B89

PASSAVANT RETIREMENT AND HEALT

Grade B 89/100 composite score

Non profit - Church related

CMS Star Ratings

Overall
5/5
Health Insp.
3/5
Quality
5/5
Staffing
5/5
RN Staffing
Not rated

Certified Beds

102

Ownership

Non profit - Church related

Total Fines

None

Last Survey

N/A

105 BURGESS DRIVE, ZELIENOPLE, PA 16063
7244525400

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
1.40h
LPN
0.61h
CNA
2.50h
Total
4.50h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

LUTHERAN SENIORLIFE

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Jan 1986

GARRETT, ELIZABETH

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Oct 2008

CARRAWAY, JEFFREY

IndividualCORPORATE DIRECTORSince May 2021

FENOGLIETTO, DAVID

IndividualCORPORATE DIRECTORSince May 2021

CARRAWAY, JEFFREY

IndividualCORPORATE OFFICERSince May 2021

FENOGLIETTO, DAVID

IndividualCORPORATE OFFICERSince May 2021

ROY, LAURA

IndividualCORPORATE OFFICERSince Feb 2025

Penalties & Fines

No penalties or fines on record.

Health Inspection Deficiencies (19)

July 7, 2025Health1 deficiency
0609DMinimal harm, Isolated

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Aug 24, 2025
February 21, 2025Health6 deficiencies
0554DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Apr 1, 2025
0584DMinimal harm, Isolated

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

Corrected Apr 1, 2025
0758DMinimal harm, Isolated

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

Corrected Apr 1, 2025
0761DMinimal harm, Isolated

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

Corrected Apr 1, 2025
0847DMinimal harm, Isolated

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

Administration Deficiencies

Corrected Apr 1, 2025
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Apr 1, 2025
January 13, 2025Health1 deficiency
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Feb 27, 2025
September 10, 2024Health1 deficiency
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Oct 29, 2024
March 28, 2024Health8 deficiencies
0583DMinimal harm, Isolated

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies

Corrected Apr 22, 2024
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Apr 22, 2024
0690EMinimal harm, Pattern

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

Corrected Apr 22, 2024
0695DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Apr 22, 2024
0699DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Apr 22, 2024
0700EMinimal harm, Pattern

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

Corrected Apr 22, 2024
0761DMinimal harm, Isolated

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

Corrected Apr 22, 2024
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Apr 22, 2024
April 6, 2023Health2 deficiencies
0686DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected May 1, 2023
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected May 1, 2023

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Frequently Asked Questions

What is the CareGrader rating for PASSAVANT RETIREMENT AND HEALT?

PASSAVANT RETIREMENT AND HEALT in ZELIENOPLE, Pennsylvania has a CareGrader grade of B (Good), with a composite score of 88.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for PASSAVANT RETIREMENT AND HEALT?

PASSAVANT RETIREMENT AND HEALT has an overall CMS star rating of 5 out of 5, a health inspection rating of 3/5, and a staffing rating of 5/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does PASSAVANT RETIREMENT AND HEALT have?

PASSAVANT RETIREMENT AND HEALT has 19 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

How many beds does PASSAVANT RETIREMENT AND HEALT have?

PASSAVANT RETIREMENT AND HEALT has 102 certified beds with approximately 96 current residents (94% occupancy). The facility is located at 105 BURGESS DRIVE, ZELIENOPLE, Pennsylvania 16063. It is a non profit - church related facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.