Passavant Retirement And Healt
Zelienople, Butler County, Pennsylvania · CCN 395001 · Non-profit (Church related) · not part of a chain
CMS rates Passavant Retirement And Healt 2 of 5 overall as of August 2026. 102 certified beds, 96 residents a day on average. 38 citations on record from the current inspection cycles, 3 involving actual harm; no fines on record.
On record
- Abuse icon. CMS marks this facility for a citation of abuse that led to harm, or a repeated potential for it, within the recent inspection cycles.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★☆☆☆ 2 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★★★★★ 5 of 5 |
| Quality measures | ★★★★★ 5 of 5 |
| Quality: long-stay / short-stay | 4 / 5 of 5 |
Staffing
| Total nurse staffing | 4.50511 hours per resident per day |
|---|---|
| Registered nurses | 1.55085 hours per resident per day |
| Weekend total | 4.06028 hours per resident per day |
| Nursing staff turnover | 36.1% (registered nurses 18.2%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-02-27 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2026-04-21 |
| 2026-02-27 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-04-21 |
| 2026-02-27 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · tag F0628 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-04-21 |
| 2026-02-27 | 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. Quality of Life and Care Deficiencies · tag F0700 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-04-21 |
| 2026-02-27 | 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. Pharmacy Service Deficiencies · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-04-21 |
| 2026-02-27 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · tag F0944 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-04-21 |
| 2026-02-27 | Provide training in compliance and ethics. Administration Deficiencies · tag F0946 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-04-21 |
| 2026-02-27 | Ensure 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 Services Deficiencies · tag F0947 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-04-21 |
| 2026-02-27 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · tag F0949 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-04-21 |
| 2026-02-27 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-21 |
| 2026-02-27 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-21 |
| 2026-02-27 | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0691 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-21 |
| 2026-02-27 | 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. Infection Control Deficiencies · tag F0887 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-21 |
| 2026-02-27 | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · tag F0941 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-21 |
| 2026-02-27 | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Resident Rights Deficiencies · tag F0942 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-21 |
| 2026-02-27 | Give 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 Exploitation Deficiencies · tag F0943 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-21 |
| 2026-02-27 | Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Infection Control Deficiencies · tag F0945 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-21 |
| 2026-02-27 | 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. Resident Rights Deficiencies · tag F0575 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2026-04-21 |
| 2025-09-09 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2025-10-24 |
| 2025-09-09 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2025-10-24 |
| 2025-07-07 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-08-24 |
| 2025-02-21 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · tag F0554 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-01 |
| 2025-02-21 | 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. Resident Rights Deficiencies · tag F0584 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-01 |
| 2025-02-21 | 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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-01 |
| 2025-02-21 | 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. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-01 |
| 2025-02-21 | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Administration Deficiencies · tag F0847 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-01 |
| 2025-02-21 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-01 |
| 2025-01-13 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-27 |
| 2024-09-10 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-29 |
| 2024-05-21 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-03 |
| 2024-03-28 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · tag F0690 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-22 |
| 2024-03-28 | 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. Quality of Life and Care Deficiencies · tag F0700 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-22 |
| 2024-03-28 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · tag F0583 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-22 |
| 2024-03-28 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-22 |
| 2024-03-28 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-22 |
| 2024-03-28 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · tag F0699 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-22 |
| 2024-03-28 | 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. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-22 |
| 2024-03-28 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-22 |
Fines and payment denials
No fines or payment denials on record since 2023.
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Lutheran Seniorlife Organization | adp of the snf | — | 2025-04-15 |
| Lutheran Seniorlife Organization | operational/managerial control | — | 1986-01-01 |
| Garrett, Elizabeth Individual | adp of the snf | — | 2008-10-20 |
| Carraway, Jeffrey Individual | corporate director | — | 2021-05-27 |
| Fenoglietto, David Individual | corporate director | — | 2021-05-27 |
| Carraway, Jeffrey Individual | corporate officer | — | 2021-05-27 |
| Fenoglietto, David Individual | corporate officer | — | 2021-05-27 |
| Roy, Laura Individual | corporate officer | — | 2025-02-25 |
| Garrett, Elizabeth Individual | operational/managerial control | — | 2008-10-20 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Passavant Retirement And Healt.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Butler County.