for all appointments.
- monitoring for any side effects.

Review of the clinical record revealed that Resident R3 was admitted to the facility on 12/7/25.

Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/13/25, indicated the diagnosis of arthritis (swelling and tenderness of joints), anxiety and chronic pain.

Review of nursing progress note dated 12/8/25, indicated resident left via wheelchair with nurse escort at baseline condition to appointment.

Review of physician order dated 12/8/25, indicated resident to dose every Monday at clinic and to receive six take home doses in lunchbox to be administered by facility Staff.

Review of physician order dated 12/9/25 indicated Methadone HCl Oral Concentrate 10 MG/ML(Methadone HCl) give 8.5 ml by mouth one time a day every Tue, Wed, Thu, Fri, Sat, Sun for opioid disorder Monday dose is given at clinic. The order failed to include:
- name of methadone clinic.
- address of methadone clinic.
- methadone clinic contact phone number.
- time of methadone clinic appointment.
- transportation service information.
- the need for an escort for all appointments.
- monitoring of any side effects.

During an interview completed on 3/4/26, at 12:23 p.m. upon asking Registered Nurse Employee E1 concerning the process for residents that go out to the methadone clinic for medication management replied, "we have more than one resident who goes, a nurse goes with the resident and takes the box".

During an interview completed on 3/4/26, at 12:25 p.m. upon asking Licensed Practical Nurse (LPN) Employee E2 concerning the process for residents that go out to the methadone clinic for medication management replied, "they go to the clinic once a week a nurse always goes with them and takes the box".

During an interview completed on 3/4/26, at 1:45 p.m. upon asking the Director of Nursing concerning the process for residents that go out to the methadone clinic for medication management replied, "when the resident arrives at the facility we find out the day they are scheduled and the schedular sets up the transportation. On the day of the appointment a nurse goes with them to the clinic. Upon asking concerning the content of the orders stated, "I will have to look".

During an interview completed on 4/4/26, at 2:10 p.m. the Director of Nursing returned to conference room and stated the orders were incomplete "I just updated them now" and confirmed that that the facility failed to procure complete physician orders for two of three residents who receive outside services (Resident R2 and R3).

28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 201.18 (b)(1) Management.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Plan of Correction - To be completed: 04/06/2026

Director of Nursing reviewed and updated physician orders on 3/04/26 for residents R2 and R3. Director of Nursing reviewed and updated all physician orders for all current residents receiving methadone to ensure completeness with the necessary information. Director of Nursing or designee will inservice all licensed nursing staff by 4/06/26 on complete physician orders for residents receiving methadone to include name of methadone clinic, address of methadone clinic, methadone clinic contact phone number, time of methadone clinic appointment, transportation service information, the need for an escort for all appointments, and monitoring of any side effects. Director of Nursing or designee will audit new admission orders daily for two weeks, then three times a week for one month, then weekly for three months to ensure compliance on methadone physician orders. Results will be reported at Quarterly QAPI committee meeting.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

�483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:

Based 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).

Findings include:

Review of facility policy, " Flow of Care", dated 11/1/25, revealed care will be provided to residents, as needed 24-hour a day to attain and maintain the highest level of functioning.

Clinical record review revealed Resident R5 was admitted to the facility on 1/2/26, with diagnosis to include, fibromyalgia (chronic disorder that cause widespread pain, fatigue and other symptoms), adult failure to thrive and diabetes mellitus.

Review of physician orders dated 1/2/26 indicated showers to be given evening shift on Tuesday and Fridays.

Review of Resident R5's bathing records from January 2026 indicated resident received two bed baths, 1/6/26 and 1/16/26, missing six showers.

Interview with the Director of Nursing on March 4, 2026, at 2:30 p.m., confirmed Resident R5 missed six showers and did not get showers when she was supposed to.

28 Pa. Code 211.5(f) Clinical records
28 Pa. Code: 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 04/06/2026

R5 was discharged to home on 1/29/2026. Shower schedules for all residents were reviewed and updated by Director of Nursing to ensure person centered care for all residents. Director of Nursing or designee will inservice all nursing staff will be educated by 4/06/2026 on personalized ADL care and shower schedules for all residents. Director of Nursing or designee will complete daily audits of shower schedules for two weeks, then three times a week for one month, then monthly for three months to ensure care is provided as ordered. Results of audits will be reviewed at quarterly QAPI committee meeting.

35 P. S. � 448.809b LICENSURE Photo Id Reg:

Law amended July 11, 2022 Act 79 2022 HB 2604

(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.

(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.

Observations:

Based on observations, and staff interviews, it was determined that the facility failed to make certain that staff members displayed identification badges to include a name, title, and a photo as required for five of six employees (Employee E1, E3, E5, E6 and E8).

Findings include:

Review of the facility policy "Identification Name Badges" last reviewed 11/1/25, indicated in order to promote safety and security measures each employee must wear his/her identification name badge at all times while on duty.

During an observation and interview completed on 3/4/26, at 12:17 p.m. Registered Nurse (RN) Employee E6 was at the nursing station. She had a piece of tape on her chest with her name on it, upon asking about the tape replied, "I made this, I don't have a name tag".

During an observation and interview completed on 3/4/26, at 12:19 p.m. Nurse Aid (NA) Employee E5 was passing out lunch trays no visible identification was seen. Upon asking about an identification badge replied "I have one, I just didn't bring it today"

During an observation and interview completed on 3/4/26, at 12:20 p.m. Licensed Practical Nurse (LPN) Employee E8 was in the hallway, a piece of tape was noted on his shirt unable to read what it said as it was smeared ink. Upon asking how long how long you have worked at facility replied, "since December". Upon asking about the smeared piece of tape replied, "they did not give me a name badge".

During an observation and interview completed on 3/4/26, at 12:23 p.m. RN Employee E1 was at the nursing station upon asking RN Employee E1 how long she has worked in the facility replied, "a couple of months" upon asking if she has an identification badge replied, "they did not give me one".

During an observation completed on 3/4/26, at 12:37 p.m. Housekeeping Employee E3 was on the second floor, upon asking Employee E3 how long you have worked at facility replied "about 3 months" upon asking about identification badge replies "they haven't given me any"

During an interview on 3/4/26, at 2:47 p.m. p.m. the Director of Nursing confirmed that the facility failed to make certain staff members display identification badges to include a name, title, and a photo as required for five of six employees (Employee E1, E3, E5, E6 and E8).

Plan of Correction - To be completed: 04/06/2026

On 3/18/2026, Director of Human Resources and Administrator completed an inservice training with the Regional Director of Human Resources on how to create facility identification badges that are compliant with Pennsylvania State Regulations. Director of Human Resources completed audit on 3/24/26 of all staff and presence of a facility identification badge with picture, name and role. Director of Human Resources will ensure that all staff have identification badges that are compliant with Pennsylvania State Regulations to include name, title, and a photo. Director of Human Resources will audit that identification badges are present for working staff weekly for one month, then monthly for three months. Results will be reported at Quarterly QAPI committee meeting.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright � 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement