PASSAVANT RETIREMENT AND HEALT
Open-data reference.
PASSAVANT RETIREMENT AND HEALT is a non profit - church related facility in ZELIENOPLE, PA with 102 certified beds and a 4-star overall CMS rating. The facility has 22 deficiency records on file.
105 BURGESS DRIVE, ZELIENOPLE, PA 16063
Phone: 7244525400
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 395001
- Ownership
- Non profit - Church related
- Provider Type
- Medicare and Medicaid
- Beds
- 102
- Residents
- 97
- In Hospital
- No
- County
- Butler
- Last Inspection
- Feb 21, 2025
Staffing Data
- RN Hours
- 1.41 (nat'l avg: 0.68)
- LPN Hours
- 0.62
- CNA Hours
- 2.52
- Total Nursing Hours
- 4.55 (nat'l avg: 3.89)
- PT Hours
- 0.07
- Nursing Turnover
- 26.9%
- RN Turnover
- 25.8%
What the CMS Record Reveals About PASSAVANT RETIREMENT AND HEALT
PASSAVANT RETIREMENT AND HEALT operates 102 certified beds in ZELIENOPLE, PA with approximately 97 residents currently in care, and carries a CMS overall rating of 4 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (5★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 22 deficiency records from recent surveys, of which 2 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 4.55 total nursing hours per resident day (national average 3.89), with RN coverage at 1.41 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Church related" ownership and operating as a "Medicare and Medicaid" provider, PASSAVANT RETIREMENT AND HEALT falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 26.9%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (22 most recent)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 24, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Oct 24, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 24, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 1, 2025
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Category: Administration Deficiencies
Corrected: Apr 1, 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.
Category: Pharmacy Service Deficiencies
Corrected: Apr 1, 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.
Category: Pharmacy Service Deficiencies
Corrected: Apr 1, 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.
Category: Resident Rights Deficiencies
Corrected: Apr 1, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Apr 1, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 27, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 29, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 3, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 22, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Apr 22, 2024
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.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 22, 2024
Provide care or services that was trauma informed and/or culturally competent.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 22, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 22, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 22, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 22, 2024
Keep residents' personal and medical records private and confidential.
Category: Resident Rights Deficiencies
Corrected: Apr 22, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: May 1, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: May 1, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 25.7% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 9.2% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.9% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 8.1% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 90.4% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 89.2% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.9% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 18.3% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 15.0% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 96.6% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 93.1% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 6.9% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 30.1% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 19.2% | Yes |
Penalty History
No penalties on record.
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Frequently Asked Questions
What is the overall CMS rating for PASSAVANT RETIREMENT AND HEALT?
What are the staffing levels at PASSAVANT RETIREMENT AND HEALT?
How many beds does PASSAVANT RETIREMENT AND HEALT have?
Does PASSAVANT RETIREMENT AND HEALT have any deficiencies on record?
Has PASSAVANT RETIREMENT AND HEALT received any fines or penalties?
Who owns PASSAVANT RETIREMENT AND HEALT?
When was PASSAVANT RETIREMENT AND HEALT last inspected?
What quality measures are tracked for PASSAVANT RETIREMENT AND HEALT?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.