CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Passavant Retirement and Healt
View the most recent health deficiencies and inspection results for Passavant Retirement and Healt. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Passavant Retirement and Healt. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| 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. | Health | 2026-02-27 | 2026-04-21 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2026-02-27 | 2026-04-21 | N |
| 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. | Health | 2026-02-27 | 2026-04-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2026-02-27 | 2026-04-21 | N |
| 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. | Health | 2026-02-27 | 2026-04-21 | N |
| 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. | Health | 2026-02-27 | 2026-04-21 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2026-02-27 | 2026-04-21 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2026-02-27 | 2026-04-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2026-02-27 | 2026-04-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2026-02-27 | 2026-04-21 | N |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2026-02-27 | 2026-04-21 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2026-02-27 | 2026-04-21 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2026-02-27 | 2026-04-21 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2026-02-27 | 2026-04-21 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2026-02-27 | 2026-04-21 | N |
| Provide training in compliance and ethics. | Health | 2026-02-27 | 2026-04-21 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2026-02-27 | 2026-04-21 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2026-02-27 | 2026-04-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-09-09 | 2025-10-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-09-09 | 2025-10-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-07-07 | 2025-08-24 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-02-21 | 2025-04-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2025-02-21 | 2025-04-03 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2025-02-21 | 2025-04-01 | N |
| 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. | Health | 2025-02-21 | 2025-04-01 | N |
| 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. | Health | 2025-02-21 | 2025-04-01 | N |
| 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. | Health | 2025-02-21 | 2025-04-01 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2025-02-21 | 2025-04-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-02-21 | 2025-04-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-01-13 | 2025-02-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-10 | 2024-10-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-21 | 2024-06-03 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-28 | 2024-05-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-28 | 2024-05-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-28 | 2024-05-31 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-03-28 | 2024-05-31 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-03-28 | 2024-04-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-28 | 2024-04-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-28 | 2024-04-22 | N |
| 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. | Health | 2024-03-28 | 2024-04-22 | N |
| 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. | Health | 2024-03-28 | 2024-04-22 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-03-28 | 2024-04-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-28 | 2024-04-22 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-03-28 | 2024-04-22 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-04-06 | 2023-04-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-06 | 2023-04-28 | N |