Southwestern Manor Nursing And Rehabilitation
Pittsburgh, Allegheny County, Pennsylvania · CCN 395742 · For-profit (Corporation) · part of Imperial Healthcare Group (9 facilities, chain average 2.3 stars)
CMS rates Southwestern Manor Nursing And Rehabilitation 1 of 5 overall as of August 2026. 118 certified beds, 78 residents a day on average. 56 citations on record from the current inspection cycles, 4 involving actual harm; 1 fine totalling $60,520.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★☆☆☆☆ 1 of 5 |
|---|---|
| Health inspections | ★★☆☆☆ 2 of 5 |
| Staffing | ★☆☆☆☆ 1 of 5 |
| Quality measures | ★★★☆☆ 3 of 5 |
| Quality: long-stay / short-stay | 5 / 2 of 5 |
Staffing
| Total nurse staffing | 3.11325 hours per resident per day |
|---|---|
| Registered nurses | 0.5397 hours per resident per day |
| Weekend total | 2.8907 hours per resident per day |
| Nursing staff turnover | 65.4% (registered nurses 61.5%) |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2025-01-24 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-03-04 |
| 2025-01-24 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · tag F0947 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-03-04 |
| 2025-01-24 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-03-04 |
| 2025-01-24 | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0943 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-03-04 |
| 2025-01-24 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident Rights Deficiencies · tag F0578 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-04 |
| 2025-01-24 | Assess the resident when there is a significant change in condition Resident Assessment and Care Planning Deficiencies · tag F0637 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-04 |
| 2025-01-24 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-04 |
| 2025-01-24 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-04 |
| 2025-01-24 | Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Infection Control Deficiencies · tag F0945 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-04 |
| 2025-01-24 | Provide a neutral and fair arbitration process and agree to arbitrator and venue. Administration Deficiencies · tag F0848 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2025-03-04 |
| 2025-01-24 | Provide training in compliance and ethics. Administration Deficiencies · tag F0946 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2025-03-04 |
| 2025-01-24 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · tag F0949 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2025-03-04 |
| 2025-01-24 | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · tag F0941 |
B No actual harm, with potential for minimal harm; pattern | Deficient, Provider has date of correction 2025-03-04 |
| 2025-01-24 | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Resident Rights Deficiencies · tag F0942 |
B No actual harm, with potential for minimal harm; pattern | Deficient, Provider has date of correction 2025-03-04 |
| 2025-01-24 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · tag F0944 |
B No actual harm, with potential for minimal harm; pattern | Deficient, Provider has date of correction 2025-03-04 |
| 2024-06-13 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
H Actual harm that is not immediate jeopardy; pattern | Deficient, Provider has date of correction 2024-08-06 |
| 2024-06-13 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-06-13 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-06-13 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-06-13 complaint survey |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-08-06 |
| 2024-06-13 complaint survey |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · tag F0725 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-06 |
| 2024-06-13 complaint survey |
Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies · tag F0940 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-06 |
| 2024-06-13 complaint survey |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · tag F0726 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-06-13 complaint survey |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · tag F0744 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-06-13 complaint survey |
Provide medically-related social services to help each resident achieve the highest possible quality of life. Quality of Life and Care Deficiencies · tag F0745 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-06-13 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-03-13 complaint survey |
Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · tag F0583 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-02 |
| 2023-12-15 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-02-06 |
| 2023-12-15 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-02-06 |
| 2023-12-15 | Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Nursing and Physician Services Deficiencies · tag F0710 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-02-06 |
| 2023-12-15 | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Nutrition and Dietary Deficiencies · tag F0809 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-02-06 |
| 2023-12-15 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-02-06 |
| 2023-12-15 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · tag F0565 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-06 |
| 2023-12-15 | Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Resident Rights Deficiencies · tag F0575 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-06 |
| 2023-12-15 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-06 |
| 2023-12-15 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · tag F0582 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-06 |
| 2023-12-15 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · tag F0585 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-06 |
| 2023-12-15 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-06 |
| 2023-12-15 | Ensure the activities program is directed by a qualified professional. Quality of Life and Care Deficiencies · tag F0680 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-06 |
| 2023-12-15 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · tag F0756 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-06 |
| 2023-12-15 | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Administration Deficiencies · tag F0838 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-06 |
| 2023-12-15 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · tag F0944 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2024-02-06 |
| 2023-02-12 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-03-20 |
| 2023-02-12 | Ensure the activities program is directed by a qualified professional. Quality of Life and Care Deficiencies · tag F0680 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-03-20 |
| 2023-02-12 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-03-20 |
| 2023-02-12 | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Nutrition and Dietary Deficiencies · tag F0809 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-03-20 |
| 2023-02-12 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-03-20 |
| 2023-02-12 | Ensure residents have reasonable access to and privacy in their use of communication methods. Resident Rights Deficiencies · tag F0576 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-03-20 |
| 2023-02-12 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · tag F0582 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-03-20 |
| 2023-02-12 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · tag F0584 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-03-20 |
| 2023-02-12 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-03-20 |
| 2023-02-12 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-03-20 |
| 2023-02-12 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · tag F0805 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-03-20 |
| 2023-02-12 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · tag F0849 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-03-20 |
| 2023-02-12 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-03-20 |
| 2023-02-12 | Put firmly secured handrails on each side of hallways. Environmental Deficiencies · tag F0924 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-03-20 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2024-06-13 | Fine | $60,520 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Southwestern Healthcare Operations Holdings LLC Organization | 5% or greater direct ownership interest | 100% | 2021-04-30 |
| Ch Pa7 Snf Holdings LLC Organization | 5% or greater indirect ownership interest | — | 2021-04-30 |
| Ens Holdings, LLC Organization | 5% or greater indirect ownership interest | — | 2021-07-11 |
| Sk Sw Operations Holdings LLC Organization | 5% or greater indirect ownership interest | — | 2021-04-30 |
| The Ens Family Trust Organization | 5% or greater indirect ownership interest | — | 2021-07-11 |
| Gottesman, Daniel Individual | 5% or greater indirect ownership interest | — | 2021-07-11 |
| Gottesman, Daniel Individual | corporate officer | — | 2021-07-11 |
| Herzka, Yisroel Individual | corporate officer | — | 2021-07-11 |
| Delp, Sara Individual | w-2 managing employee | — | 2023-12-05 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Southwestern Manor Nursing And Rehabilitation.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Allegheny County.