Inspection·March 20, 2025

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based 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. Findings include: A review of facility Menu policy dated 8/5/24, revealed that standardized cycle menus are prepared by the corporate menu team and fulfill residents' nutritional and therapeutic needs. The faciliy Registered Dietician reviews and approves the menu. A review of the facility's Four Week Spring Summer Cycle Menu extension spreadsheets provided by the facility revealed that the menus failed to provide documented evidence that the facility's Registered Dietician (RD) reviewed, dated and approved the four week Spring Summer cycle menu. During an interview on 3/19/25, at 11:45 am Food Service Director Employee E5 confirmed that the facility implemented the four week Spring Summer cycle menu prior to his hiring in 11/24. During an observation of the lunch meal service on 3/19/25, it was revealed that the facility failed to follow the preplanned cycle menu by failing to provide the correct dessert to residents prescribed a mechanical soft diet and pureed diet. See also F 805. During an interview at 12:30 pm Food Service Director Employee E5 confirmed that the facility failed to provide documented evidence that the facility's RD reviewed, dated, and approved the four week Spring Summer cycle menu prior to implementation and during the lunch meal on 3/19/25, the facility failed to follow the menu as planned. Pa Code: 211.6(a) Dietary services Pa Code: 201.14(a) Responsibility of Licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395538 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Cheswick 3876 Saxonburg Boulevard Cheswick, PA 15024 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based 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) Residents Affected - Some Findings include: A review of facility Standardize Recipes policy date 8/5/24, it was revealed that standardized recipes are used in the production of food products. During an interview on 3/19/25, at 10:30 am Food Service Worker Employee E3 confirmed that tray line service for the lunch meal begins at 11:00 am. She further confirmed that the production sheets indicated 33 servings of diet (sugar free) pudding was needed for the lunch meal service. During an observation on 3/19/25, at 10:30 am it was revealed that the facility failed to prepare 33 serving of diet (sugar free) pudding needed for the lunch meal service. During an observation on 3/19/25, at 10:35 am Food Service Worker Employee E2 was observed preparing diet (sugar free) pudding by pouring two quarts of 2% milk onto a mixing bowl and adding two packets of sugar free vanilla instant pudding and pie filling mix to the milk. Food Service Worker Employee E2 whisked the milk and pudding mix together. She determined that the pudding was not thick enough and added one more package of the pudding mix to the mixture. Food Service Worker Employee E3 portioned the pudding mixture into serving bowls. While portioning the pudding mixture she determined that she did not have enough product to fill all the portions (33) required for the meal service. Food Service Worker Employee E3 proceeded to produce additional pudding by measuring and adding two cups of 2% milk to a bowl and adding 2 packets of sugar free vanilla pudding and pie filling mix. When it was brought to her attention that she incorrectly measured the milk she added additional 2% milk to equal a total of two quarts. Food Service Worker Employee E3 determined that the product was not thick enough and added a packet of sugar free butterscotch pudding and pie filling mix to the vanilla pudding mixture. A review of the manufacture instructions on the back label of the sugar free vanilla pudding and pie filling mix and the back label of the sugar free butterscotch pudding and pie mix indicated that each packet yielded 8 serving and was to be mixed with one quart of skim milk per packet. Once mixed with a mixer the pudding mixture was to be poured into serving containers and refrigerated for 30 minutes until set. During an interview on 3/19/25, at 11:45 am the Food Service Director Employee E5 confirmed that the facility failed to follow the manufacture instructions for diet (sugar free) pudding by improperly measuring the milk for each batch of pudding produced, using the improper milk product, and not producing the product prior to meal service to permit the product to set properly. Food Service Director Employee E5 confirmed that the facility's failure to follow the manufacture instructions created the potential for inaccurate nutrients and possible non palatable food product to be served to the residents. Pa Code: 201.14(a) Responsibility of Licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395538 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Cheswick 3876 Saxonburg Boulevard Cheswick, PA 15024 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based 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. Findings include: A review of facility Menu policy dated 8/5/24, revealed that standardized cycle menus are prepared by the corporate menu team and fulfill residents' nutritional and therapeutic needs. The faciliy Registered Dietician reviews and approves the menu. A review of facility Description of Standard Diets policy date 8/5/24, revealed that a mechanical diet is used when a resident has difficulty chewing and or swallowing. A puree diet is used for residents that have difficulty chewing or swallowing, the food consistency is pureed. During a review of the resident's tray cards for the lunch meal on 3/19/25, it was revealed that for dessert the resident prescribed a mechanical soft diet were to receive a mechanical soft lemon blueberry tart and the residents prescribed a puree diet were to receive a pureed lemon blueberry tart. During an observation on 3/19/25, at 11:25 am [NAME] Employee E 4 confirmed that the facility failed to make mechanical lemon blueberry tarts for those residents prescribed a mechanical soft diet and pureed lemon blueberry tarts for those residents prescribed a puree diet. A review of the facility menu extension sheets for the lunch meal on 3/19/25, indicated that the residents prescribed a mechanical soft diet were to receive a mechanical soft lemon blueberry tart and the residents prescribed a puree diet were to receive a pureed lemon blueberry tart for their dessert. During an interview on 3/19/25, at 12:30 pm Food Service Director Employee E5 confirmed that the facility failed to produce and serve the approved dessert to those residents prescribed a mechanical soft diet and resident prescribed a puree diet as required Pa Code: 201.14(a) Responsibility of Licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395538 If continuation sheet Page 4 of 4