Health inspection·February 6, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/29/25, indicated diagnoses of alcoholic cirrhosis of liver, chronic kidney disease and hepatic encephalopathy(condition where the brain becomes impaired due to severe liver disease). Review of Resident R1's clinical record revealed social services did not do an initial admission assessment. Review of Resident R2's admission record indicated the resident was admitted to the facility 1/29/25. A review of Resident R2's MDS dated [DATE], included diagnoses of orthopedic aftercare, absence of left leg below knee and alcohol-induced chronic pancreatitis. Review of Resident R2's clinical record revealed social services did not do an initial admission assessment. Review of Resident R3's admission record indicated the resident was admitted to the facility 1/31/25. A review of Resident R3's MDS dated [DATE], included diagnoses fracture of shaft of right tibia, protein-calorie malnutrition and polyosteoarthritis (condition where multiple joints experience osteoarthritis). Review of Resident R3's clinical record revealed social services did not do an initial admission assessment. During an interview on 2/6/25 at 11:30 a.m. Nursing Home Administrator confirmed that the facility did not complete social service initial admission assessment as required. Page 1 of 2 395538 395538 02/06/2025 Kadima Rehabilitation & Nursing at Cheswick 3876 Saxonburg Boulevard Cheswick, PA 15024

F 0842 28 Pa. Code: 211.5(f)(g)(h) Clinical records. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395538 Page 2 of 2