Zelienople, PA

Passavant Retirement And Healt

4-star overall rating with 2-star inspections with abuse icon flag with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

105 Burgess Drive, Zelienople, PA

(724) 452-5400

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

102

Certified beds

Average residents

97

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1967-01-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

1.41

Registered nurse staffing

LPN hours / resident day

0.62

Licensed practical nurse staffing

Aide hours / resident day

2.52

Nurse aide staffing

Weekend hours

4.14

Weekend nurse staffing

RN turnover

26%

Annual RN turnover

Total nurse turnover

27%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 0
1.7
1.7 pts better
1.9
1.9 pts better
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 0.2
1.2
1 pts better
1.8
1.6 pts better
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 90.4%
86.9%
3.5 pts better
93.4%
3 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 96.6%
93.5%
3.1 pts better
95.5%
1.1 pts better
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 8.1%
3.2%
4.9 pts worse
3.3%
4.8 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 0.0%
6.5%
6.5 pts better
11.4%
11.4 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 9.2%
6.5%
2.7 pts worse
5.4%
3.8 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 15.0%
19.9%
4.9 pts better
19.6%
4.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 19.2%
18.7%
0.5 pts worse
16.7%
2.5 pts worse
Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents whose ability to walk independently worsened 18.3%
19.6%
1.3 pts better
16.3%
2 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 25.7%
18.3%
7.4 pts worse
14.9%
10.8 pts worse
Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents with a urinary tract infection 0.9%
1.7%
0.8 pts better
1.7%
0.8 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 30.1%
26.4%
3.7 pts worse
19.8%
10.3 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 6.9%
5.3%
1.6 pts worse
5.1%
1.8 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 89.2%
68.9%
20.3 pts better
81.7%
7.5 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 2.1%
9.8%
7.7 pts better
12.0%
9.9 pts better
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 0.9%
1.5%
0.6 pts better
1.6%
0.7 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 93.1%
68.7%
24.4 pts better
79.7%
13.4 pts better
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 16.7%
23.1%
6.4 pts better
23.9%
7.2 pts better
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-21 · Fire 2025-02-21

9 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2024-03-28 · Fire 2024-03-28

11 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

4 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2023-04-06 · Fire 2023-04-06

2 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

2 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-21

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-04-03

C · Minimal harm 2025-02-21

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-04-03

F · Potential for more than minimal harm 2024-03-28

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-05-31

F · Potential for more than minimal harm 2024-03-28

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-05-31

E · Potential for more than minimal harm 2024-03-28

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-05-31

B · Minimal harm 2024-03-28

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-05-31

D · Potential for more than minimal harm 2023-04-06

K325 · Smoke Deficiencies

Fire Safety

Have properly installed hallway dispensers for alcohol-based hand rub.

Corrected 2023-04-28

B · Minimal harm 2023-04-06

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-04-28

Inspection history

Recent health citations

G · Actual harm 2025-09-09

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-10-24

G · Actual harm 2025-09-09

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 2025-10-24

D · Potential for more than minimal harm 2025-07-07

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-08-24

D · Potential for more than minimal harm 2025-02-21

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2025-04-01

D · Potential for more than minimal harm 2025-02-21

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2025-04-01

D · Potential for more than minimal harm 2025-02-21

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2025-04-01

D · Potential for more than minimal harm 2025-02-21

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2025-04-01

D · Potential for more than minimal harm 2025-02-21

F847 · Administration Deficiencies

Health

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Corrected 2025-04-01

D · Potential for more than minimal harm 2025-02-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-01

D · Potential for more than minimal harm 2025-01-13

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 2025-02-27

D · Potential for more than minimal harm 2024-09-10

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 2024-10-29

D · Potential for more than minimal harm 2024-05-21

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-06-03

E · Potential for more than minimal harm 2024-03-28

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-04-22

E · Potential for more than minimal harm 2024-03-28

F700 · Quality of Life and Care Deficiencies

Health

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Corrected 2024-04-22

D · Potential for more than minimal harm 2024-03-28

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2024-04-22

D · Potential for more than minimal harm 2024-03-28

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 2024-04-22

D · Potential for more than minimal harm 2024-03-28

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-04-22

D · Potential for more than minimal harm 2024-03-28

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2024-04-22

D · Potential for more than minimal harm 2024-03-28

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-04-22

D · Potential for more than minimal harm 2024-03-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-04-22

D · Potential for more than minimal harm 2023-04-06

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-05-01

D · Potential for more than minimal harm 2023-04-06

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 2023-05-01

Penalties and ownership

What sits behind the stars

Ownership

Carraway, Jeffrey

Corporate Director · Individual

0% 2 facilities 2021-05-27
Carraway, Jeffrey

Corporate Officer · Individual

0% 2 facilities 2021-05-27
Fenoglietto, David

Corporate Director · Individual

0% 2 facilities 2021-05-27
Fenoglietto, David

Corporate Officer · Individual

0% 2 facilities 2021-05-27
Garrett, Elizabeth

Operational/Managerial Control · Individual

0% 3 facilities 2008-10-20
Lutheran Seniorlife

Operational/Managerial Control · Organization

0% 1 facilities 1986-01-01
Roy, Laura

Corporate Officer · Individual

0% 1 facilities 2025-02-25

Nearby options

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1-star overall rating with 1-star inspections with abuse icon flag with $174,201 in total fines with 22 recent health deficiencies with 29 fire-safety deficiencies in the latest cycle

Overall
1 / 5
Health
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Staffing
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Fines
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#2

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4-star overall rating with 2-star inspections with $8,281 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

Overall
4 / 5
Health
2 / 5
Staffing
5 / 5
Fines
$8,281
#3

Cranberry Place

Cranberry Township, PA

1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $60,855 in total fines with 40 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

Overall
1 / 5
Health
1 / 5
Staffing
3 / 5
Fines
$60,855

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