SOUTHWESTERN MANOR NURSING AND REHABILITATION
SOUTHWESTERN MANOR NURSING AND REHABILITATION is a 118-bed nursing home in PITTSBURGH, Pennsylvania. CMS has certified it for Medicare and Medicaid since 1987-09-22. It averages 77.7 residents a day.
What harm was found in the violations cited at SOUTHWESTERN MANOR NURSING AND REHABILITATION?
CMS lists 56 health-inspection deficiencies for SOUTHWESTERN MANOR NURSING AND REHABILITATION since 2023-02-12, 42 of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is H; the most recent health inspection was 2025-01-24.
| Survey date | Tag | Deficiency | Severity |
|---|---|---|---|
| 2025-01-24 | F0812, F0947 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | F |
| 2025-01-24 | F0641, F0943 | Ensure each resident receives an accurate assessment. / Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | E |
| 2025-01-24 | F0578, F0637, F0684, F0758, F0945 | 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. / Assess the resident when there is a significant change in condition / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / 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. / Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | D |
| 2025-01-24 | F0848, F0946, F0949 | Provide a neutral and fair arbitration process and agree to arbitrator and venue. / Provide training in compliance and ethics. / Provide behavior health training consistent with the requirements and as determined by a facility assessment. | C |
| 2025-01-24 | F0941, F0942, F0944 | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. / Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. / Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | B |
| 2024-06-13 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | H |
| 2024-06-13 | F0600, F0686, F0689 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G |
| 2024-06-13 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F |
| 2024-06-13 | F0725, F0940 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. / Develop, implement, and/or maintain an effective training program for all new and existing staff members. | E |
| 2024-06-13 | F0726, F0744, F0745, F0880 | 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. / Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. / Provide medically-related social services to help each resident achieve the highest possible quality of life. / Provide and implement an infection prevention and control program. | D |
| 2024-03-13 | F0583 | Keep residents' personal and medical records private and confidential. | D |
| 2023-12-15 | F0684, F0686, F0710, F0809, F0880 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. / 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. / Provide and implement an infection prevention and control program. | E |
| 2023-12-15 | F0565, F0575, F0580, F0582, F0585, F0677, F0680, F0756, F0838 | Honor the resident's right to organize and participate in resident/family groups in the facility. / 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. / Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. / 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. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Ensure the activities program is directed by a qualified professional. / Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. / 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. | D |
| 2023-12-15 | F0944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | C |
| 2023-02-12 | F0679, F0680, F0761, F0809, F0812 | Provide activities to meet all resident's needs. / Ensure the activities program is directed by a qualified professional. / 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. / 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. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E |
| 2023-02-12 | F0576, F0582, F0584, F0600, F0686, F0805, F0849, F0883, F0924 | Ensure residents have reasonable access to and privacy in their use of communication methods. / Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. / 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. / Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. / 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. / Develop and implement policies and procedures for flu and pneumonia vaccinations. / Put firmly secured handrails on each side of hallways. | D |
Why was SOUTHWESTERN MANOR NURSING AND REHABILITATION fined?
| Date | Type | Amount |
|---|---|---|
| 2024-06-13 | Fine | $60,520 |
How is SOUTHWESTERN MANOR NURSING AND REHABILITATION staffed relative to the PA average?
| Measure | This facility | PA average |
|---|---|---|
| Total nurse staffing hours per resident per day | 3.11325 | 3.88823 |
| Total nursing staff turnover (%) | 65.4 | 44.5 |
| Average number of residents per day | 77.7 | 104.6 |
Who owns SOUTHWESTERN MANOR NURSING AND REHABILITATION, and what chain is it in?
SOUTHWESTERN MANOR NURSING AND REHABILITATION is registered with CMS as For profit - Corporation, operates under the legal business name SOUTHWESTERN HEALTHCARE OPERATIONS LLC and belongs to the IMPERIAL HEALTHCARE GROUP chain.
| Role | Owner | Association date |
|---|---|---|
| 5% OR GREATER DIRECT OWNERSHIP INTEREST | SOUTHWESTERN HEALTHCARE OPERATIONS HOLDINGS LLC | since 04/30/2021 |
| 5% OR GREATER INDIRECT OWNERSHIP INTEREST | CH PA7 SNF HOLDINGS LLC, ENS HOLDINGS, LLC, SK SW OPERATIONS HOLDINGS LLC, THE ENS FAMILY TRUST, GOTTESMAN, DANIEL | since 04/30/2021 |
| W-2 MANAGING EMPLOYEE | DELP, SARA | since 12/05/2023 |
| CORPORATE OFFICER | GOTTESMAN, DANIEL, HERZKA, YISROEL | since 07/11/2021 |
Were you or a family member harmed at SOUTHWESTERN MANOR NURSING AND REHABILITATION?