Southwestern Manor Nursing and Rehabilitation
500 North Lewis Run Road, Pittsburgh, PA 15122 · Allegheny County · 118 certified beds · avg 78 residents/day · certified since Sep 22, 1987
Part of chain: IMPERIAL HEALTHCARE GROUP (9 facilities, chain avg rating 2.3★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, repeated · Jun 13, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Aug 6, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 13, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 6, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 13, 2024 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 6, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 13, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 6, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (56)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 24, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 24, 2025 | F · Potential for harm, facility-wide | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Jan 24, 2025 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jan 24, 2025 | E · Potential for harm, repeated | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. |
| Jan 24, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Jan 24, 2025 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Jan 24, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jan 24, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jan 24, 2025 | D · Potential for harm, one-off | The facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program. |
| Jan 24, 2025 | C · Minimal risk, facility-wide | The facility did not provide a neutral and fair arbitration process. Arbitration is a way of settling disputes outside of court, and if it's used, the facility must agree with the resident on a neutral arbitrator and a convenient location. |
| Jan 24, 2025 | C · Minimal risk, facility-wide | The facility did not provide its staff with training in compliance and ethics — teaching employees the laws and ethical standards that govern how residents must be treated. |
| Jan 24, 2025 | C · Minimal risk, facility-wide | The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. |
| Jan 24, 2025 | B · Minimal risk, repeated | The facility did not develop or maintain an effective training program for its direct care staff, including training on how to communicate effectively with residents. |
| Jan 24, 2025 | B · Minimal risk, repeated | The facility did not educate its staff on residents' rights and the facility's responsibilities toward residents. Staff can only respect rights they've been taught about. |
| Jan 24, 2025 | B · Minimal risk, repeated | The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. |
| Jun 13, 2024 | ▲ H · Actual harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jun 13, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jun 13, 2024 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jun 13, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 13, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Jun 13, 2024 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Jun 13, 2024 | E · Potential for harm, repeated | The facility did not develop, carry out, or maintain an effective training program for all new and existing staff members. · from a complaint |
| Jun 13, 2024 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Jun 13, 2024 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · from a complaint |
| Jun 13, 2024 | D · Potential for harm, one-off | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint |
| Jun 13, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Mar 13, 2024 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Dec 15, 2023 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Dec 15, 2023 | E · Potential for harm, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Dec 15, 2023 | E · Potential for harm, repeated | The facility admitted a resident without a doctor's order, or did not make sure each resident stayed under a doctor's ongoing care. |
| Dec 15, 2023 | E · Potential for harm, repeated | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| Dec 15, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Dec 15, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Dec 15, 2023 | D · Potential for harm, one-off | The facility did not post the names, addresses, and phone numbers of state agencies and advocacy groups, along with a notice that residents may file complaints with the state survey agency. |
| Dec 15, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Dec 15, 2023 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Dec 15, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Dec 15, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Dec 15, 2023 | D · Potential for harm, one-off | The facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials. |
| Dec 15, 2023 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Dec 15, 2023 | D · Potential for harm, one-off | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. |
| Dec 15, 2023 | C · Minimal risk, facility-wide | The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. |
| Feb 12, 2023 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Feb 12, 2023 | E · Potential for harm, repeated | The facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials. |
| Feb 12, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 12, 2023 | E · Potential for harm, repeated | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| Feb 12, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 12, 2023 | D · Potential for harm, one-off | The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. |
| Feb 12, 2023 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Feb 12, 2023 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Feb 12, 2023 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Feb 12, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Feb 12, 2023 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Feb 12, 2023 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Feb 12, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Feb 12, 2023 | D · Potential for harm, one-off | The facility did not have firmly secured handrails on both sides of its hallways. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (15 → 15).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 29 | 0 | E |
| 2024 | 12 | 4 | H ▲ |
| 2025 | 15 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $60,520.
| Date | Type | Amount / length |
|---|---|---|
| Jun 13, 2024 | Fine | $60,520 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Pennsylvania avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.86 | 3.94 | 3.95 | bottom 5% in Pennsylvania; bottom 10% in the U.S. |
| Registered Nurse hours | 0.50 | 0.80 | 0.69 | bottom 25% in Pennsylvania; bottom 37% in the U.S. |
| Weekend total nurse staffing | 2.66 | 3.58 | 3.50 | bottom 8% in Pennsylvania; bottom 15% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.31 | 0.56 | 0.48 | bottom 25% in Pennsylvania; bottom 35% in the U.S. |
| Total nursing staff turnover (%) | 65.4 | 44.5 | 45.8 | bottom 6% in Pennsylvania; bottom 9% in the U.S. |
| RN turnover (%) | 61.5 | 39.9 | 42.9 | bottom 15% in Pennsylvania; bottom 20% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.11, RN 0.54, weekend 2.89. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 5/5 · short-stay residents: 2/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| CH Pa7 SNF Holdings LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 04/30/2021 |
| Ens Holdings, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 07/11/2021 |
| Gottesman, Daniel | Individual | 5% or Greater Indirect Ownership Interest | — | 07/11/2021 |
| SK SW Operations Holdings LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 04/30/2021 |
| Southwestern Healthcare Operations Holdings LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 04/30/2021 |
| The Ens Family Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 07/11/2021 |
| Delp, Sara | Individual | W-2 Managing Employee | NOT APPLICABLE | 12/05/2023 |
| Gottesman, Daniel | Individual | Corporate Officer | NOT APPLICABLE | 07/11/2021 |
| Herzka, Yisroel | Individual | Corporate Officer | NOT APPLICABLE | 07/11/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What specific training do your nurse aides complete in dementia care and abuse prevention, and how often is it refreshed?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "What training do all staff get on dementia care and on spotting and reporting abuse?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Rehabilitation Center at Jefferson Hills, the | 0.6 mi | Jefferson Hills, PA | ★★☆☆☆ | 2/5 | |
| Rose Meadows Health & Rehab Center | 2.9 mi | Pittsburgh, PA | ★☆☆☆☆ | 1/5 | abuse |
| John J Kane Regional Center-Mc | 3.9 mi | McKeesport, PA | ★★★☆☆ | 2/5 | |
| Riverside Health & Rehab Center | 3.9 mi | McKeesport, PA | ★☆☆☆☆ | 1/5 | |
| Whitehall Borough Post Acute | 4.0 mi | Pittsburgh, PA | ★★☆☆☆ | 1/5 | |
| Eldercrest Rehabilitation & Healthcare Center | 4.6 mi | Munhall, PA | ★★★☆☆ | 2/5 | abuse |
| John J Kane Regional Center-Gl | 5.5 mi | Pittsburgh, PA | ★★☆☆☆ | 2/5 | abuse |
| South Hills Post Acute | 5.9 mi | Bethel Park, PA | ★★★☆☆ | 4/5 | |
| Meadowcrest Rehabilitation & Healthcare Center | 6.1 mi | Bethel Park, PA | ★☆☆☆☆ | 1/5 | |
| Wecare at Mt Lebanon Rehabilitation and Nrsg Ctr | 6.8 mi | Pittsburgh, PA | ★★☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 395742.