B-
71/100PASSAVANT RETIREMENT AND HEALT Inspection Report, Violations & Safety Grade (ZELIENOPLE, Pennsylvania)
105 BURGESS DRIVE, ZELIENOPLE, Pennsylvania 16063
Phone: 7244525400
CMS Overall:4/5
Overview & Bed Count
Certified Beds
102
Avg Residents/Day
96.3
Ownership
Non profit - Church related
Provider Type
Medicare and Medicaid
County
Butler
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall4/5
Health2/5
Staffing5/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | Pennsylvania Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 1.47 | 0.78 | +0.69 |
| Total Nurse Hours per Resident per Day | 4.45 | 3.90 | +0.56 |
| CMS Staffing Rating | 5/5 | 3.1/5 | - |
| Nursing Staff Turnover | 31.9% | 44.6% | - |
Health Citation History
38 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-02-27 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G – Actual Harm |
| 2026-02-27 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2026-02-27 | Resident Rights Deficiencies | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | E – Moderate Harm Potential |
| 2026-02-27 | Quality of Life and Care Deficiencies | 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. | E – Moderate Harm Potential |
| 2026-02-27 | Pharmacy Service Deficiencies | 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. | E – Moderate Harm Potential |
| 2026-02-27 | Administration Deficiencies | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | E – Moderate Harm Potential |
| 2026-02-27 | Administration Deficiencies | Provide training in compliance and ethics. | E – Moderate Harm Potential |
| 2026-02-27 | Nursing and Physician Services Deficiencies | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | E – Moderate Harm Potential |
| 2026-02-27 | Administration Deficiencies | Provide behavior health training consistent with the requirements and as determined by a facility assessment. | E – Moderate Harm Potential |
| 2026-02-27 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2026-02-27 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2026-02-27 | Quality of Life and Care Deficiencies | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2026-02-27 | Infection Control Deficiencies | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | D – Moderate Harm Potential |
| 2026-02-27 | Administration Deficiencies | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | D – Moderate Harm Potential |
| 2026-02-27 | Resident Rights Deficiencies | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | D – Moderate Harm Potential |
| 2026-02-27 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | D – Moderate Harm Potential |
| 2026-02-27 | Infection Control Deficiencies | Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | D – Moderate Harm Potential |
| 2026-02-27 | Resident Rights Deficiencies | 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. | C – Minimal Harm Potential |
| 2025-09-09 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G – Actual Harm |
| 2025-09-09 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2025-07-07 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2025-02-21 | Resident Rights Deficiencies | Allow residents to self-administer drugs if determined clinically appropriate. | D – Moderate Harm Potential |
| 2025-02-21 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2025-02-21 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2025-02-21 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2025-02-21 | Administration Deficiencies | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | D – Moderate Harm Potential |
| 2025-02-21 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2025-01-13 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2024-09-10 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2024-05-21 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2024-03-28 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | E – Moderate Harm Potential |
| 2024-03-28 | Quality of Life and Care Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-03-28 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | D – Moderate Harm Potential |
| 2024-03-28 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2024-03-28 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2024-03-28 | Quality of Life and Care Deficiencies | Provide care or services that was trauma informed and/or culturally competent. | D – Moderate Harm Potential |
| 2024-03-28 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-03-28 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
Fire Safety Citation History
8 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-02-21 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2025-02-21 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | C – Minimal Harm Potential |
| 2024-03-28 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2024-03-28 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2024-03-28 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | E – Moderate Harm Potential |
| 2024-03-28 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | B – Minimal Harm Potential |
| 2023-04-06 | Smoke Deficiencies | Have properly installed hallway dispensers for alcohol-based hand rub. | D – Moderate Harm Potential |
| 2023-04-06 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | B – Minimal Harm Potential |
Total Penalties & Fines
$76,665
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2026-02-27 | Fine | $76,665 | - |
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the ZELIENOPLE area at no cost.
Find Safe, Vetted Facilities Near ZELIENOPLE
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.