Inspection Reports for
Pass Christian Health and Rehabilitation Center

CI MS# not explicitly stated. The complaint survey was completed on 06/29/26-06/30/26. The facility was found in compliance and no deficiencies were cited.

The facility was found to be in compliance with no deficiencies cited during this complaint investigation.

Two complaint investigations were conducted: CI MS #3040053 for quality of care/treatment and infection control with no citations, and CI MS #3040416 for abuse and accidents which resulted in deficiency F0657 being cited.

The facility failed to revise Resident #1's comprehensive, person-centered care plan to include individualized interventions for falls following multiple incidents. The care plan was not updated after falls on 05/04/2026 and 05/09/2026 despite nursing staff implementing interventions.

CI MS #3040053 was investigated for quality of care/treatment and infection control and CI MS #3040416 was investigated for abuse and accidents. The facility was found in compliance with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and there were no deficiencies cited.

CI MS #3020626 was investigated for misappropriation of property and neglect. The SA determined the facility was in compliance with no deficiencies cited.

The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

Complaint number CI MS #3020626 was investigated for misappropriation of property and neglect. The facility was found in compliance with no deficiencies cited.

The survey determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

CI MS# not explicitly stated. The complaint survey was completed on 04/15/26 and the facility was found to be in compliance after corrective actions.

The facility was found to be in compliance as of 05/22/26 following the corrective measures implemented after the complaint survey.

Complaint investigation CI MS #2804426 was related to misappropriation, nursing services, and resident rights. Deficiency M500 was cited. CI MS #2980721 was investigated for environmental and infection control with no citation.

The facility was found not in compliance with state licensure requirements due to failure to ensure medications were properly secured, safeguarded, and tracked, resulting in a prescribed injectable medication pen being lost for one resident.

Complaint Investigations MS #2980721 and MS #2804426 were conducted. MS #2980721 for environmental and infection control had no citations. MS #2804426 related to misappropriation, nursing services, and resident rights resulted in citations for F602 and F842.

Two deficiencies were cited related to medication misappropriation and documentation. The facility failed to properly secure and track a prescribed injectable medication pen for one resident, and nursing staff documented insulin administration several hours late for another resident.

The SA is recommending that your facility be placed back in compliance effective 10/01/25. No deficiencies were cited in this desk review.

The facility failed to ensure that PRN psychotropic medication orders were limited to 14 days or properly justified for extension, resulting in one resident receiving Lorazepam beyond the regulatory limit without appropriate documentation. Additionally, the facility did not develop a comprehensive, resident-centered care plan addressing a diagnosis of Type 2 Diabetes Mellitus for one resident.

Complaint Investigations MS #2608320 and MS #2607032 were investigated for allegations of abuse and found with no citations related to those investigations.

The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies related to chemical restraints and comprehensive care planning.

Complaint Investigations MS #2608320 and MS #2607032 were investigated for allegations of abuse and found no citations related to those investigations.

During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and there were no citations.

The facility met all applicable Life Safety Code and Emergency Preparedness requirements with no deficiencies cited.

CI MS# not explicitly stated; complaint survey completed on 05/01/25. The facility was found in compliance with no deficiencies cited.

The State Agency found the facility in compliance and is recommending the facility be placed back in compliance effective 05/22/25. No deficiencies were cited in this desk review.

CI MS#28690 was investigated for nursing services, medication not given according to physician instructions, and facility not clean. Deficiency F684 was cited. Other complaints (CI MS #28428, CI MS #28469, CI MS #28678, CI MS #28766) were investigated with no deficiencies cited.

The facility was found not in compliance due to failure to administer intravenous antibiotics as ordered for Resident #1. The facility missed two of three scheduled doses and improperly documented medication administration, placing the resident at risk for delayed treatment and prolonged infection.

The complaint investigation found that Resident #1 did not receive any prescribed antibiotics until mid-morning on 3/29/25, with no further doses administered. The resident's family requested transfer to the hospital due to the facility's inability to administer IV antibiotics on schedule. The former Director of Nursing admitted to not administering doses and improper documentation. The Nurse Practitioner and Interim Director of Nursing confirmed the medication administration failures and associated risks.

The facility failed to administer two of three scheduled doses of intravenous antibiotics to Resident #1 as ordered, resulting in delayed treatment and transfer of the resident to the hospital. Interviews and record reviews confirmed late and missed doses, improper documentation, and violation of facility medication administration policies.

CI MS#26995 - Complaint survey completed on 03/06/25; the facility was found in compliance after the desk review.

The State Agency found the facility in compliance and recommended it be placed back in compliance effective 03/21/25. No deficiencies were cited in this desk review.

The investigation was complaint-related concerning failure to notify medical providers and incomplete post-fall assessments. The complaint was substantiated based on interviews and record reviews confirming delayed notification and missing vital signs documentation.

The facility failed to notify the medical provider immediately after Resident #1's fall and did not complete a detailed post-fall assessment including vital signs. Documentation was incomplete and the nurse responsible did not report the fall incident timely or record vital signs as required by facility policy.

CI MS #28011 was investigated for neglect, resident safety, and unwitnessed falls. Deficiencies were cited for failure to notify the medical provider promptly after a fall and incomplete post-fall assessments.

The facility failed to promptly notify the medical provider of a resident fall and failed to complete a detailed post-fall assessment including vital signs for one sampled resident. The facility also failed to maintain complete and accurate resident records as required.

Complaint Investigations CI MS #27466 and CI MS #27500 were conducted. CI MS #27466 for resident rights and physical environment had no deficiencies cited. CI MS #27500 for quality of care and medication administration was substantiated with deficiencies cited.

The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited for nursing staff competency, registered nurse coverage, and medication errors affecting residents.

The investigation was complaint-driven, focusing on medication errors involving Resident #1 receiving another resident's medications and Resident #4 missing doses of prescribed IV antibiotics. The complaint was substantiated with findings of medication errors and staffing deficiencies.

The facility failed to ensure staff competency in medication reconciliation, resulting in a resident receiving incorrect medications for multiple days. Additionally, the facility failed to have a Registered Nurse on duty for at least eight consecutive hours on one day and failed to administer prescribed intravenous antibiotics on multiple occasions for another resident.

Two complaint investigations were conducted: CI MS #27226 for pressure sores, improper incontinent care, medications, residents not turned, and quality of care; and CI MS #27306 for pressure sores, residents left wet, residents not turned, call bell not answered, and quality of care. The facility was found in compliance with no deficiencies cited.

The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

Complaint investigations MS #27226 and MS #27306 were conducted related to pressure sores, incontinent care, medications, residents not turned, call bell response, and quality of care. The facility was found in compliance with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

CI MS #26975 was investigated related to discharge rights and residents privacy not protected. The SA determined the facility was in compliance with no deficiencies cited.

The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

Complaint number CI MS#26975 was investigated related to discharge rights and residents privacy not protected. The SA determined the facility was in compliance with no deficiencies cited.

The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

Complaint Investigations MS #26275, MS #26313, and MS #26368 were conducted related to quality of care, therapeutic diets, cleanliness, roaches, staffing, neglect, and nursing services. The facility was found in compliance with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

Complaint Investigations MS #26275, MS #26313, and MS #26368 were conducted related to quality of care, therapeutic diets, facility cleanliness, roaches, staffing, neglect, and nursing services. The facility was found in compliance with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.

The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and recommends the facility be placed back in compliance effective 5/21/24.

The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 5/21/24.

The facility was found not in compliance with state licensure requirements, with deficiencies related to pressure sore treatment, accident prevention, and safe food handling procedures.

The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies in comprehensive care planning, pressure ulcer treatment, accident prevention, and food safety practices.

The facility met the applicable provisions of the 2012 Edition of the Life Safety Code. There were no Life Safety Code deficiencies cited during this survey.

The investigation was complaint-driven, focusing on allegations of inadequate care planning, improper resident transfers, pressure ulcer management failures, accident risks, and food safety violations. The complaints were substantiated based on observations, interviews, and record reviews.

The facility failed to develop a comprehensive care plan within required timeframes, did not use physician-ordered mechanical lifts for resident transfers, failed to identify and treat new pressure ulcers before deterioration, did not prevent potential accidents related to improper transfers, and stored food improperly with expired, unlabeled, and spoiled items.

Two complaint investigations were conducted: CI MS #23071 related to abuse and CI MS #23085 related to verbal abuse. The facility was found in compliance with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

Two complaint investigations (CI MS #23071 and CI MS #23085) related to abuse were conducted and no deficiencies were cited.

The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

Complaint survey completed on 08/01/23; the facility was found to have corrected the deficient practice and sustained compliance.

The State Agency found the facility in compliance and is recommending the facility be placed back in compliance effective 08/31/23.

Complaint MS #22275 was investigated and found to be unsubstantiated as no deficiencies were cited.

The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and no deficiencies were cited during this complaint survey.

Complaint MS #22275 was investigated regarding staffing and was determined to have no deficiencies cited.

The facility was found in compliance with the requirements for participation in Medicare and Medicaid during this complaint survey. However, the facility remains out of compliance due to deficiencies cited on the 8/1/23 survey.

The complaint was substantiated. The investigation confirmed that the resident's pain medication was not administered as prescribed due to staff not following procedures to obtain medication after pharmacy hours.

The facility failed to ensure pain management was provided to treat a newly admitted resident's pain. Interviews and record reviews revealed that prescribed pain medication was not administered due to after-hours pharmacy access issues and staff not following procedures.

Complaint MS #21950 alleged physical environment issues, client services not performed per plan of care, cold food, and resident food preferences not honored. Deficiency F697 was cited related to pain management. Complaints MS #21741 (neglect) and MS #22032 (environment, infection control, facility cleanliness) were investigated with no deficiencies cited.

The facility was found not in compliance with Medicare and Medicaid requirements due to failure to provide pain management to a newly admitted resident. The deficiency involved failure to administer prescribed pain medication because nursing staff did not obtain medication from the automated dispenser after hours.

The State Agency is recommending that the facility be placed back in compliance effective 09/20/22. No deficiencies were cited in this desk review.

Complaint CI MS#19517 alleged neglect related to wounds, weight loss, and dehydration. The complaint was not substantiated and no deficiencies were cited.

No deficiencies were cited during this complaint investigation survey. The facility remains out of compliance due to deficiencies cited on the prior 08/10/2022 survey.

Complaint investigations CI MS #18611 and CI MS #18612 were not substantiated for abuse and no citations were related to these complaints.

The facility failed to ensure feeding tube placement was checked prior to flushing the tube for one of two residents observed with feeding tubes, Resident #15. Registered Nurse #1 flushed the enteral feeding tube without aspirating to confirm placement, which could have caused complications.

Complaint investigations MS #18611 and MS #18612 were not substantiated for abuse and no citations were related to these complaints.

The facility was found not in compliance with participation requirements and cited for three deficiencies related to transfer/discharge notification and care plan implementation. The complaints MS #18611 and MS #18612 were not substantiated and no citations were related to them.

There were no Life Safety Code deficiencies cited during this survey. The facility met the applicable provisions of the 2012 Edition of the Life Safety Code.

The facility failed to provide timely written notification to residents and their representatives before hospital transfers for two residents. Additionally, the facility did not ensure care plan interventions were implemented to prevent complications related to PEG tube placement for one resident. The facility also failed to ensure professional standards were met regarding checking PEG tube placement prior to flushing.

CI MS #17229: The investigation was unsubstantiated with no deficiencies cited for Abuse related to Employee To Resident, Neglect related to Access/monitor, and Quality of Care related to Not Being Offered Water.

The facility was found to be in compliance with infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19. The complaint investigation was unsubstantiated with no deficiencies cited.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The facility was found to be in compliance with infection control regulations and no deficiencies were cited.

The facility was found to be in compliance with infection control regulations and no deficiencies were cited.

The facility was found not in compliance with deficiencies cited at F0656 and F0690 related to failure to follow the care plan for incontinent care and failure to prevent risk of urinary tract infection due to improper incontinent care.

The facility was found not in compliance with state statute M620 regarding urinary incontinence care. The facility failed to provide Resident #28's incontinent care in a manner to prevent the possibility of a urinary tract infection and/or cross contamination.