Health inspection·July 7, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based 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. Residents Affected - Few Findings include: Abuse, is defined at §483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Review of Closed Record Resident R1 (CRR1) indicated admission to the facility on 4/4/22. Review of Resident CRR1's Minimum Data Set assessment (MDS periodic assessment of resident care needs) dated 2/12/25, indicated the diagnosis of non-traumatic brain dysfunction (damage to the brain not caused by external physical force), Alzheimer's disease (neurological disorder that affects memory, thinking and behavior) and psychotic disorder (severe disorder that causes abnormal thinking and perception) Section C1000 Brief Interview for Mental Status (BIMS- a 15-point test used to measure cognitive decline) score was a three which indicated severely impairment. 0-7 points: Severely impaired 8-12 points: Moderate impairment 13-15 points: Intact cognition Review of a progress note dated 1/7/25, at 8:28 p.m. indicated Resident CRR1 observed following another resident around and yelling at her in Italian multiple times throughout this shift. Resident CRR1 easily redirected each time but continued to follow resident once she seen her again. This Resident CRR1 was observed smacking this other resident in the face and was immediately redirected. Staff educated Resident CRR1 that she cannot hit other residents. This Resident CRR1 began to yell at staff in Italian but eventually did calm down and began to laugh. The other resident was not injured and did not complain of any pain. Staff will continue watching both residents throughout the rest of the shift. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395001 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Passavant Retirement and Healt 105 Burgess Drive Zelienople, PA 16063 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)