Inspection Reports for
Pass Christian Health and Rehabilitation Center

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.

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.

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.

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.

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.

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.

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.