01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-01-24 | 15 | 2025-01-24 | 1 |
| Cycle 2 | 2023-12-15 | 15 | 2023-12-15 | 10 |
| Cycle 3 | 2023-02-12 | 26 | 2023-02-12 | 2 |
CMS CCN 3957422026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Southwestern Manor Nursing And Rehabilitation
500 North Lewis Run Road · Pittsburgh, PA 15122 · Allegheny County
Certified beds118CMS provider file
Recent citation rows69current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
69 rows in the current release
4 rows carry G–L scope/severity codes; 0 carry J–L. 10 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-01-24 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-03-042025-01-24 · HEALTHF0637Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
Correction field: Deficient, Provider has date of correction · 2025-03-042025-01-24 · HEALTHF0641Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2025-03-042025-01-24 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-03-042025-01-24 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-03-042025-01-24 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-03-042025-01-24 · HEALTHF0848Severity C · widespread; potential for minimal harm
Administration Deficiencies
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Correction field: Deficient, Provider has date of correction · 2025-03-042025-01-24 · HEALTHF0941Severity B · pattern; potential for minimal harm
Administration Deficiencies
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Correction field: Deficient, Provider has date of correction · 2025-03-042025-01-24 · HEALTHF0942Severity B · pattern; potential for minimal harm
Resident Rights Deficiencies
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Correction field: Deficient, Provider has date of correction · 2025-03-042025-01-24 · HEALTHF0943Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Correction field: Deficient, Provider has date of correction · 2025-03-042025-01-24 · HEALTHF0944Severity B · pattern; potential for minimal harm
Administration Deficiencies
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Correction field: Deficient, Provider has date of correction · 2025-03-042025-01-24 · HEALTHF0945Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Correction field: Deficient, Provider has date of correction · 2025-03-042025-01-24 · HEALTHF0946Severity C · widespread; potential for minimal harm
Administration Deficiencies
Provide training in compliance and ethics.
Correction field: Deficient, Provider has date of correction · 2025-03-042025-01-24 · HEALTHF0947Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Correction field: Deficient, Provider has date of correction · 2025-03-042025-01-24 · HEALTHF0949Severity C · widespread; potential for minimal harm
Administration Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Correction field: Deficient, Provider has date of correction · 2025-03-042025-01-24 · FIREK0712Severity C · widespread; potential for minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2025-02-202024-06-13 · HEALTHF0600Severity G · isolated actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2024-08-06 · complaint2024-06-13 · HEALTHF0684Severity H · pattern of actual harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-08-06 · complaint2024-06-13 · HEALTHF0686Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-08-06 · complaint2024-06-13 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-08-06 · complaint2024-06-13 · HEALTHF0725Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Correction field: Deficient, Provider has date of correction · 2024-08-06 · complaint2024-06-13 · HEALTHF0726Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-08-06 · complaint2024-06-13 · HEALTHF0744Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Correction field: Deficient, Provider has date of correction · 2024-08-06 · complaint2024-06-13 · HEALTHF0745Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Correction field: Deficient, Provider has date of correction · 2024-08-06 · complaint03 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-06-13 | Fine | $60,520 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- SOUTHWESTERN HEALTHCARE OPERATIONS HOLDINGS LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 04/30/2021
- CH PA7 SNF HOLDINGS LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 04/30/2021
- ENS HOLDINGS, LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 07/11/2021
- SK SW OPERATIONS HOLDINGS LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 04/30/2021
- THE ENS FAMILY TRUSTOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 07/11/2021
- GOTTESMAN, DANIELIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 07/11/2021
- DELP, SARAIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 12/05/2023
- GOTTESMAN, DANIELIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/11/2021
- HERZKA, YISROELIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/11/2021
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.11per resident day
RN hours0.54per resident day
Weekend nurse hours2.89per resident day
Staff turnover65.4%CMS reported field
06 / LOCAL RECORDS
Open the Pittsburgh ledger →Other published facilities nearby
Asbury Health Center139 beds · CMS overall 3/540 citation rowsBurgh Care Center126 beds · CMS overall 1/5141 citation rowsCarnegie Park Post Acute180 beds · CMS overall 1/576 citation rowsChampion City Nursing And Rehabilitation Center187 beds · CMS overall 1/5110 citation rowsConcordia Of The South Hills46 beds · CMS overall 5/56 citation rowsCanterbury Place115 beds · CMS overall 1/556 citation rowsConcordia At Rp Home58 beds · CMS overall 3/540 citation rowsEast End Health & Rehab Center144 beds · CMS overall 3/537 citation rows