Passavant Retirement and Healt
105 Burgess Drive · Zelienople, PA · 16063 · 7244525400
102 certified beds Non profit - Church related Part of a CCRC
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
- 3 citations involved actual harm to residents.
- Staffing hours comfortably above national benchmarks.
- No federal fines or payment denials in CMS’s 3-year window.
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Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
3 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 1 of 5 Staffing: 5 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 4.55 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 1.45 | 0.55–0.75 |
| Weekend hours / resident-day | 4.15 | ≈ weekday level |
| Nursing turnover / year | 33% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (38 in the current record)
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Actual harm · G February 27, 2026
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected April 21, 2026 · Quality of Life and Care
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Potential for harm · E February 27, 2026
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected April 21, 2026 · Resident Rights
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Potential for harm · D February 27, 2026
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected April 21, 2026 · Quality of Life and Care
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Potential for harm · D February 27, 2026
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 April 21, 2026 · Quality of Life and Care
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Potential for harm · D February 27, 2026
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected April 21, 2026 · Quality of Life and Care
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Potential for harm · E February 27, 2026
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 April 21, 2026 · Quality of Life and Care
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Potential for harm · E February 27, 2026
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 April 21, 2026 · Pharmacy Service
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Potential for harm · F February 27, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected April 21, 2026 · Nutrition and Dietary
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Potential for harm · D February 27, 2026
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.
Corrected April 21, 2026 · Infection Control
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Potential for harm · D February 27, 2026
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected April 21, 2026 · Administration
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Potential for harm · D February 27, 2026
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected April 21, 2026 · Resident Rights
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Potential for harm · D February 27, 2026
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected April 21, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E February 27, 2026
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected April 21, 2026 · Administration
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Potential for harm · D February 27, 2026
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected April 21, 2026 · Infection Control
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Potential for harm · E February 27, 2026
Provide training in compliance and ethics.
Corrected April 21, 2026 · Administration
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Potential for harm · E February 27, 2026
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected April 21, 2026 · Nursing and Physician Services
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Potential for harm · E February 27, 2026
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected April 21, 2026 · Administration
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No harm found · C February 27, 2026
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.
Corrected April 21, 2026 · Resident Rights
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Actual harm · G September 9, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected October 24, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G September 9, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 24, 2025 · Quality of Life and Care
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Potential for harm · D July 7, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected August 24, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 21, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected April 1, 2025 · Resident Rights
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Potential for harm · D February 21, 2025
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 April 1, 2025 · Resident Rights
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Potential for harm · D February 21, 2025
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 April 1, 2025 · Pharmacy Service
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Potential for harm · D February 21, 2025
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 April 1, 2025 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 395001 · certified since January 1, 1967. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.