Kadima Rehabilitation & Nursing at Cheswick

In the surveyor’s words

From the most serious findings on record at Kadima Rehabilitation & Nursing at Cheswick, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689May 8, 2026

  Based 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.Findings include: Review of facility policy Accidents and Incidents dated 4/28/26, indicated all accidents and incidents occurring on our premises must be investigated and reported to the administrator. The charge nurse should conduct initial assessment and provide any emergency interventions. […]

• Immediate jeopardy, isolatedF689Oct 31, 2025

  Based 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. 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. […]

• Actual harm, isolatedF699Jun 11, 2026

  Based 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).Findings include: Review of facility policy Trauma Informed Care dated 4/28/26, indicated the facility will provide individualized and personalized care to the residents. Understanding and adapting care to those with known trauma is an important part of the care provided. […]

• Actual harm, isolatedF600Mar 20, 2023

  Based on review of facility policies, clinical records, incident reports, facility documents, employee file, written employee statement, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by not providing the required assistance of two people for a safe transfer, which resulted in actual physical harm (laceration of the right posterior scalp- a deep cut on the back of the head) for one of three residents reviewed (Resident R1). Findings include: Review of the facility policy Abuse Protection, last reviewed 7/21/22, indicated that neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. […]

• Actual harm, isolatedF689Mar 20, 2023

  Based on review of facility policy, clinical records, incident reports, facility documents, employee file, a written employee statement, and staff interviews, it was determined that the facility failed to ensure that a resident was free from a preventable accident and received adequate supervision during a transfer, which resulted in actual physical harm (laceration of the right posterior scalp- a deep cut on the back of the head) for one of three residents reviewed (Resident R1). […]