Passavant Retirement and Healt
105 Burgess Drive, Zelienople, PA 16063 · Butler County · 102 certified beds · avg 96 residents/day · certified since Jan 1, 1967
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Feb 27, 2026 · F-0684
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 21, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 9, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 24, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 9, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 24, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (38)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 27, 2026 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Feb 27, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 27, 2026 | E · Potential for harm, repeated | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Feb 27, 2026 | E · Potential for harm, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Feb 27, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 27, 2026 | E · Potential for harm, repeated | The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. |
| Feb 27, 2026 | E · Potential for harm, repeated | The facility did not provide its staff with training in compliance and ethics — teaching employees the laws and ethical standards that govern how residents must be treated. |
| Feb 27, 2026 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Feb 27, 2026 | E · Potential for harm, repeated | The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. |
| Feb 27, 2026 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Feb 27, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Feb 27, 2026 | D · Potential for harm, one-off | The facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy. |
| Feb 27, 2026 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Feb 27, 2026 | D · Potential for harm, one-off | The facility did not develop or maintain an effective training program for its direct care staff, including training on how to communicate effectively with residents. |
| Feb 27, 2026 | D · Potential for harm, one-off | The facility did not educate its staff on residents' rights and the facility's responsibilities toward residents. Staff can only respect rights they've been taught about. |
| Feb 27, 2026 | D · Potential for harm, one-off | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. |
| Feb 27, 2026 | D · Potential for harm, one-off | The facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program. |
| Feb 27, 2026 | C · Minimal risk, facility-wide | The facility did not post the names, addresses, and phone numbers of state agencies and advocacy groups, along with a notice that residents may file complaints with the state survey agency. |
| Sep 9, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Sep 9, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jul 7, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Feb 21, 2025 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Feb 21, 2025 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Feb 21, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Feb 21, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 21, 2025 | D · Potential for harm, one-off | The facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign. |
| Feb 21, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 13, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 10, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 21, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Mar 28, 2024 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Mar 28, 2024 | E · Potential for harm, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Mar 28, 2024 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Mar 28, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Mar 28, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Mar 28, 2024 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Mar 28, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Mar 28, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (6 → 18).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 10 | 0 | E |
| 2025 | 10 | 2 | G ▲ |
| 2026 | 18 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Pennsylvania avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.39 | 3.94 | 3.95 | top 26% in Pennsylvania; top 26% in the U.S. |
| Registered Nurse hours | 1.51 | 0.80 | 0.69 | top 8% in Pennsylvania; top 5% in the U.S. |
| Weekend total nurse staffing | 3.96 | 3.58 | 3.50 | top 26% in Pennsylvania; top 24% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.09 | 0.56 | 0.48 | top 6% in Pennsylvania; top 5% in the U.S. |
| Total nursing staff turnover (%) | 36.1 | 44.5 | 45.8 | top 26% in Pennsylvania; top 27% in the U.S. |
| RN turnover (%) | 18.2 | 39.9 | 42.9 | top 12% in Pennsylvania; top 12% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.51, RN 1.55, weekend 4.06. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 4/5 · short-stay residents: 5/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Carraway, Jeffrey | Individual | Corporate Director | NOT APPLICABLE | 05/27/2021 |
| Carraway, Jeffrey | Individual | Corporate Officer | NOT APPLICABLE | 05/27/2021 |
| Fenoglietto, David | Individual | Corporate Director | NOT APPLICABLE | 05/27/2021 |
| Fenoglietto, David | Individual | Corporate Officer | NOT APPLICABLE | 05/27/2021 |
| Garrett, Elizabeth | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/20/2008 |
| Garrett, Elizabeth | Individual | ADP of the SNF | NOT APPLICABLE | 10/20/2008 |
| Lutheran Seniorlife | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/1986 |
| Lutheran Seniorlife | Organization | ADP of the SNF | NOT APPLICABLE | 04/15/2025 |
| Roy, Laura | Individual | Corporate Officer | NOT APPLICABLE | 02/25/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "How do frontline staff report care problems, and how does your quality improvement program act on them?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Kadima Rehabilitation & Nursing at Harmony | 1.7 mi | Harmony, PA | ★☆☆☆☆ | 1/5 | abuse |
| Sherwood Oaks | 6.2 mi | Cranberry Township, PA | ★★★☆☆ | 2/5 | |
| Cranberry Place | 7.8 mi | Cranberry Township, PA | ★☆☆☆☆ | 1/5 | abuse |
| St John Specialty Care Center | 9.3 mi | Mars, PA | ★☆☆☆☆ | 1/5 | abuse |
| Rochester Residence and Care Center | 9.5 mi | Rochester, PA | —/5 | SFF | |
| Providence Health & Rehab Center | 9.7 mi | Beaver Falls, PA | ★☆☆☆☆ | 1/5 | abuse |
| Harmony Hills Healthcare and Rehabilitation Center | 11.2 mi | Wexford, PA | ★★☆☆☆ | 2/5 | |
| Friendship Rehab and Health | 11.5 mi | Beaver, PA | ★☆☆☆☆ | 1/5 | abuseSFF |
| Concordia at Villa St Joseph | 11.6 mi | Baden, PA | ★★☆☆☆ | 2/5 | |
| St Barnabas Nursing Home | 13.4 mi | Gibsonia, PA | ★★★★☆ | 3/5 | |
| Sunnyview Nursing and Rehabilitation Center | 13.6 mi | Butler, PA | ★☆☆☆☆ | 1/5 | abuseSFF |
| Perry Health & Rehab Center | 14.7 mi | Wexford, PA | ★☆☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 395001.