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Southwestern Manor Nursing and Rehabilitation

500 North Lewis Run Road, Pittsburgh, PA 15122 · Allegheny County · (412) 466-0600

118 certified beds, about 78 residents a day · For profit - Corporation · Medicare and Medicaid since 1987

Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
2 of 5
Staffing
1 of 5
Quality measures
3 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 395742 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on January 24, 2025, inspectors cited 15 health deficiencies (the Pennsylvania average is 10, the national average 9.2).

Of 57 health citations since February 2023, 4 were rated as actual harm or immediate jeopardy to residents.

CMS lists 1 fine totaling $60,520 in the last three years; the largest was $60,520, and the latest is dated June 13, 2024.

Nurses and nurse aides worked 3.11 hours per resident per day, against 3.89 across Pennsylvania and 3.86 nationally. Registered nurses accounted for 0.54 of those hours.

65.4% of nursing staff left within the year CMS measured (Pennsylvania average 44.5%).

CMS links it to Imperial Healthcare Group, an affiliated group of 9 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 57 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
1H
0I
Potential for more than minimal harm
29D
14E
3F
Potential for minimal harm
0A
3B
4C
July 22, 2026Complaint inspection · 1 citation
  1. D
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 5, 2026
    Inspectors wroteBased on review of facility policy, observations and staff interviews, it was determined that the facility failed to properly secure the a medication cart for one of two carts observed (First Floor Short Hall).
January 24, 2025Standard inspection · 15 citations
  1. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) March 4, 2025
    Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to verify the dish washing temperature and staff education on the use of chemical sanitation to prevent the potential for cross contamination and failed to store food products in a manner to prevent foodborne illness in the main kitchen.
  2. F
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    F947 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) March 4, 2025
    Inspectors wroteBased on review of staff education records and interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for four of four nurse aides (Employees E6, E7, E8, and E9).
  3. E
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 4, 2025
    Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set (MDS - periodic assessment of care needs) assessments were accurate and fully completed for seven of eight residents without a BIMS assessment completed (Resident R7, R21, R22, R24, R38, R43, and R60).
  4. E
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    F943 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 4, 2025
    Inspectors wroteBased on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on abuse and neglect prevention for three of nine staff members (Employee E9, E13, and E14).
  5. D
    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.
    F578 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 4, 2025
    Inspectors wroteBased on review of the facility policy and clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for three of the eight residents reviewed (Resident R41, R75, and R77). Findings Include: A review of the facility policy Advanced Directives last reviewed 11/5/24, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. [...]
  6. D
    Assess the resident when there is a significant change in condition
    F637 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 4, 2025
    Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS- assessments completed indicating a change in condition of a resident requiring change in care) assessment for one of four residents reviewed (Residents R27).
  7. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 4, 2025
    Inspectors wroteBased on review of facility policies and documents, clinical records, and staff interviews, it was determined that the facility failed to provide care and services after hospitalization for one of three residents (Resident R27). Review of the facility policy, Resident Hydration and Prevention of Dehydration dated 11/5/24, previously dated 11/30/23, indicated the facility will strive to provide adequate hydration and to prevent dehydration. Review of the clinical record indicated that Resident R27 was admitted to the facility on [DATE]. [...]
  8. D
    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.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 4, 2025
    Inspectors wroteBased on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that each resident's drug regimen was free from unnecessary drugs used without adequate indications for use for one of five residents. (Resident R23).
  9. D
    Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
    F945 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 4, 2025
    Inspectors wroteBased on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on infection control for one of nine staff members (Employee E13).
  10. C
    Provide a neutral and fair arbitration process and agree to arbitrator and venue.
    F848 · Administration · No actual harm, potential for minimal harm, widespread · Corrected (the home has a date of correction) March 4, 2025
    Inspectors wroteBased on review of the facility's admission and financial agreement and staff interviews, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident or his or her representative, and the facility agree on the selection of a neutral arbitrator.
  11. C
    Provide training in compliance and ethics.
    F946 · Administration · No actual harm, potential for minimal harm, widespread · Corrected (the home has a date of correction) March 4, 2025
    Inspectors wroteBased on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on compliance and ethics for nine of nine staff members (Employee E6, E7, E8, E9, E10, E11, E12, E13, and E14).
  12. C
    Provide behavior health training consistent with the requirements and as determined by a facility assessment.
    F949 · Administration · No actual harm, potential for minimal harm, widespread · Corrected (the home has a date of correction) March 4, 2025
    Inspectors wroteBased on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on behavioral health for eight of nine staff members (Employee E6, E7, E8, E9, E10, E11, E13, and E14).
  13. B
    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
    F941 · Administration · No actual harm, potential for minimal harm, pattern · Corrected (the home has a date of correction) March 4, 2025
    Inspectors wroteBased on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on effective communication for eight of nine staff members (Employee E6, E7, E8, E9, E10, E11, E13, and E14).
  14. B
    Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
    F942 · Resident Rights · No actual harm, potential for minimal harm, pattern · Corrected (the home has a date of correction) March 4, 2025
    Inspectors wroteBased on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on resident rights for eight of nine staff members (Employee E6, E7, E8, E9, E10, E11, E12, and E14).
  15. B
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    F944 · Administration · No actual harm, potential for minimal harm, pattern · Corrected (the home has a date of correction) March 4, 2025
    Inspectors wroteBased on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for eight of nine staff members (Employee E6, E7, E8, E9, E10, E11, E13, and E14).
June 13, 2024Complaint inspection · 11 citations
  1. H
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · Actual harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) August 6, 2024
    Inspectors wroteBased on review of facility policies clinical records, observations, and staff and resident interviews, it was determined that the facility failed to ensure that residents received care and treatment by failing to identify signs and symptoms of constipation in one of five residents reviewed (Resident R28), resulting in actual harm by admissions to the hospital and failed to provide prescribed treatment and services related to the care of wounds for four of six residents (Resident R4, R11, R12, and R29).
  2. G
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 6, 2024
    Inspectors wroteBased on review of facility policies and documents, clinical records and documentation, and staff interviews, it was determined that the facility failed to protect residents from neglect for one of four residents (Resident R2), that resulted in actual harm of a low leg skin tear.
  3. G
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 6, 2024
    Inspectors wroteBased on review of clinical records, observations, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for four of seven residents (Resident R1, R12, R13, and R14) and failed to prevent avoidable pressure ulcer development that resulted in the actual harm of a new pressure ulcer for one of seven residents (Resident R1).
  4. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 6, 2024
    Inspectors wroteBased on review of facility policy, facility documentation, and staff interviews, it was determined that the facility failed to protect residents from injury that resulted in actual harm of a lower leg skin tear for two of four residents (Resident R2 and R10).
  5. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) August 6, 2024
    Inspectors wroteBased on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly label and date food, maintain refrigerator temperature logs, and maintain cleanliness in two of two nursing unit nutrition rooms (First and Second floor nursing units).
  6. E
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) August 6, 2024
    Inspectors wroteBased on review of facility policies and documents, resident observations, resident and staff interviews, and resident care records, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 22 of 47 residents (R1, R4, R5, R6, R7, R8, R9, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, and R27). Findings Include: Review of the facility policy Activity of Daily Living (ADLs), Supporting dated 1/30/24, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene, mobility, elimination (toileting), dining, and communication. [...]
  7. E
    Develop, implement, and/or maintain an effective training program for all new and existing staff members.
    F940 · Administration · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) August 6, 2024
    Inspectors wroteBased on review of facility documentation and staff interviews, it was determined that the facility failed to develop, implement, and maintain an effective training program, including additional training topics based on the resident population, outcome of the facility assessment, or non-common procedures for three of six staff members sampled (RN Employee E12, LPN Employee E15 and E16).
  8. D
    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.
    F726 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 6, 2024
    Inspectors wroteBased on a review of nursing job descriptions, facility documents, clinical record, and staff interviews, it was determined that the facility failed to assure that licensed nurses displayed the appropriate competencies and skills sets to provide nursing services for one of two residents (Resident R11).
  9. D
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    F744 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 6, 2024
    Inspectors wroteBased on facility documents, clinical record review, and staff interview, it was determined that the facility failed to provide the necessary services and failed to make certain appropriate treatment, and services for dementia were provided to one of four residents (Resident R2).
  10. D
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    F745 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 6, 2024
    Inspectors wroteBased on review of the clinical record, physician records, documents, and staff interviews, it was determined that the facility failed to schedule ordered appointments and failed to provide transportation for one of three residents (Resident R11), which resulted in the actual harm of a delay in cancer treatment.
  11. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 6, 2024
    Inspectors wroteBased on facility policy, observation, and staff interview, it was determined that the facility failed to maintain infection control practices to prevent the potential of infection and/or reinfection occurring for one of four residents (Resident R1).
March 13, 2024Complaint inspection · 1 citation
  1. D
    Keep residents' personal and medical records private and confidential.
    F583 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 2, 2024
    Inspectors wroteBased on a review of facility policy, resident record review, resident interview, and staff interviews, it was determined the facility failed to protect the right of resident personal privacy and confidentiality of medical records for one of two residents (Resident R1). Findings Include: Review of facility policy titled Protected Health Information (PHI), Safeguarding Electronic last reviewed 11/30/23, informed this facility ensures the confidentiality, integrity and availability of all e-PHI created, maintained, received, or transmitted by our information system. Employees and staff have access to e-PHI only to the degree that such access is appropriate for their job requirements and responsibilities. Review of Resident R1's record indicated the resident was admitted to the facility on [DATE], and discharged on 2/8/24. [...]
December 15, 2023Standard inspection, Complaint inspection · 15 citations
  1. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 6, 2024
    Inspectors wroteBased on observations and resident and staff interviews, it was it was determined that the facility failed to correctly apply elastic ACE wraps for one of four residents (Resident R74) and failed to follow physician's orders for two of four residents (Resident R60, R74, and R89).
  2. E
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 6, 2024
    Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to consistently provide prescribed treatments for three of four residents (Resident R46, R49 and R63).
  3. E
    Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
    F710 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 6, 2024
    Inspectors wroteBased on a review of facility policy, observations, resident record reviews, resident interviews and staff interviews, it was determined the facility failed to obtain physician orders for smoking and to ensure the medical care of each resident is supervised by a physician for eight of eight residents (Residents R2, R5, R31, R32, R55, R56, R70, and R199).
  4. E
    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.
    F809 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 6, 2024
    Inspectors wroteBased on review of facility policy, facility observations, facility documentation, resident and staff interviews, it was determined the facility failed to routinely offer evening snacks or provide snacks as requested for seven of seven residents (Resident R500, R501, R502, R503, R504, R505 and R506).
  5. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 6, 2024
    Inspectors wroteBased on a review of facility policy, clinical records, and staff interview, it was determined that the agency failed to maintain surveillance data and analysis for four of ten months (August, September, October, and November 2023) which caused six reportable infections not to be documented for five residents (Resident R5, R12, R23, R67, and R197).
  6. D
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    F565 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 6, 2024
    Inspectors wroteBased on a review of facility policy, resident interviews and staff interviews, it was determined the facility impeded residents' ability to meet or organize a resident or family group and failed to provide a designated staff person responsible for providing assistance and respond to written requests that result from group meetings for 10 of 11 months (1/23, 2/23, 3/23, 4/23, 5/23, 6/23, 7/23, 8/23, 9/23, and 10/23).
  7. D
    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.
    F575 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 6, 2024
    Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined the facility failed to display the contact information (name, address, email address, and phone number) for the local State Survey Agency and a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation on 3 of 3 resident information areas (Reception, 100 unit and 200 unit).
  8. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 6, 2024
    Inspectors wroteBased on facility policy and clinical record review and staff interview, it was determined the facility failed to notify the physician of a change in condition for one of four residents (Resident R59).
  9. D
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    F582 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 6, 2024
    Inspectors wroteBased on a review of facility documentation and staff interview, it was determined the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice form published by the Centers for Medicare and Medicaid Services (SNF ABN CMS-10055) which provides information to residents/resident representatives so they can decide if they wish to continue skilled nursing services that may not be paid for by Medicare and assume financial responsibility for one of three residents (Resident R700).
  10. D
    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.
    F585 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 6, 2024
    Inspectors wroteBased on facility observations and staff interviews, it was determined the facility failed to provide grievance forms for filing anonymous grievances on one of two units (100 unit).
  11. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 6, 2024
    Inspectors wroteBased on a review of facility policy, resident record, observation, resident interview and staff interview, it was determined the facility failed to provide necessary services to maintain good grooming and personal hygiene for thirteen of 43 residents (Resident R28, R22, R40, R29, R46, R201, R200, R250, R50, R81, R1, R90 and R15).
  12. D
    Ensure the activities program is directed by a qualified professional.
    F680 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 6, 2024
    Inspectors wroteBased on a review of facility policy, staff record review and staff interview it was determined the facility failed to have a qualified Activities Director to oversee the activities department for all 101 current residents in the facility.
  13. D
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 6, 2024
    Inspectors wroteBased on clinical record review, review of facility policy, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for one of five residents reviewed (Resident R36).
  14. D
    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.
    F838 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 6, 2024
    Inspectors wroteBased on review of facility documents and staff interview it was determined that the facility failed to complete the Facility Assessment annually.
  15. C
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    F944 · Administration · No actual harm, potential for minimal harm, widespread · Corrected (the home has a date of correction) February 6, 2024
    Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to facility staff.
February 12, 2023Standard inspection · 14 citations
  1. E
    Provide activities to meet all resident's needs.
    F679 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 20, 2023
    Inspectors wroteBased on review of activity calendars, resident group interview, observations, and staff interviews, it was determined that the facility failed to meet the activity needs for two of two nursing units (First and Second Floor)
  2. E
    Ensure the activities program is directed by a qualified professional.
    F680 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 20, 2023
    Inspectors wroteBased on a review of federal code, facility documentation and staff interview, it was determined that the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program.
  3. E
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 20, 2023
    Inspectors wroteBased on review of facility policy, observation, and staff interview, it was determined that the facility failed to store drugs and biological properly on one of two medication rooms (100 Unit) and one of two medication carts (F Hall Cart).
  4. E
    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.
    F809 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 20, 2023
    Inspectors wroteBased on resident and staff interviews, it was determined that the facility failed to routinely offer bedtime snacks for seven of seven residents (Resident R3, R26, R57, R59, R 500, R 501, and R 502).
  5. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 20, 2023
    Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain a sanitary environment and store foods in accordance with professional standards for food service safety for one of two nursing units (100 Unit.)
  6. D
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    F576 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 20, 2023
    Inspectors wroteBased on resident and staff interviews, it was determined that the facility failed to ensure all residents were granted privacy in opening their mail for one of three residents in resident council (Resident R900), and for one of four residents reviewed (Resident R51).
  7. D
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    F582 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 20, 2023
    Inspectors wroteBased on facility policy, facility documents, and staff interviews, it was determined that the facility failed to provide the Notice of Medicare Non-Coverage in a timely manner, for one of three residents (Resident R52).
  8. D
    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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 20, 2023
    Inspectors wroteBased on observations and staff interview it was determined that the facility failed to provide a homelike environment for one of four resident room hallways (2nd floor 207 hallway)
  9. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 20, 2023
    Inspectors wroteBased on facility policy, facility provided documentation and resident and staff interviews, the facility failed to ensure residents were free from misappropriation of funds for one of two residents reviewed (Resident R51).
  10. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 20, 2023
    Inspectors wroteBased on review of facility policy, national accepted guidelines for Pressure Ulcers, and staff interview, it was determined that the facility failed to prevent the development and accurately assess pressure ulcers for two of five residents (Resident R2 and Resident R56).
  11. D
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    F805 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 20, 2023
    Inspectors wroteBased on clinical record review, review of facility provided documents, review of facility diet manual and staff interview, it was determined that the facility failed to provide the appropriate diet to meet the needs for one of eight residents reviewed. (Resident R11).
  12. D
    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.
    F849 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 20, 2023
    Inspectors wroteBased on review of hospice contracts, clinical record review and staff interviews, it was determined that the facility failed to ensure that the facility received the required information from and communicated with the contracted hospice provider for one of two residents receiving hospice services (Resident R92)
  13. D
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    F883 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 20, 2023
    Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that a pneumococcal immunization was offered to two of seven residents (R45 and R90).
  14. D
    Put firmly secured handrails on each side of hallways.
    F924 · Environmental · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 20, 2023
    Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to provide handrails in a safe and functional environment for residents use in corridors in one four resident room hallways (2nd floor 207 hallway)

Fire safety inspections

13 fire safety citations on file: 1 on January 24, 2025, 10 on December 15, 2023, 2 on February 12, 2023.

Every fire safety citation13 citations
  1. C
    Have simulated fire drills held at unexpected times.
    K 712 · January 24, 2025 · Corrected (the home has a date of correction)
  2. E
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · December 15, 2023 · Corrected (the home has a date of correction)
  3. E
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · December 15, 2023 · Corrected (the home has a date of correction)
  4. E
    Install corridor and hallway doors that block smoke.
    K 363 · December 15, 2023 · Corrected (the home has a date of correction)
  5. E
    Have power receptacles that are properly grounded.
    K 912 · December 15, 2023 · Corrected (the home has a date of correction)
  6. E
    Ensure proper usage of power strips and extension cords.
    K 920 · December 15, 2023 · Corrected (the home has a date of correction)
  7. C
    Develop and maintain an Emergency Preparedness Program (EP).
    E 4 · December 15, 2023 · Corrected (the home has a date of correction)
  8. C
    Meet other general requirements.
    K 100 · December 15, 2023 · Corrected (the home has a date of correction)
  9. C
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · December 15, 2023 · Corrected (the home has a date of correction)
  10. C
    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
    K 521 · December 15, 2023 · Corrected (the home has a date of correction)
  11. C
    To conduct inspection, testing and maintenance of fire doors by qualified individuals.
    K 761 · December 15, 2023 · Corrected (the home has a date of correction)
  12. E
    Install an approved automatic sprinkler system.
    K 351 · February 12, 2023 · Corrected (the home has a date of correction)
  13. E
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · February 12, 2023 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
June 13, 2024Fine $60,520

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homePennsylvaniaUnited States
All nursing staff (RN, LPN and aides)3.113.893.86
Registered nurses0.540.790.69
All nursing staff on weekends2.893.533.42
Nurse aides1.74
Licensed practical nurses0.84
Nursing staff turnover (share who left in a year)65.4%44.5%45.8%
Registered nurse turnover61.5%39.9%42.9%
Administrators who leftnot reported

CMS expects 4.17 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.20 on weekdays and 2.89 on weekends, 10% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 15.1% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 2.97 in April to June 2025 to 3.11 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.110.543.202.89 15.1%0 of 9078
Oct to Dec 20253.090.523.192.85 10.8%0 of 9278
Jul to Sep 20253.060.493.112.93 18.8%0 of 9281
Apr to Jun 20252.970.483.052.78 9.3%0 of 9181
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Pennsylvania, Jan to Mar 20263.690.653.823.3411.3%0.1% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.

Official wage estimates for Pennsylvania

JobMedianMiddle halfEmployed
Pennsylvania, all employers
CNAs (nursing assistants)$21.44$18.88 to $22.5267,740
LPNs and LVNs$30.74$29.02 to $35.0138,260
Registered nurses$46.36$38.75 to $50.35146,520
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homePennsylvaniaUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
5.016.813.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
1.20.70.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.01.41.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
2.63.13.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
0.41.41.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
3.217.014.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
6.24.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
20.117.715.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
32.122.523.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
13.79.512.0

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Southwestern Manor Nursing and Rehabilitation's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (42.0% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

42.0% this home

No different from the national rate

US median of homes 51.5% · Pennsylvania: 100 better, 108 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 45 eligible stays.

Potentially preventable readmissions

10.1% this home

No different from the national rate

US median of homes 10.7% · Pennsylvania: 3 better, 9 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 67 eligible stays.

Infections that led to a hospital stay

6.4% this home

No different from the national rate

US median of homes 7.1% · Pennsylvania: 7 better, 5 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 31 eligible stays.

Self-care and mobility at discharge

68.8% this home

Median of homes: Pennsylvania54.4% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 32 residents counted.

Falls with major injury

0.0% this home

Median of homes: Pennsylvania0.0% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 51 residents counted.

New or worsened pressure ulcers

4.2% this home

Median of homes: Pennsylvania2.0% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 51 residents counted.

Medication list given at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Pennsylvania100.0% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 19 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: SOUTHWESTERN HEALTHCARE OPERATIONS LLC. CMS links this home to Imperial Healthcare Group, a group of 9 nursing homes averaging 2.2 stars overall.

NameRoleTypeShareSince
Southwestern Healthcare Operations Holdings LLC5% or greater direct ownership interestOrganization100%04/30/2021
Ch Pa7 SNF Holdings LLC5% or greater indirect ownership interestOrganization04/30/2021
Ens Holdings, LLC5% or greater indirect ownership interestOrganization07/11/2021
Sk Sw Operations Holdings LLC5% or greater indirect ownership interestOrganization04/30/2021
The Ens Family Trust5% or greater indirect ownership interestOrganization07/11/2021
Gottesman, Daniel5% or greater indirect ownership interestIndividual07/11/2021
Delp, SaraW-2 managing employeeIndividual12/05/2023
Gottesman, DanielCorporate officerIndividual07/11/2021
Herzka, YisroelCorporate officerIndividual07/11/2021

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 13 problems in this area, most recently on January 24, 2025: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 11 problems in this area, most recently on January 24, 2025: "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."
  3. Who is the administrator and director of nursing, and how long have they been in the job?Inspectors cited 9 problems in this area, most recently on January 24, 2025: "Provide a neutral and fair arbitration process and agree to arbitrator and venue."
  4. Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 6 problems in this area, most recently on January 24, 2025: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.89 hours per resident per day, below the Pennsylvania average of 3.53.

Other nursing homes nearby

Pennsylvania contacts for a concern about a nursing home

These are the official offices in Pennsylvania. NursingHomeClear cannot take or act on complaints.

Common questions

What is Southwestern Manor Nursing and Rehabilitation's Medicare star rating?
CMS rates Southwestern Manor Nursing and Rehabilitation 1 out of 5 stars overall, with 2 for health inspections, 1 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Southwestern Manor Nursing and Rehabilitation get at its last inspection?
15 health deficiencies at the standard inspection on January 24, 2025. The Pennsylvania average is 10.
Has Southwestern Manor Nursing and Rehabilitation been fined?
Yes. CMS lists 1 fine totaling $60,520 in the last three years.
Does Southwestern Manor Nursing and Rehabilitation accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Southwestern Manor Nursing and Rehabilitation?
CMS lists 9 owners and managers, and links the home to Imperial Healthcare Group. Legal business name: SOUTHWESTERN HEALTHCARE OPERATIONS LLC.

Sources

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