Home / Pennsylvania / Zelienople
105 Burgess Drive, Zelienople, PA 16063 · Butler County · (724) 452-5400
102 certified beds, about 96 residents a day · Non profit - Church related · Medicare and Medicaid since 1967
CMS Care Compare ratings, data as of September 1, 2026 · CCN 395001 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on February 27, 2026, inspectors cited 18 health deficiencies (the Pennsylvania average is 10, the national average 9.2).
Of 38 health citations since March 2024, 3 were rated as actual harm or immediate jeopardy to residents.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 4.51 hours per resident per day, against 3.89 across Pennsylvania and 3.86 nationally. Registered nurses accounted for 1.55 of those hours.
36.1% of nursing staff left within the year CMS measured (Pennsylvania average 44.5%).
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 38 health citations on file.
Inspectors wroteBased on facility policy, review of clinical records, review of hospital records and staff interview, it was determined that the facility failed to provide care and services consistent with professional standards of practice by failing to follow physician-ordered bowel protocol for one of six residents (Resident R10) reviewed, which required hospitalization and actual harm resulting in fecal impaction, and failed to make certain that residents were provided appropriate preventative treatments for skin care for one of three residents (Resident R92).
Inspectors wroteBased on facility policy, observations and staff interviews it was determined that the facility failed to maintain sanitary conditions in the dish room which created the potential for cross contamination in one of three households. (Mountain Laurel, Brandywine).
Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of three residents sampled with facility-initiated transfers (Residents R5 and R102), and failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three of three residents (Residents R5, R102, and R104).
Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to obtain informed consent before installation of bed rails for three of three residents (Residents R59, R72, and R94).
Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for three of six medication rooms (Larkspur, Allegheny and Tionesta medication rooms).
Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program for five of seven staff members (Licensed Practical Nurse (LPN) Employee E3, Food Service Assistant (FSA) Employee E4, Nurse Aide (NA) Employee E5, Agency NA Employee E6, and NA Employee E7).
Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Compliance and Ethics for four of seven staff members (Licensed Practical Nurse (LPN) Employee E3, Food Service Assistant (FSA) Employee E4, Nurse Aide (NA) Employee E5 and Agency NA Employee E6).
Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Dementia Management for four of seven staff members (Registered Nurse (RN) Employee E1, Nurse Aide (NA) Employee E2, Food Service Assistant (FSA) Employee E4, and NA Employee E5), and failed to ensure that two of four sampled Nurse Aides received a minimum of 12 hours of in-service education per year (NA Employee E5 and Agency NA Employee E6).
Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Behavioral Health for six of seven staff members (Registered Nurse (RN) Employee E1, Nurse Aide (NA) Employee E2, Food Service Assistant (FSA) Employee E4, NA Employee E5, Agency NA Employee E6, and NA Employee E7).
Inspectors wroteBased on review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for two of three residents (Resident R1, and R92).
Inspectors wroteBased on review facility policies, observations, clinical records, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of a suprapubic catheter (a thin flexible tube inserted through a small incision in the lower abdomen directly into the bladder to drain urine) as required for one of three residents (Resident R51).
Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews it was determined that the facility failed to obtain a physician order for care of an urostomy (surgical procedure that creates an opening in the abdomen wall to allow urine to exit the body when the bladder is not functioning properly) for one of three residents reviewed (Resident R7).
Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccination for one of five residents (Resident R88).
Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Effective Communication for one of seven staff members (Licensed Practical Nurse (LPN) Employee E3).
Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Resident Rights for two of seven staff members (Licensed Practical Nurse (LPN) Employee E3 and Nurse Aide (NA) Employee E5).
Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for one of seven staff members (Nurse Aide (NA) Employee E5).
Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Infection Control for one of seven staff members (Nurse Aide (NA) Employee E5).
Inspectors wroteBased on observations and staff interview it was determined that the facility failed to have required postings for the facility in areas that are accessible to all residents with complete contact information for State Agency, Adult Protective Services, Medicaid Fraud Control Unit, and State Long-Term Care Ombudsman program posted in six of six neighborhoods (Brandywine, Mountain Laurel, Trillium, Tionesta, Allegheny, and Larkspur).
Inspectors wroteBased on review of facility provided documents, facility policies, clinical records, employee education, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by not ensuring a safe transfer, which resulted in actual harm (abrasion to right forehead and a right nondisplaced tibial (leg) plateau fracture with pain) for one of two residents (Resident R1).
Inspectors wroteBased on review of facility policy, clinical records, incident reports, facility documents, employee education, and staff interviews, it was determined that the facility failed to ensure that a resident was free from a preventable accident during a transfer, which resulted in actual physical harm (an abrasion to right forehead and a right nondisplaced tibial (leg) plateau fracture with pain) for one of two residents (Resident R1).
Inspectors wroteBased on clinical record review, reports submitted to the State, and staff interview, it was determined that the facility failed to report and investigate an allegation of physical abuse for two of three residents.
Inspectors wroteBased on observations, resident, and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of three residents (Residents R51).
Inspectors wroteBased on a review of facility policies, documents, observations and staff interviews it was determined that the facility failed to provide a non-institutional dining experience by administering medications during the breakfast meal service for two of six residents. (Resident R3 and Resident R66).
Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to ensure residents medication regime was free from unnecessary psychotropic medications for two of four residents (Resident R46 and R86).
Inspectors wroteBased on review of facility policy, observations and staff interview it was determined that the facility failed to date opened medications, and properly store/label medication in three of three medication rooms (Mountain Laurel, Tionesta, and Trillium Medication Rooms), failed to discard expired nursing supplies in one of three medication rooms (Tionesta Medication Room), and failed to properly store medications in one of three residents' medication cabinet in the resident room (Resident R77).
Inspectors wroteBased on review of facility documents, resident clinical records and staff interviews it was determined that the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement (A binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not.) for one of five residents (Resident R67).
Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure droplet precautions were ordered and a care plan implemented for one of three residents (Resident R40), and failed to provide a safe and sanitary environment to help prevent the potential for cross contamination for one of six household kitchen areas (Mountain Laurel Neighborhood).
Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to provide adequate supervision transfers for one of six residents (Resident R1), which resulted in a fall.
Inspectors wroteBased on review of facility policy, clinical records, observations, and staff interviews it was determined that the facility failed to make certain each resident received adequate supervision that resulted in one elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of three residents (Resident R1).
Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by not providing a two-person transfer per physician's order for one of four residents (Resident R1) resulting in a fall.
Inspectors wroteBased on facility policy, clinical record review, and interview, the facility failed to have a physician's order, and a care plan, for the use of an indwelling catheter (a tube placed in the bladder to drain urine), for one of four residents (Resident R193), and failed to ensure that appropriate treatment and services were provided for two of four residents (Resident R67 and R73) with an indwelling urinary catheter.
Inspectors wroteBased on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for five of five residents (Residents R6, R14, R31, R32, and R34).
Inspectors wroteBased on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of resident's medical information on one of six nursing households (second floor Tionesta household).
Inspectors wroteBased on review of facility policies, clinical records, facility documents and staff interview, it was determined that the facility failed to ensure that residents received neurological assessment after an incident involving a fall for two of five residents (Resident R9 and Resident R69).
Inspectors wroteBased on facility policy review, resident observations and interviews, clinical record review and staff interviews, it was determined that the facility failed to make certain a physician order for use of and cleaning of a Bi-PAP/CPAP machine (machines used to make breathing easier) and failed to develop a plan of care for one of three residents (Resident R58).
Inspectors wroteBased on review of facility policy, resident record review, and staff interviews, it was determined to facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of one residents (Resident R69).
Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly secure a medication drawer on four occasions in one of six households (Tionesta household).
Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined that the facility failed to implement measures to prevent the potential for cross contamination during finger stick blood sugar monitoring for one of two residents (Resident R301) and failed to complete hand hygiene after a finger stick blood sampling on one of two residents (Resident R299)
8 fire safety citations on file: 2 on February 21, 2025, 4 on March 28, 2024, 2 on April 6, 2023.
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Pennsylvania | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.51 | 3.89 | 3.86 |
| Registered nurses | 1.55 | 0.79 | 0.69 |
| All nursing staff on weekends | 4.06 | 3.53 | 3.42 |
| Nurse aides | 2.45 | ||
| Licensed practical nurses | 0.50 | ||
| Nursing staff turnover (share who left in a year) | 36.1% | 44.5% | 45.8% |
| Registered nurse turnover | 18.2% | 39.9% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.93 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.69 on weekdays and 4.06 on weekends, 13% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 12.8% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.51 in April to June 2025 to 4.51 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.51 | 1.55 | 4.69 | 4.06 | 12.8% | 0 of 90 | 96 |
| Oct to Dec 2025 | 4.55 | 1.45 | 4.71 | 4.15 | 13.9% | 0 of 92 | 96 |
| Jul to Sep 2025 | 4.55 | 1.41 | 4.71 | 4.14 | 17.9% | 0 of 92 | 97 |
| Apr to Jun 2025 | 4.51 | 1.45 | 4.67 | 4.13 | 13.0% | 0 of 91 | 97 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Pennsylvania, Jan to Mar 2026 | 3.69 | 0.65 | 3.82 | 3.34 | 11.3% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Nurse aide training here: a state-approved CNA program is listed at this home's address and phone number (state list: PDE Approved NATCEP by County, as of March 1, 2026). A nursing home cannot charge aides it employs, or has offered a job, for state-approved training (42 CFR 483.152(c)). See Lutheran Senior Life Passavant Community CNA training on CareerFunded, our sister site for career training.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Pennsylvania, all employers | |||
| CNAs (nursing assistants) | $21.44 | $18.88 to $22.52 | 67,740 |
| LPNs and LVNs | $30.74 | $29.02 to $35.01 | 38,260 |
| Registered nurses | $46.36 | $38.75 to $50.35 | 146,520 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Pennsylvania | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 20.6 | 16.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.2 | 0.7 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.9 | 1.4 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 5.5 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.7 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 17.1 | 17.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 3.8 | 4.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 21.3 | 17.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 9.9 | 22.5 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 2.2 | 9.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.6 | 1.6 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.5 | 1.2 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Passavant Retirement and Healt's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (52.0% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
52.0% this home
No different from the national rate
US median of homes 51.5% · Pennsylvania: 100 better, 108 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 85 eligible stays.
10.9% this home
No different from the national rate
US median of homes 10.7% · Pennsylvania: 3 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 91 eligible stays.
6.2% this home
No different from the national rate
US median of homes 7.1% · Pennsylvania: 7 better, 5 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 54 eligible stays.
68.8% this home
Median of homes: Pennsylvania54.4% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 48 residents counted.
0.0% this home
Median of homes: Pennsylvania0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 51 residents counted.
1.9% this home
Median of homes: Pennsylvania2.0% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 51 residents counted.
100.0% this home
Median of homes: Pennsylvania100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 32 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: PASSAVANT RETIREMENT AND HEALTH CENTER.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Carraway, Jeffrey | Corporate director | Individual | 05/27/2021 | |
| Fenoglietto, David | Corporate director | Individual | 05/27/2021 | |
| Carraway, Jeffrey | Corporate officer | Individual | 05/27/2021 | |
| Fenoglietto, David | Corporate officer | Individual | 05/27/2021 | |
| Roy, Laura | Corporate officer | Individual | 02/25/2025 | |
| Lutheran Seniorlife | Operational/managerial control | Organization | 01/01/1986 | |
| Garrett, Elizabeth | Operational/managerial control | Individual | 10/20/2008 | |
| Lutheran Seniorlife | Adp of the SNF | Organization | 04/15/2025 | |
| Garrett, Elizabeth | Adp of the SNF | Individual | 10/20/2008 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
Licensed assisted living residences and personal care homes in the same town or within 5 miles, each with its Pennsylvania licence record.
These are the official offices in Pennsylvania. NursingHomeClear cannot take or act on complaints.