Your report for Southwestern Nursing and Rehabilitation Center
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- PennsylvaniaLowest tier among peers653 rated homes · average 3.0★
- Allegheny CountyLowest tier among peers52 rated homes · average 2.3★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.8 vs PA avg
- StaffingCan add or remove a star1★−2.3 vs PA avg
- Quality measuresCan add or remove a star2★−1.5 vs PA avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersPA avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersPA avg3.3★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 6% of peersPA avg3.5★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.06hrsAbove only 5% of peersPA avg3.89Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.49hrsAbove only 22% of peersPA avg0.78Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better65%Above only 8% of peersPA avg47%RN turnover55%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$60,520Above only 13% of peersPA avg$28,640Fines · denials1 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthFeb 2023 – Jan 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Jan 24, 2025Cycle 1worst F · no actual harm
- F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Mar 4, 2025
- F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Infection ControlD · isolatedCorrected Mar 4, 2025
- F946Provide training in compliance and ethics.AdministrationC · widespreadCorrected Mar 4, 2025
- F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesF · widespreadCorrected Mar 4, 2025
- F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.AdministrationC · widespreadCorrected Mar 4, 2025
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Mar 4, 2025
- Conduct mandatory training, for all staff, on the facilityâs Quality Assurance and Performance Improvement Program.AdministrationB · patternCorrected Mar 4, 2025
- F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Resident RightsD · isolatedCorrected Mar 4, 2025
- F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningD · isolatedCorrected Mar 4, 2025
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningE · patternCorrected Mar 4, 2025
- F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceD · isolatedCorrected Mar 4, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Mar 4, 2025
- F848Provide a neutral and fair arbitration process and agree to arbitrator and venue.AdministrationC · widespreadCorrected Mar 4, 2025
- F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.AdministrationB · patternCorrected Mar 4, 2025
- F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Resident RightsB · patternCorrected Mar 4, 2025
Jun 13, 2024Cycle 2worst H · actual harm$60,520
- F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareD · isolatedCorrected Aug 6, 2024
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareH · patternCorrected Aug 6, 2024
- F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.AdministrationE · patternCorrected Aug 6, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Aug 6, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Aug 6, 2024
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Aug 6, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Aug 6, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Aug 6, 2024
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected Aug 6, 2024
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesD · isolatedCorrected Aug 6, 2024
- F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareD · isolatedCorrected Aug 6, 2024
Mar 13, 2024Cycle 2worst D · no actual harm
- F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Apr 2, 2024
Dec 15, 2023Cycle 2worst E · no actual harm
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Feb 6, 2024
- Conduct mandatory training, for all staff, on the facilityâs Quality Assurance and Performance Improvement Program.AdministrationC · widespreadCorrected Feb 6, 2024
- Ensure meals and snacks are served at times in accordance with residentâs needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Nutrition and DietaryE · patternCorrected Feb 6, 2024
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareE · patternCorrected Feb 6, 2024
- F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsD · isolatedCorrected Feb 6, 2024
- F575Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.Resident RightsD · isolatedCorrected Feb 6, 2024
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsD · isolatedCorrected Feb 6, 2024
- F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsD · isolatedCorrected Feb 6, 2024
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Feb 6, 2024
- F680Ensure the activities program is directed by a qualified professional.Quality of Life and CareD · isolatedCorrected Feb 6, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareE · patternCorrected Feb 6, 2024
- F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.Nursing and Physician ServicesE · patternCorrected Feb 6, 2024
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Feb 6, 2024
- F838Conduct 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.AdministrationD · isolatedCorrected Feb 6, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Feb 6, 2024
Jun 6, 2023Cycle 3worst E · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jun 27, 2023
- F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Nutrition and DietaryE · patternCorrected Jun 27, 2023
Apr 21, 2023Cycle 3worst J · immediate jeopardy
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected May 11, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected May 11, 2023
Feb 12, 2023Cycle 3worst E · no actual harm
- F924Put firmly secured handrails on each side of hallways.EnvironmentalD · isolatedCorrected Mar 20, 2023
- F576Ensure residents have reasonable access to and privacy in their use of communication methods.Resident RightsD · isolatedCorrected Mar 20, 2023
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsD · isolatedCorrected Mar 20, 2023
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsD · isolatedCorrected Mar 20, 2023
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 20, 2023
- F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Mar 20, 2023
- F680Ensure the activities program is directed by a qualified professional.Quality of Life and CareE · patternCorrected Mar 20, 2023
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Mar 20, 2023
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceE · patternCorrected Mar 20, 2023
- F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryD · isolatedCorrected Mar 20, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Mar 20, 2023
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationD · isolatedCorrected Mar 20, 2023
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Mar 20, 2023
- Ensure meals and snacks are served at times in accordance with residentâs needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Nutrition and DietaryE · patternCorrected Mar 20, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.06hrs
- Registered nursesRN hours only0.49hrs
- Licensed practical nursesLPN hours0.80hrs
- Nurse aidesCNA hours1.77hrs
- Weekend nursingAll staff on Saturdays and Sundays2.93hrs
- Pennsylvania average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better65%Above only 8% of peersPA avg 47%
- RN turnoverRegistered nurses only55%Not ranked by CMS
- Administrators who leftIn the past year3Leadership changed
- Occupancy118 certified beds · ~81 residents a day69%Above only 15% of peersPA avg 82%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $60,520In fines
- 1Fine
- 0Payment denials
- $28,640PA avg in fines
Actions on record
- Jun 13, 2024Civil money penalty$60,520
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Corporation
- Chain
- Imperial Healthcare Group13 facilities in the chain2.4★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Southwestern Healthcare Operations Holdings LLC
- Ch Pa7 SNF Holdings LLC
- Ens Holdings, LLC
- Lionheart SNF LLC
- Sk Sw Operations Holdings LLC
- The Ens Family Trust
- Daniel Gottesman
- Yisroel Herzka
- Daniel Gottesman
- Yisroel Herzka
- Sara Delp
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 395742 · 500 NORTH LEWIS RUN ROAD, PITTSBURGH, PA, 15122.
- Percentiles compare this facility with every rated nursing home in Pennsylvania and Allegheny County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









