Passavant Retirement and Healt

In the surveyor’s words

From the most serious findings on record at Passavant Retirement and Healt, in the surveyor’s own words.

• Actual harm, isolatedF684Feb 27, 2026

  Based 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). […]

• Actual harm, isolatedF600Sep 9, 2025

  Based 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).Findings include: Review of facility Abuse, Neglect, Mental Abuse, Reports of Theft, Exploitation and Misappropriation of Property policy dated 1/2025, indicated that facility will provide a safe and secure environment for all residents and will protect a resident's right to be free from any form of abuse, mental abuse, and neglect. […]

• Actual harm, isolatedF689Sep 9, 2025

  Based 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). Findings include:Review of the facility Accidents and Incidents policy dated 1/2025, indicated that the facility will provide a safe and secure environment in order to prevent incidents and accidents from occurring.Review of Resident R1's admission record indicated resident was admitted to the facility on [DATE].Review of Resident R1's Minimum Data Set (MDS)… […]

• No harm, potential for more than minimal, widespreadF812Feb 27, 2026

  Based 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). Findings include: Review of facility policy Infection control for Household Dish room dated 1/26/26 indicated household dish rooms are appropriately disinfected. During an observation of dish room on 2/24/26, at 10:00 a.m. it was revealed two fans area above clean side of dish machine area had a build up of a black substance, dirt and grime on the mountain laurel, brandywine household. During an interview on 2/24/26, at 10:30 a.m. […]

• No harm, potential for more than minimal, patternF628Feb 27, 2026

  Based 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).Findings include: Review of facility policy Transfer to Hospital/Emergency and Non-Emergency dated January 2026, indicated when medically indicated and desired by the resident (or by resident representative, if appropriate), resident will be transferred to the hospital with all necessary… […]