01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-02-27 | 20 | 2025-02-21 | 2 |
| Cycle 2 | 2025-02-21 | 9 | 2024-03-28 | 4 |
| Cycle 3 | 2024-03-28 | 9 | 2023-04-06 | 2 |
CMS CCN 3950012026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Passavant Retirement And Healt
105 Burgess Drive · Zelienople, PA 16063 · Butler County
Certified beds102CMS provider file
Recent citation rows46current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
46 rows in the current release
3 rows carry G–L scope/severity codes; 0 carry J–L. 7 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-02-27 · HEALTHF0575Severity C · widespread; potential for minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-02-27 · HEALTHF0628Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-02-27 · HEALTHF0684Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-02-27 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-02-27 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-02-27 · HEALTHF0691Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-02-27 · HEALTHF0700Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-02-27 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-02-27 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-02-27 · HEALTHF0887Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-02-27 · HEALTHF0941Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-02-27 · HEALTHF0942Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-02-27 · HEALTHF0943Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-02-27 · HEALTHF0944Severity E · pattern; potential for more than minimal harm
Administration Deficiencies
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-02-27 · HEALTHF0945Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-02-27 · HEALTHF0946Severity E · pattern; potential for more than minimal harm
Administration Deficiencies
Provide training in compliance and ethics.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-02-27 · HEALTHF0947Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-02-27 · HEALTHF0949Severity E · pattern; potential for more than minimal harm
Administration Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Correction field: Deficient, Provider has date of correction · 2026-04-212025-09-09 · HEALTHF0600Severity G · isolated actual harm
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.
Correction field: Deficient, Provider has date of correction · 2025-10-24 · complaint2025-09-09 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-10-24 · complaint2025-07-07 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-08-24 · complaint2025-02-21 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2025-04-012025-02-21 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-012025-02-21 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-0103 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CARRAWAY, JEFFREYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/27/2021
- FENOGLIETTO, DAVIDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/27/2021
- CARRAWAY, JEFFREYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/27/2021
- FENOGLIETTO, DAVIDIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/27/2021
- ROY, LAURAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 02/25/2025
- LUTHERAN SENIORLIFEOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/1986
- GARRETT, ELIZABETHIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/20/2008
- LUTHERAN SENIORLIFEOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/15/2025
- GARRETT, ELIZABETHIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/20/2008
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.51per resident day
RN hours1.55per resident day
Weekend nurse hours4.06per resident day
Staff turnover36.1%CMS reported field
06 / LOCAL RECORDS
Open the Pennsylvania ledger →Other published facilities nearby
No second facility in the same city met the directory rule.