Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

SETON MANOR NURSING AND REHABILITATION CENTER

ORWIGSBURG, PA · 129 certified beds · Last Life Safety survey March 7, 2025

CMS Certification Number 396063 · first certified February 1999

Ownership

Operated by IMPERIAL HEALTHCARE GROUP · For profit - Corporation

  • Ownership changed July 1, 2019 (change of ownership)from SETON MANOR SNF LLC
12
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
2
Tags cited more than once
Across separate surveys
5
Inspection & testing records
Of the citations on file

Position within PA

12 citations — more than 56% of the 656 certified nursing homes in PA. Compared within PA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 3 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (January 2026 to March 2026), and past the point by which nine in ten PA facilities have been surveyed. This facility’s last Life Safety survey was March 2025. Facilities in PA are typically surveyed 10–12 months after the last one (median 11), measured over 1,113 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 12 Life Safety citations above. The Physical Environment Index

  • F-0584 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.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in PA, and nationally. Surveyors differ markedly between states, so the PA figure is the meaningful one.

This facility12PA median10National median11
Citations on file over three years, compared
MeasureCitations
This facility12
Median facility in PA10
Median facility nationally11

Survey history

Citations at each Life Safety survey
42023-0452024-0432025-03
Citations at each Life Safety survey
Survey dateCitations
April 26, 20234
April 26, 20245
March 7, 20253

Most-cited tags

Most-cited tags at this facility
K-03633K-09202K-07121K-03251K-02111K-09291K-03531K-03741
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0363Install corridor and hallway doors that block smoke.32025-03-07
K-0920Ensure proper usage of power strips and extension cords.22025-03-07
K-0712Have simulated fire drills held at unexpected times.12023-04-26
K-0325Have properly installed hallway dispensers for alcohol-based hand rub.12025-03-07
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.12023-04-26
K-0929Ensure precautions for handling oxygen cylinders and equipment are correctly followed.12024-04-26
K-0353Inspect, test, and maintain automatic sprinkler systems.12024-04-26
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.12023-04-26

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 6
  • Gas, Vacuum, and Electrical Systems Deficiencies 3
  • Egress Deficiencies 2
  • Miscellaneous Deficiencies 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies6
Gas, Vacuum, and Electrical Systems Deficiencies3
Egress Deficiencies2
Miscellaneous Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

March 7, 2025 — 3 citations

Citations issued on March 7, 2025
TagWhat the surveyor checksStatus
K-0325Have properly installed hallway dispensers for alcohol-based hand rub.Deficient, Provider has date of correction (April 9, 2025)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (April 9, 2025)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (April 9, 2025)

April 26, 2024 — 5 citations

Citations issued on April 26, 2024
TagWhat the surveyor checksStatus
K-0225Have stairways and smokeproof enclosures used as exits that meet safety requirements.Deficient, Provider has date of correction (April 23, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (April 23, 2024)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (April 23, 2024)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (April 23, 2024)
K-0929Ensure precautions for handling oxygen cylinders and equipment are correctly followed.Deficient, Provider has date of correction (April 23, 2024)

April 26, 2023 — 4 citations

Citations issued on April 26, 2023
TagWhat the surveyor checksStatus
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (May 23, 2023)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (May 23, 2023)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (May 23, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (May 23, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.