Cycle 1
Health 2025-03-07 · Fire 2025-03-07
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Orwigsburg, PA
Seton Manor Nursing And Rehabilitation Center
3-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1000 Seton Drive, Orwigsburg, PA
(570) 366-0400
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
129
Certified beds
Average residents
121
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Imperial Healthcare Group
Operator or chain grouping
Approved since
1999-02-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.32
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.54
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,055
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9882
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.91% · Performance 23.32% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.50
Baseline 9.62% · Performance 6.38% · Measure score 6.50 · Achievement 4.86 · Improvement 6.50
Total nurse turnover
5.87
Baseline 51.43% · Performance 39.67% · Measure score 5.87 · Achievement 5.87 · Improvement 3.92
Adjusted total nurse staffing
1.28
Baseline 3.32 hours · Performance 3.44 hours · Measure score 1.28 · Achievement 1.28 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.92% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 278 · Observed rate 10.79% · Lower 95% interval 8.63% |
| Discharge to community | 50.34% |
50.57%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 266 · Observed rate 45.49% · Lower 95% interval 43.94% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 120 · Denominator 120 |
| Falls with major injury | 0.83% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 120 |
| Discharge self-care score | 45.33% |
53.69%
8.4 pts worse
|
Numerator 34 · Denominator 75 |
| Discharge mobility score | 42.67% |
50.94%
8.3 pts worse
|
Numerator 32 · Denominator 75 |
| Pressure ulcers or injuries, new or worsened | 5.83% |
2.29%
3.5 pts worse
|
Numerator 7 · Denominator 120 · Adjusted rate 6.36% |
| Healthcare-associated infections requiring hospitalization | 6.38% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 148 · Observed rate 4.73% · Lower 95% interval 4.28% |
| Staff COVID-19 vaccination coverage | 0.65% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 153 |
| Staff flu vaccination coverage | 13.42% |
42%
28.6 pts worse
|
Numerator 20 · Denominator 149 |
| Discharge function score | 42.67% |
56.45%
13.8 pts worse
|
Numerator 32 · Denominator 75 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 28 · Denominator 28 |
| Transfer of health information to patient | 97.92% |
96.28%
1.6 pts better
|
Numerator 47 · Denominator 48 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 59 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
1.7
1.1 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.2
0.5 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.1% |
86.9%
0.8 pts worse
|
93.4%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.6% · Q2 83.8% · Q3 83.5% · Q4 91.8% · 4Q avg 86.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.8% |
93.5%
8.7 pts worse
|
95.5%
10.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.2%
1.8 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.6% · Q3 4.3% · Q4 8.2% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.6% |
6.5%
0.1 pts worse
|
11.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 7.8% · Q3 3.7% · Q4 5.4% · 4Q avg 6.6% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
6.5%
0.3 pts better
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 8.6% · Q3 5.3% · Q4 6.1% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.5% |
19.9%
11.6 pts worse
|
19.6%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 30.6% · Q3 31.7% · Q4 32.7% · 4Q avg 31.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.2% |
18.7%
0.5 pts better
|
16.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 17.8% · Q3 16.7% · Q4 18.8% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.8% |
19.6%
6.2 pts worse
|
16.3%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 39.8% · Q3 19.8% · Q4 12.8% · 4Q avg 25.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.6% |
18.3%
11.3 pts worse
|
14.9%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.8% · Q2 29.4% · Q3 29.2% · Q4 14.1% · 4Q avg 29.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
1.7%
1.7 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.5% · Q3 4.7% · Q4 2.8% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.8% |
26.4%
4.4 pts worse
|
19.8%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 31.3% · Q3 35.0% · Q4 31.8% · 4Q avg 30.8% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
5.3%
1.2 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 7.1% · Q3 5.0% · Q4 10.0% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.1% |
68.9%
7.2 pts better
|
81.7%
5.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 60.3% · Q2 80.3% · Q3 84.7% · Q4 79.6% · 4Q avg 76.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.0% |
9.8%
3.2 pts worse
|
12.0%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 11.7% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 1.5% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.5% |
68.7%
8.8 pts better
|
79.7%
2.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.7% |
23.1%
9.6 pts worse
|
23.9%
8.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.7% · Observed 30.5% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-26 · Fire 2024-04-26
8 health deficiencies
Top issue: Resident Rights (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-04-26 · Fire 2023-04-26
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-07
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-09
E · Potential for more than minimal harm
2024-04-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-04-26
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-04-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-04-26
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-04-23
C · Minimal harm
2024-04-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-23
E · Potential for more than minimal harm
2023-04-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-23
E · Potential for more than minimal harm
2023-04-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-23
E · Potential for more than minimal harm
2023-04-26
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-05-23
C · Minimal harm
2023-04-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-07
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-09
C · Minimal harm
2025-03-07
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-01-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-11-08
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-03
E · Potential for more than minimal harm
2024-04-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-03
E · Potential for more than minimal harm
2024-04-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-06-03
D · Potential for more than minimal harm
2024-04-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-06-03
D · Potential for more than minimal harm
2024-04-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-03
D · Potential for more than minimal harm
2024-04-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-03
D · Potential for more than minimal harm
2024-04-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-03
D · Potential for more than minimal harm
2023-04-26
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-23
Penalties and ownership
What sits behind the stars
Ownership
Bh Opco Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Chrh Equities LLC
5% Or Greater Indirect Ownership Interest · Organization
Ens Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Gottesman, Daniel
5% Or Greater Indirect Ownership Interest · Individual
Grove, Joshua
W-2 Managing Employee · Individual
Herzka, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Herzka, Yisroel
Corporate Officer · Individual
Kopelowitz, Shaul
5% Or Greater Indirect Ownership Interest · Individual
The Ens Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Ymcs Equities LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Orwigsburg Nursing And Rehabilitation Center
Orwigsburg, PA
3-star overall rating with 4-star inspections with $22,128 in total fines with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Rosewood Rehabilitation and Nursing Center
Schuylkill Haven, PA
3-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Edenbrook Of Greenwood Hill
Pottsville, PA
2-star overall rating with 2-star inspections with abuse icon flag with $240,099 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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