Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pass Christian Health And Rehabiliation Center during CMS and state inspections, most recent first.
A resident with type 2 DM had a prescribed Mounjaro (tirzepatide) injection pen delivered to the facility, but staff failed to follow policies requiring secure storage, timely verification, and documentation in the controlled substance log. An LPN electronically signed for the delivery and reported placing the medication in the medication room refrigerator, and another LPN and an additional LPN stated they checked the delivery against the manifest. However, no documentation was completed to show receipt, no accountability record was initiated, the medication was not entered into the controlled substance log, and there was no record it was secured in the medication refrigerator. The pharmacist later confirmed the facility did not verify the delivery or report the missing medication within the expected timeframe, and the DON acknowledged the medication and related documentation were missing.
A resident with chronic systolic CHF, type 2 DM, and moderate cognitive impairment had a physician order for bedtime Insulin Glargine, with facility policy requiring administration within 60 minutes of the scheduled time and documentation on the MAR after administration. Review of medication records showed that the insulin, ordered for 9 PM, was repeatedly documented several hours later, including after midnight on the following day, without any clinical rationale. An LPN acknowledged documenting the insulin late, stating it was given at the correct time but recorded later when time allowed. The DON confirmed insulin is a time-critical medication that must be administered and documented as ordered and that giving it several hours late is inconsistent with professional standards and increases the risk of unstable blood glucose levels, while the Administrator stated he expects staff to follow physician orders and facility policy.
Missing Diabetes Care Plan: A resident with Type 2 DM and moderately impaired cognition did not have a care plan with interventions for diabetes. Record review showed the diagnosis was identified in the MDS, but the clinical record had no diabetes care plan. An LPN said care plans were behind and had not been updated for the resident, and the DON confirmed she was unaware the resident lacked a diabetes care plan.
A resident on hospice with anxiety and moderate cognitive impairment received a PRN Lorazepam order with no stop date beyond the 14-day limit for psychotropic medications, and the record lacked the required provider documentation for extending therapy. The eMAR showed repeated administrations over multiple days, with behaviors documented only once, and the consultant pharmacist recommended discontinuation or documentation of the indication, intended duration, and rationale for continuation; the recommendation was declined due to hospice status without a provider signature or date.
A resident admitted with sialoadenitis and bacteremia did not receive two of three scheduled doses of IV cefazolin as ordered. Only one dose was given, and it was administered late and documented incorrectly. Facility staff confirmed the missed and late doses, and the resident's family requested hospital transfer due to the failure to provide timely antibiotic treatment.
A resident on apixaban experienced a fall, but the medical provider was not notified until the next day, contrary to facility policy. The resident was found on the floor and assisted back to their wheelchair by an LPN, who failed to report the incident immediately. The DON confirmed the lapse in policy adherence, and the NP stated that immediate notification would have led to an earlier emergency department evaluation.
A resident with muscle weakness experienced a fall, and the facility failed to document a complete post-fall assessment, including vital signs, as required by policy. Despite being on anticoagulant medication, the resident's Change in Condition form was incomplete. Interviews with staff confirmed the oversight, with an LPN admitting to not recording vital signs immediately after the fall due to being busy.
A medication reconciliation error occurred when a nurse accessed the wrong resident's records and transcribed incorrect medication orders without verification, leading to the administration of incorrect medications to a cognitively intact resident admitted with a fracture. The nurse, who was the interim DON, admitted to not following the five rights of medication administration due to being overwhelmed with multiple admissions.
The facility failed to have an RN on duty for at least eight consecutive hours due to severe weather conditions. The Interim DON worked extended hours the previous day and could not return, leaving only two LPNs to manage resident care. The facility's staffing plan was not adhered to, resulting in a deficiency.
A facility failed to prevent significant medication errors, leading to a resident receiving unprescribed medications for eight days, causing heavy sedation and therapy disruption. Another resident did not receive prescribed IV antibiotics on multiple occasions due to documentation and administration failures. The errors were linked to inadequate verification of resident information and physician orders, as well as insufficient oversight of medication administration.
A resident developed two new Stage 3 pressure ulcers on the right buttock and scrotum, which were not documented or treated according to the facility's policy. The staff failed to report and document these new wounds, leading to a lack of appropriate care.
The facility failed to develop a comprehensive care plan for a resident within the required timeframe and did not implement a care plan intervention for another resident, leading to non-compliance with established care protocols.
The facility failed to use a physician-ordered mechanical lift for transferring a resident with age-related osteoporosis and osteoarthritis. Two CNAs manually transferred the resident without checking the Kardex for instructions, despite the resident's recent decline necessitating the use of the mechanical lift. Interviews confirmed the staff should have followed the physician's orders.
The facility failed to store food in accordance with professional standards, resulting in undated, mislabeled, exposed, expired, and spoiled food items in the kitchen. The Certified Dietary Manager and kitchen staff did not follow proper labeling and storage practices, despite receiving regular training. The Administrator acknowledged the deficiencies and expected proper food storage and labeling.
Failure to Secure and Account for Delivered Injectable Diabetes Medication
Penalty
Summary
The facility failed to protect a resident’s belongings by not properly securing, documenting, and tracking a prescribed injectable medication, resulting in the loss of the medication. Facility policies on Abuse/Neglect/Exploitation & Misappropriation, Medication Storage, and Controlled Substance Administration & Accountability required that medications be secured in locked compartments, accurately documented upon receipt, reconciled with delivery records, and entered into accountability logs to prevent diversion. Pharmacy records showed that a Mounjaro (tirzepatide) 5 mg/0.5 ml pen for a resident with type 2 diabetes mellitus was delivered and electronically signed as received by an LPN. However, the controlled substance log contained no entry for the medication, no accountability record was initiated, and there was no documentation that the medication was placed in the medication refrigerator or otherwise secured. Interviews and record reviews revealed multiple failures in the receipt and verification process. An LPN confirmed receiving the medication and stated it was placed in the medication room refrigerator, but it was later found to be missing. Another LPN reported that she had ordered the medication and, upon returning to work, discovered it was not available; she then learned from the pharmacy that it had already been delivered. The pharmacist stated the facility was expected to verify all delivered medications within 24 hours and report discrepancies promptly, but the facility did not notify the pharmacy of the missing medication until several days after delivery. A third LPN reported that she and the receiving LPN checked the delivery against the manifest but did not complete any documentation to reflect receipt, secure storage, or entry into the accountability log. The DON confirmed the medication could not be located and that there was no documentation verifying proper receipt, storage, or tracking, and that both the medication and associated documentation were missing.
Failure to Document Insulin Administration in Accordance With Orders and Standards
Penalty
Summary
The deficiency involves the facility’s failure to ensure that insulin administration was documented in accordance with physician orders, facility policy, and accepted professional standards of practice for one resident receiving insulin. Facility policy required medications to be administered as ordered by the physician, within 60 minutes before or after the scheduled time unless otherwise ordered, and for the MAR to be signed after administration. The resident had an active order for Insulin Glargine 49 units subcutaneously at bedtime for diabetes. Review of the Location of Administration Report for the month showed multiple instances where the insulin, ordered for 9 PM, was documented several hours later, including entries at 2:05 AM, 12:05 AM, and 12:14 AM on the following day, and other late-night times. Staff were unable to provide a clinical rationale for these late documentation times. The resident involved had been admitted with diagnoses including chronic systolic (congestive) heart failure and type 2 diabetes without complications, and a recent MDS indicated moderate cognitive impairment with a BIMS score of 8. During interviews, an LPN confirmed that the insulin was documented outside the ordered time frame and stated that the medication was given at the correct time but documented later when time allowed, adding that she tried to do the best she could. The DON confirmed that insulin is a time-critical medication that should be administered and documented as ordered and acknowledged that administering insulin several hours after the scheduled time is not consistent with professional standards of practice and increases the risk for unstable blood glucose levels. The DON also stated that medication should be documented after being administered, and the Administrator stated he expects nursing staff to follow physician orders and facility policy when administering medications.
Missing Diabetes Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive, resident-centered care plan was developed for a resident with a diagnosis of Type 2 Diabetes Mellitus. The facility policy stated that an individualized person-centered plan of care would be established by the interdisciplinary team with the resident and/or representative and updated according to regulatory requirements, and that the plan should include measurable objectives and timetables to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Record review showed the resident was admitted with Type 2 Diabetes Mellitus and had a Significant Change MDS with a BIMS score of 9, indicating moderately impaired cognition. The MDS also identified a diagnosis of Diabetes Mellitus. Review of the clinical record found no care plan developed with interventions for the diagnosis of Diabetes Mellitus. An LPN stated the care plans were behind and that the resident’s care plan had not been updated to address diabetes. The DON confirmed the resident had Type 2 Diabetes Mellitus and stated she was not aware the resident did not have a diabetes care plan. The Administrator stated staff were expected to follow professional standards in developing comprehensive resident-centered care plans for all residents.
PRN Lorazepam Continued Beyond Regulatory Limit Without Required Documentation
Penalty
Summary
The facility failed to ensure a PRN psychotropic medication order was limited to 14 days or that the prescribing practitioner documented the rationale for extending therapy, including the duration of use. Resident #10 was admitted with diagnoses including anxiety and atherosclerotic heart disease and had a BIMS score of 10, indicating moderate cognitive impairment; the resident was also on hospice care. The resident had an active order for Lorazepam 0.5 mg, two tablets by mouth every two hours as needed for anxiety/terminal agitation, with no stop date. Review of the August and September 2025 eMAR showed Lorazepam was administered repeatedly over multiple days, including on 14 separate days in August and again on several days in September, with documentation of behaviors noted only once in August and no behaviors documented for the September administrations. The consultant pharmacist recommended discontinuing the PRN Lorazepam or documenting the indication, intended duration, and rationale for continuation, but the recommendation was declined due to hospice status without a physician or NP signature and without a date. During interviews, the LPN stated the resident could become aggressive and that Lorazepam and Morphine were used almost daily for comfort, while the DON acknowledged she was not aware hospice residents still had to comply with federal requirements for PRN psychotropic medications. The NP stated she knew the regulatory requirements and would have signed the pharmacist recommendation if she had reviewed it.
Failure to Administer IV Antibiotics as Ordered
Penalty
Summary
The facility failed to administer intravenous (IV) antibiotics as ordered for a resident admitted with sialoadenitis and bacteremia. The physician's order specified cefazolin sodium 2 grams IV every eight hours for parotitis and sepsis. Documentation showed that only one dose was administered, and two scheduled doses were missed. The medication administration record (EMAR) indicated that the 6:00 AM dose was documented as given but was actually administered late at 10:12 AM, while the 10:00 PM and 2:00 PM doses were not administered at all. The Omnicell dispensing record confirmed the timing of the medication removal, and progress notes reflected the resident's arrival and the inability to administer the antibiotics as ordered. Interviews with facility staff, including the former DON and the interim DON, confirmed the missed and late doses, as well as improper documentation. The former DON acknowledged not administering the 10:00 PM dose due to personal circumstances and failing to inform the administrator. The resident's representative reported that the resident did not receive the prescribed antibiotics until mid-morning the following day and that no further doses were given, leading the family to request a transfer to the hospital for proper administration. Facility policies required timely and accurate medication administration, which was not followed in this case.
Delayed Notification of Medical Provider After Resident Fall
Penalty
Summary
The facility failed to promptly notify the medical provider of a fall incident involving a resident who was prescribed apixaban, an anticoagulant medication. The resident experienced a fall in the dining room, but the Nurse Practitioner (NP) was not informed until the following day. The facility's policy requires immediate notification of the attending physician and resident representative following any change in condition, including accidents. However, the Change in Condition form was incomplete, lacking documentation of the physician's notification and recommendations. Interviews with staff confirmed the delay in notification. An LPN found the resident on the floor and assisted them back to their wheelchair without notifying the NP on the day of the incident. The Director of Nursing (DON) acknowledged the lapse in following the facility's policy. The NP confirmed that had she been notified immediately, she would have ordered the resident to be sent to the emergency department for evaluation and treatment on the day of the fall.
Incomplete Post-Fall Assessment Documentation
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate, as evidenced by missing documentation of a post-fall assessment for a resident. The resident, who was admitted with a diagnosis of muscle weakness, experienced a fall. The facility's policy required a post-fall assessment, including vital signs, to be documented. However, the Change in Condition (SBAR) form was incomplete and did not include the necessary information, such as recent vital signs, despite the resident being on anticoagulant medication. Interviews with staff confirmed the deficiency. An LPN acknowledged assisting with the resident's assessment but admitted to not recording the vital signs immediately after the fall due to being busy. The DON confirmed that the nurse did not complete a detailed evaluation, including vital signs, following the fall, which was against the facility's policy. This lack of documentation and adherence to policy led to the deficiency being identified during the survey.
Medication Reconciliation Error Due to Staff Incompetency
Penalty
Summary
The facility failed to ensure staff competency in medication reconciliation, leading to a significant medication error. A registered nurse accessed the wrong resident's records and transcribed incorrect medication orders into the system without verification. This resulted in the prolonged administration of incorrect medications to a resident who was cognitively intact and had been admitted with a fracture of the manubrium. The nurse, who was the interim Director of Nursing at the time, admitted to not verifying the physician's orders or confirming the correct resident's information before entering the orders into the electronic health records system. The error was discovered after the resident received the wrong medication for several days. The nurse involved stated that she was overwhelmed with admitting numerous residents and did not follow the five rights of medication administration, which include verifying the right patient, medication, route, dose, and time. The facility's policy required that physician orders be appropriately documented and verified, but this was not adhered to, resulting in the medication error.
RN Staffing Deficiency Due to Severe Weather
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was present for at least eight consecutive hours on one of the days reviewed. On 01/21/2025, the staffing grid indicated that no RN was on duty. The Interim Director of Nursing (DON) had worked a night shift due to a staff shortage and was unable to return to the facility the following day because of severe weather conditions. The facility's Facility Assessment Tool, dated 07/31/2024, outlined a staffing plan based on resident needs, with licensed nurses adjusted per shift. However, the absence of an RN on the specified day indicates a deviation from this plan. Interviews with the Interim DON and the Administrative Assistant confirmed the absence of an RN on 01/21/2025. The Interim DON had worked extended hours the previous day and was unable to return due to a snowstorm. The Administrative Assistant reported that the severe weather prevented staff from coming in, leaving only two Licensed Practical Nurses (LPNs) available to ensure resident safety. The facility was actively recruiting RNs to address the staffing gap, but on the day in question, the absence of an RN was not mitigated, leading to the deficiency.
Significant Medication Errors and Missed Antibiotic Doses
Penalty
Summary
The facility failed to prevent significant medication errors, resulting in a resident receiving multiple unprescribed medications for up to eight consecutive days. This error occurred when a nurse mistakenly accessed another patient's chart instead of the new admission's chart, leading to the administration of incorrect medications. The resident, who was initially alert and oriented, became heavily sedated and unable to participate in therapy, as reported by her daughter and confirmed by the nursing and therapy staff. The error was discovered when a nurse noticed discrepancies between the resident's Medication Administration Record (MAR) and the physician's orders. Another resident was affected by the facility's failure to administer prescribed intravenous (IV) antibiotics on multiple occasions. The resident, who had a diagnosis of a deep incisional surgical site infection, did not receive Vancomycin and Ceftriaxone as ordered on several days. The MAR lacked documentation of the administration of these antibiotics, and the Licensed Practical Nurse (LPN) confirmed that only Registered Nurses (RNs) were permitted to administer IV medications. The Interim Director of Nursing (DON) acknowledged the scheduling issues that contributed to the missed doses. The facility's medication administration policy, which requires medications to be administered in accordance with prescriber orders and verified before administration, was not followed. The errors were compounded by inadequate verification of resident information and physician orders, as well as insufficient documentation and oversight of medication administration. These deficiencies resulted in significant medication errors that adversely affected the residents' health and therapy participation.
Failure to Identify and Treat New Pressure Ulcers
Penalty
Summary
The facility failed to identify and treat two new pressure ulcers before they deteriorated to Stage 3 for a resident. The resident was admitted with a wound to the sacrum, but during the stay, new wounds developed on the right buttock and scrotum. These new wounds were not documented or treated as per the facility's policy, which requires weekly skin evaluations and immediate reporting of any new skin impairments to the physician and documentation in the medical record. During an interview and observation, it was confirmed that the resident had new open areas with slough on the right buttock and scrotum, which were not present upon admission. The Director of Nursing confirmed the lack of documentation and physician orders for these new wounds. The resident and his family were unaware of the new wounds until the day of the survey, and the staff had not communicated these changes in skin integrity. The facility's records showed that the resident had a Braden Scale score indicating a risk for pressure sores and had a Stage 3 pressure ulcer upon admission. However, the weekly skin integrity reviews and wound reports did not reflect the new wounds until they were observed by the surveyors. The staff, including CNAs and nurses, failed to document and report the new skin impairments, leading to a lack of appropriate treatment and care for the resident's new pressure ulcers.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident #22 within the required 21 days of admission. Resident #22 was admitted on 3/27/24, and the Minimum Data Set (MDS) assessment was completed on 4/03/24. However, there was no comprehensive care plan developed for Resident #22, as confirmed by RN #1, who acknowledged the oversight and stated that the care plan should have been developed within seven days of the MDS completion. This failure means that staff did not have a formalized plan to guide the care of Resident #22, potentially impacting the resident's care and well-being. Additionally, the facility failed to implement a care plan intervention for Resident #32. Despite having a physician's order and a care plan intervention dated 3/30/24 that required the use of a mechanical lift with two-person assistance for transfers, CNAs manually transferred Resident #32 without using the mechanical lift. This was observed on 4/21/24, and CNA #1 confirmed that they did not follow the care plan as they did not check the Kardex for transfer instructions. The DON confirmed that staff should follow the care plan and physician orders, indicating a lapse in adherence to established care protocols for Resident #32, who has diagnoses including age-related osteoporosis and osteoarthritis.
Failure to Use Physician-Ordered Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to prevent a potential accident by not using the physician-ordered mechanical lift for transferring a resident. The facility's policy required the use of mechanical lifts for certain residents, and Resident #32 had a physician's order for a mechanical lift with a two-person assist due to her diagnoses of age-related osteoporosis and osteoarthritis. However, during an observation, two CNAs manually transferred Resident #32 from her bed to her wheelchair without using the mechanical lift. The CNAs admitted to not checking the Kardex for transfer instructions and decided to transfer the resident manually based on their judgment of her condition that day. Interviews with the CNAs and the LPN confirmed that the mechanical lift should have been used for the transfer. The Director of Nursing also confirmed that the staff should follow physician orders for transfers and noted that Resident #32 had recently experienced a decline, necessitating the use of the mechanical lift. The resident was cognitively intact, as indicated by a BIMS score of 15 on her recent MDS assessment. The facility admitted Resident #32 in May 2022, and the deficiency was observed in April 2024.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. During an observation of the kitchen, several deficiencies were noted, including food items that were not dated, mislabeled, exposed, expired, or spoiled. Specifically, Refrigerator #1 contained a casserole pan with no opened date, trays of lemon pudding with no date or label, and an uncovered cup. Additionally, there were opened containers of low sodium beef base and various portioned cups of pureed desserts and thickened liquids without identifying labels. Spoiled produce, such as discolored celery, spoiled lettuce, and undated coleslaw mix, was also found. The dry bin containing sugar was left open, exposing the sugar. The Certified Dietary Manager (CDM) acknowledged these issues and stated that he was responsible for discarding expired foods and labeling food items upon delivery, while kitchen staff were responsible for labeling and storing items when opened and inspecting foods daily for expiration dates. Despite receiving training every three months, these practices were not followed, leading to the observed deficiencies. Interviews with the CDM, Cook #1, and the Administrator confirmed the improper storage and labeling of food items. The CDM admitted that the expired and spoiled foods should have been discarded and that he was responsible for labeling food items upon delivery. Cook #1 confirmed that all staff were responsible for labeling and dating foods when opened and inspecting foods daily for expiration dates. The Administrator acknowledged awareness of the improperly stored food items and expected all food to be properly dated, labeled, and free of spoilage. Despite these expectations and training, the facility failed to adhere to its food storage policies, resulting in the noted deficiencies.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pass Christian
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coastal Health And Rehabilitation Center | 6.2 mi | ★★★★★ | 2 | 0 |
| Driftwood Nursing Center | 6.2 mi | ★★★★★ | 3 | 0 |
| Dunbar Village Terrace | 7.3 mi | ★★★★★ | 1 | 0 |
| Gulfport Care Center | 8.9 mi | ★★★★★ | 0 | 0 |
| Memorial Woodland Village Nursing Center | 10 mi | ★★★★★ | 0 | 0 |
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