Inspection Reports for Lutheran Senior Life Passavant Community
103 BURGESS DRIVE,, ZELIENOPLE, PA, 16063
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% better than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
51% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 35
Capacity: 68
Deficiencies: 1
Date: Apr 2, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility on 04/02/2025, followed by a plan of correction submission and document review.
Findings
The submitted plan of correction was determined to be fully implemented as of the review on 04/02/2025. A deficiency was noted regarding failure to update a resident's assessment to reflect total assistance with feeding, which was corrected by the plan of correction.
Deficiencies (1)
Resident requires total assistance with feeding, but assessment was not updated to reflect this change.
Report Facts
License Capacity: 68
Residents Served: 35
Secured Dementia Care Unit Capacity: 34
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 4
Total Daily Staff: 49
Waking Staff: 37
Inspection Report
Follow-Up
Census: 33
Capacity: 68
Deficiencies: 6
Date: Jan 8, 2024
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction related to complaint and incident issues at the facility.
Complaint Details
The inspection was complaint-related, triggered by complaints and incidents reported at the facility. The report includes substantiation of multiple deficiencies related to medication errors, abuse, and failure to update support plans.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection dates. The report details multiple deficiencies related to medication errors, abuse, incident reporting, medication administration documentation, following prescriber's orders, medication error reporting, and support plan revisions, all of which have corrective actions in place and were implemented by April 5, 2024.
Deficiencies (6)
Failure to report a medication error incident to the Department within 24 hours.
Resident experienced multiple unwitnessed falls with injuries; the home failed to address falls and update assessment and support plans accordingly.
Medication administration documentation did not accurately reflect medications given; medication was documented as given but was not administered.
Failure to follow prescriber's orders by not administering prescribed medications.
Medication error was not immediately reported to the resident, designated person, and prescriber.
Support plan was not revised to include documented resident behaviors and changes.
Report Facts
License Capacity: 68
Residents Served: 33
Secured Dementia Care Unit Capacity: 32
Residents Served in Dementia Unit: 15
Total Daily Staff: 48
Waking Staff: 36
Inspection Report
Renewal
Census: 35
Capacity: 68
Deficiencies: 8
Date: Oct 13, 2023
Visit Reason
The inspection was conducted for renewal and complaint reasons as part of a full, unannounced licensing inspection.
Findings
Multiple deficiencies were identified including inadequate annual training hours for an administrator, non-operational ventilation in a bathroom, improper handling of leftover food, fire drill evacuation times exceeding safe limits, incomplete medical evaluations missing height assessments, medication labeling errors, presence of medications without orders, and failure to notify physicians of medication refusals.
Deficiencies (8)
Staff member A completed only 9 hours of Department-approved training in the calendar training year of 2022, less than the required 24 hours.
The ventilation fan located in the 3rd floor common bathroom was not operational and there was no other means of ventilation.
Approximately 12 freezer burned cheese sticks and 10 pieces of banana were found in undated zip lock freezer bags in the third floor kitchenette's floor freezer.
Fire drills conducted exceeded the maximum safe evacuation times specified by a fire safety expert.
Medical evaluations for two residents did not include a height assessment; the field was blank.
Medication labels for residents #3 and #4 did not match prescribed directions or medication administration records.
Resident #3 had a medication found in the cabinet without a corresponding medication order on the medication administration record.
Physicians were not notified within 24 hours when residents #2 and #3 refused prescribed medications on multiple dates.
Report Facts
License Capacity: 68
Residents Served: 35
Annual Training Hours Completed: 9
Fire Drill Evacuation Time: 340
Fire Drill Evacuation Time: 465
Fire Drill Evacuation Time: 358
Fire Drill Evacuation Time: 240
Freezer Burned Cheese Sticks: 12
Banana Pieces: 10
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 6, 2022
Visit Reason
The document reports on the Pennsylvania Department of Human Services, Bureau of Human Service Licensing review conducted on 10/06/2022 and 10/07/2022 to determine the status of the submitted plan of correction for the facility.
Findings
The submitted plan of correction was found to be fully implemented, and continued compliance must be maintained.
Inspection Report
Complaint Investigation
Census: 19
Capacity: 68
Deficiencies: 0
Date: Feb 24, 2022
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 02/24/2022, 03/08/2022, and 03/10/2022.
Complaint Details
The inspection was complaint-related and the exit conference was held on 03/10/2022. No deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 31
Waking Staff: 23
License Capacity: 68
Residents Served: 19
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 12
Residents Age 60 or Older: 32
Residents with Mobility Need: 12
Notice
Capacity: 68
Deficiencies: 0
Date: Sep 1, 2021
Visit Reason
The document serves as a renewal license approval for Lutheran Senior Life Passavant Community to operate a Personal Care Home, with notification that an annual inspection will be conducted within the next twelve months.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 68
Secure Dementia Care Unit capacity: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal license approval letter |
Inspection Report
Renewal
Census: 30
Capacity: 68
Deficiencies: 2
Date: Jul 8, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection of the Lutheran Senior Life Passavant Community facility on 07/08/2021 and 07/09/2021.
Findings
The facility was found to have citations which required a plan of correction. The submitted plan of correction was accepted and later determined to be fully implemented. Deficiencies included a repeat violation for refrigerator/freezer temperature control and a delayed admission support plan for a resident in the secured dementia care unit.
Deficiencies (2)
Walk-in freezer temperature measured 11 degrees Fahrenheit, exceeding the required 0°F or below. Repeat violation from 7/23/2019.
Admission support plan for Resident #1 in the secured dementia care unit was not developed within the required 72 hours of admission.
Report Facts
License Capacity: 68
Residents Served: 30
Secured Dementia Care Unit Capacity: 32
Residents Served in Secured Dementia Care Unit: 16
Total Daily Staff: 46
Waking Staff: 35
Inspection Report
Complaint Investigation
Census: 30
Capacity: 68
Deficiencies: 2
Date: May 7, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with staffing and certification requirements.
Complaint Details
The visit was complaint-related, focusing on staffing adequacy and staff certification. The plan of correction was accepted and fully implemented.
Findings
The facility was found to have staffing deficiencies during the night shift with only one direct care staff person present for two floors, and that staff person was not certified in first aid, CPR, and obstructed airway techniques. The submitted plan of correction was accepted and fully implemented.
Deficiencies (2)
Night shift was staffed with only one direct care staff person for two floors, insufficient to meet residents' evacuation needs.
Staff person on night shift was not certified in first aid, CPR, and obstructed airway techniques as required.
Report Facts
Residents present: 30
Licensed capacity: 68
Residents with mobility needs: 16
Total daily staff: 46
Waking staff: 35
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