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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 45 surveys for this facility. Please select a date to view the survey results.

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

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 740302
Component 01
Office Building

Based on a Relicensure Survey completed on October 29, 2025, it was determined that Kadima Rehabilitation and Nursing at Cheswick was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a one-story, Type III (211), protected ordinary building, with a basement, that is fully sprinklered

Plan of Correction:

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stairway doors, affecting one stairwell within the component.

Findings include:

1. Observation on October 29, 2025, at 9:45 a.m., revealed the door exiting from the stairwell to the basement was propped open with a 5 gallon paint can, which would prevent the stairwell from resisting any smoke or fire.

Interview with the Facility Administrator and Maintenance Director on October 29, 2025, at 11:00 a.m., confirmed the stairwell door deficiency.

Plan of Correction - To be completed: 11/29/2025

The 5 gallon paint can was removed immediately on 10/29/25 and door was closed. A "do not prop door open" sign was affixed to the door. All facility doors will be checked monthly by Maintenance Director or designee to ensure that none are propped open. All staff will complete an in-service in November 2025 by Maintenance Director or designee educating on appropriate door closure. Audits will be conducted by Maintenance Director or designee on facility doors to ensure appropriate closure weekly for four weeks, then monthly for three months, then quarterly and results will be reviewed at quarterly QAPI meetings.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on documentation review and interview, it was determined the facility failed to maintain the fire alarm system, in one instance, affecting the entire facility

Findings Include:

1. Review of documentation on October 29, 2025, at 9:15 a.m., revealed the facility
lacked documentation for the semi-annual visual fire alarm inspection.

Interview with the facility Administrator and Maintenance Director on October 29, 2025, at 9:15 a.m., confirmed the fire alarm system deficiency.

Plan of Correction - To be completed: 11/29/2025

Fire Alarm company will be completing the semi-annual inspection on 11/14/25. Maintenance Director created a schedule with the fire alarm company for the semi-annual inspections. Administrator or designee will educate in November 2025 all maintenance staff on inspection schedule for the fire alarm system. Audits will be completed by Maintenance Director or designee on the facility inspection schedule for the fire alarm system weekly for four weeks, then monthly for three months, then quarterly and results will be reviewed at quarterly QAPI meetings.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting one of two smoke compartments.

Findings include:

1. Observation on October 29, 2025, at 9:50 a.m., revealed a ceiling tile was missing in the Social Services office, which would allow the passage of heat and smoke which may affect operation of the automatic sprinkler system.

Interview with the Facility Administrator and Maintenance Director on October 29, 2025, at 11:00 a.m., confirmed the automatic sprinkler system deficiency.

Plan of Correction - To be completed: 11/29/2025

Ceiling tile was installed in the Social Services office on 10/31/2025. Ceiling tile stock was ordered and received 11/06/2025 for future needs. When ceiling tiles become stained or ill-fitting or are missing, they will be replaced immediately by maintenance staff. All facility ceiling tiles will be checked monthly by Maintenance Director or designee to ensure present and in good condition. Maintenance Director or designee will educate all staff in November 2025 on notifying maintenance immediately if there are missing or damaged ceiling tiles. Audits will be conducted by Maintenance Director or designee on facility ceiling tiles weekly for four weeks, then monthly for three months, then quarterly and results will be reviewed at quarterly QAPI meetings.

NFPA 101 STANDARD Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform four of 12 required fire drills, affecting the entire facility.

Findings include:

1. Review of documentation on October 29, 2025, at 8:30 a.m., revealed the facility lacked documentation for Second and Third Shift fire drills for the second quarter, and the First and Second Shifts in the third quarter of the year.

Interview with the Facility Administrator and Maintenance Director on October 29, 2025, at 8:30 a.m., confirmed the facility lacked documentation for the drills between April 2025 and September 2025.

Plan of Correction - To be completed: 11/29/2025

All fire drills will be documented by Maintenance Director or designee to ensure all three shifts have a fire drill once every three months. All Maintenance staff will be in-serviced in November 2025 by Administrator or designee on fire drill scheduling and planning to ensure no shifts are missed. The Maintenance Director or designee will audit fire drill documentation weekly for four weeks, then monthly for three months, then quarterly and results will be reviewed at quarterly QAPI meetings.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to perform emergency generator maintenance and testing in two instances, affecting the entire facility.

Findings include:

1. Review of documentation on October 29, 2025, at 9:00 a.m., revealed the facility lacked documentation verifying that the following items were performed in the last 12 months:

a) 8:40 a.m., the annual 90 minute load bank test;
b) 8:45 a.m., the annual fuel quality test.

Interview with the Facility Administrator and Maintenance Director, on October 29, 2025, at 9:00 a.m., confirmed that the required annual generator testing documentation was not available at the time of the survey.

Plan of Correction - To be completed: 11/29/2025

Annual 90 minute load bank test will be completed 11/21/25. Documentation was found supporting the annual fuel quality test was completed on 8/25/25 by outside contractor and this documentation will be available for Division of Life Safety Inspectors. Maintenance Director created a schedule for annual 90 minute load bank test and the annual fuel quality test inspections. Administrator or designee will educate all maintenance staff in November 2025 on inspection schedule for the required annual generator tests. The Maintenance Director or designee will audit inspection schedule documentation for the generator weekly for four weeks, then monthly for three months, then quarterly, and results will be reviewed at quarterly QAPI meetings.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID# 740302
Component 02
Nursing Building

Based on a Relicensure Survey completed on October 29, 2025, it was determined that Kadima Rehabilitation and Nursing at Cheswick was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a three-story Type II (222), fire resistive, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
2012 EXISTING
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in one instance, affecting one of seven smoke compartments.

Findings include:

1. Observation on October 29, 2025, at 9:50 a.m., revealed the door to the Kitchen Storage room failed to close latch when tested.

Interview with the Facility Administrator and Maintenance Director on October 20, 2025, at 11:00 a.m., confirmed the self-closing door failed to latch and would not resist the passage of smoke.

Plan of Correction - To be completed: 11/29/2025

Kitchen Storage door will be replaced 11/21/25 so that the storage door will latch appropriately. Maintenance Director or designee will complete an inspection of all storage rooms to ensure appropriate latching. All staff will complete an in-service by Maintenance Director or designee in November 2025 on notifying maintenance immediately if storage doors are not latching correctly. Maintenance Director or designee will audit via facility walkthroughs to ensure continual compliance with positive latching of storage doors. These audits will be completed weekly for four weeks, then monthly for three months, then quarterly, and results will be reviewed at quarterly QAPI.

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0324

Based on observation and interview, it was determined the facility failed to maintain cooking facilities in one instance, affecting the entire facility.

Findings include:

1. Observation and document review on October 29, 2025, at 9:30 a.m., revealed the facility lacked documentation for one of two semiannual kitchen fire suppression system inspections and maintenance at the time of the survey.

Interview with the Facility Administrator and Maintenance Director on October 29, 2025, at 9:30 a.m., confirmed the cooking facilities deficiency.

Plan of Correction - To be completed: 11/29/2025

Fire Alarm company will be completing the semi-annual inspection on 11/14/25 of the kitchen fire suppression system. Maintenance Director created a schedule with the fire alarm company for the semi-annual inspections. Administrator or designee will educate all maintenance staff in November 2025 on inspection schedule for the kitchen fire suppression system. Audits will be completed by Maintenance Director or designee on the facility inspection schedule for the kitchen fire suppression system for four weeks, then monthly for three months, then quarterly and results will be reviewed at quarterly QAPI meetings.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0345

Based on documentation review and interview, it was determined the facility failed to maintain the fire alarm system, in one instance, affecting the entire facility

Findings Include:

1. Review of documentation on October 29, 2025, at 9:15 a.m., revealed the facility
lacked documentation for the semi-annual visual fire alarm inspection.

Interview with the facility Administrator and Maintenance Director on October 29, 2025, at 9:15 a.m., confirmed the fire alarm system deficiency.

Plan of Correction - To be completed: 11/29/2025

Fire Alarm company will be completing the semi-annual visual fire alarm inspection on 11/14/25. Maintenance Director created a schedule with the fire alarm company for the semi-annual inspections. Administrator or designee will educate all maintenance staff in November 2025 on inspection schedule for the fire alarm system. Audits will be completed by Maintenance Director or designee on the facility inspection schedule for the fire alarm system weekly for four weeks, then monthly for three months, then quarterly and results will be reviewed at quarterly QAPI meetings.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in three instances, affecting three of seven smoke compartments.

Findings include:

1. Observation on October 29, 2025, revealed the following automatic sprinkler system deficiencies:

a) 10:00 a.m., there was a missing ceiling tile in the Soiled Utility Room near the Nurse's Station on the second floor;
b) 10:10 a.m., there was excessive storage, stored less than 18 inches from a sprinkler head, in the Kitchen Storage room, near the Laundry Room;
c) 10:30 a.m., there was a ceiling tile with a large separation gap, greater than 1/8 inch, located on the 2 North Hallway, near the stairwell door at the end of the hall.

Interview with the Facility Administrator and Maintenance Director on October 29, 2025, at 11:00 a.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 11/29/2025

Ceiling tile was installed in the Soiled Utility Room on the second floor on 10/31/2025. Ceiling tile stock was ordered and received 11/06/25 for future needs. When tiles become stained or ill-fitting or are missing, they will be replaced immediately by maintenance staff. All facility ceiling tiles will be checked monthly by Maintenance Director or designee to ensure present and in good condition. All staff will complete an in-service by Maintenance Director or designee in November 2025 on notifying maintenance immediately if there are missing or damaged ceiling tiles. Audits will be conducted by Maintenance Director or designee on facility ceiling tiles weekly for four weeks, then monthly for three months, then quarterly and results will be reviewed at quarterly QAPI meetings.
Excessive storage in the Kitchen Storage room was removed immediately on 10/29/25 to a lower shelf. All staff will complete an in-service by Maintenance Director or designee in November 2025 on keeping stock and other storage below the 18" threshold for the sprinkler heads. Audits will be conducted by Maintenance Director or designee on storage areas to ensure no excessive storage weekly for four weeks, then monthly for three months, then quarterly and results will be reviewed at quarterly QAPI meetings.
Ceiling tile located on the 2 North Hallway was replaced so there was no longer separation. Ceiling tile stock was ordered and received 11/06/25 for future needs. When tiles become stained or ill-fitting, they will be replaced immediately by maintenance staff. All facility ceiling tiles will be checked monthly by Maintenance Director or designee in November 2025 to ensure present and in good condition. All staff will complete an in-service by Maintenance Director or designee on notifying maintenance immediately if there are missing or damaged ceiling tiles. Audits will be conducted by Maintenance Director or designee on facility ceiling tiles weekly for four weeks, then monthly for three months, then quarterly and results will be reviewed at quarterly QAPI meetings.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
2012 EXISTING
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.
There is no impediment to the closing of the doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted.
Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.
19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors in two instances, affecting one of seven smoke compartments.

Findings include:

1. Observation on October 29, 2025, revealed the following corridor door deficiencies:

a) 9:55 a.m., the door to Room 307 on the third floor failed to latch when tested;
b) 10:00 a.m., the door to Room 312 on the third floor failed to latch when tested.

Interview with the Facility Administrator and Maintenance Director on October 29, 2025, at 11:00 a.m., confirmed the corridor door deficiencies.

Plan of Correction - To be completed: 11/29/2025

The latch to Room 312 door was adjusted on 10/30/2025 and is now latching correctly. The latch to Room 307 door was adjusted on 11/12/2025 and is now latching correctly. Maintenance Director or designee will complete an inspection of all room doors to ensure appropriate latching. All staff will complete an in-service in November 2025 by Maintenance Director or on the standards of safety in regards to corridor doors, the importance of positive latching of resident room doors, and on notifying maintenance immediately if room doors are not latching correctly. Maintenance director or designee will also audit resident room doors to ensure continual compliance with positive latching. These audits will be completed weekly for four weeks, then monthly for three months, then quarterly, and results will be reviewed at quarterly QAPI.

NFPA 101 STANDARD Fire Drills:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform four of 12 required fire drills, affecting the entire facility.

Findings include:

1. Review of documentation on October 29, 2025, at 8:30 a.m., revealed the facility lacked documentation for Second and Third Shift fire drills for the second quarter, and the First and Second Shifts in the third quarter of the year.

Interview with the Facility Administrator and Maintenance Director on October 29, 2025, at 8:30 a.m., confirmed the facility lacked documentation for the drills between April 2025 and September 2025.

Plan of Correction - To be completed: 11/29/2025

All fire drills will be documented by Maintenance Director or designee to ensure all three shifts have a fire drill once every three months. All Maintenance staff will be inserviced in November 2025 by Administrator or designee on fire drill scheduling and planning to ensure no shifts are missed. The Maintenance Director or designee will audit fire drill documentation weekly for four weeks, then monthly for three months, then quarterly and results will be reviewed at quarterly QAPI meetings.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to perform emergency generator maintenance and testing in two instances, affecting the entire facility.

Findings include:

1. Review of documentation on October 29, 2025, at 9:00 a.m., revealed the facility lacked documentation verifying that the following items were performed in the last 12 months:

a) 8:40 a.m., the annual 90 minute load bank test;
b) 8:45 a.m., the annual fuel quality test.

Interview with the Facility Administrator and Maintenance Director, on October 29, 2025, at 9:00 a.m., confirmed that the required annual generator testing documentation was not available at the time of the survey.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical equipment and power cords in three instances, affecting three of seven smoke compartments.

Findings include:

1. Observation on October 29, 2025, revealed the following electrical devices were connected to power strips:

a) 10:10 a.m., a toaster and refrigerator in the MDS Office;
b) 10:30 a.m., a refrigerator in the OMNI-Cell Office;
c) 10:45 a.m., a refrigerator in the Resident Pantry (across from the Activities Office).

Interview with the Facility Administrator and Maintenance Director, on October 29, 2025, at 11:00 a.m., confirmed the electrical wiring deficiencies.

Plan of Correction - To be completed: 11/29/2025

The toaster and refrigerator in the MDS Office were immediately unplugged from the power strip on 10/29/25. The medication refrigerator in the OMNI-Cell Office was immediately unplugged from the power strip on 10/29/25 and plugged into wall outlet. The refrigerator in the resident pantry room was immediately unplugged from the power strip on 10/29/25 and plugged into regular wall outlet. Maintenance Director or designee will complete an inspection of all facility areas to ensure no use of power strips. All staff will be in-serviced by Maintenance Director or designee in November 2025 on not using power strips. Audits will be completed by Maintenance Director or designee to ensure power strips are not being used weekly for four weeks, then monthly for three months, then quarterly thereafter; results will be reported in quarterly QAPI meetings.

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