Cycle 1
Health 2025-09-04 · Fire 2025-09-04
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Pass Christian, MS
Pass Christian Health And Rehabiliation Center
1-star overall rating with 3-star inspections with $8,224 in total fines with 5 recent health deficiencies
538 Menge Avenue, Pass Christian, MS
(228) 452-4344
Overall
1 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Consulate Health Care/Independence Living Centers/Nspire Healthcare/Raydiant Health Care
Operator or chain grouping
Approved since
2002-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
36 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.38
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.21
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
100%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
83%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,141
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9861
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.76
Baseline 19.52% · Performance 20.15% · Measure score 2.76 · Achievement 2.76 · Improvement 0
Healthcare-associated infections
7.30
Baseline 10.93% · Performance 6.30% · Measure score 7.30 · Achievement 5.14 · Improvement 7.30
Total nurse turnover
0
Performance 66.10% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.19
Baseline 3.29 hours · Performance 3.7 hours · Measure score 2.19 · Achievement 2.19 · Improvement 1.14
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.5% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 16% · Lower 95% interval 6.92% |
| Discharge to community | 40.29% |
50.57%
10.3 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 31.48% · Lower 95% interval 28.05% |
| Medicare spending per beneficiary | 1.28 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 57 · Denominator 57 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 57 |
| Discharge self-care score | 46.15% |
53.69%
7.5 pts worse
|
Numerator 12 · Denominator 26 |
| Discharge mobility score | 42.31% |
50.94%
8.6 pts worse
|
Numerator 11 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 5.26% |
2.29%
3 pts worse
|
Numerator 3 · Denominator 57 · Adjusted rate 3.74% |
| Healthcare-associated infections requiring hospitalization | 6.3% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 4.17% · Lower 95% interval 3.14% |
| Staff COVID-19 vaccination coverage | 4.11% |
8.2%
4.1 pts worse
|
Numerator 3 · Denominator 73 |
| Staff flu vaccination coverage | 2.56% |
42%
39.4 pts worse
|
Numerator 2 · Denominator 78 |
| Discharge function score | 53.85% |
56.45%
2.6 pts worse
|
Numerator 14 · Denominator 26 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 3.45% |
25.2%
21.8 pts worse
|
Numerator 1 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.4
About the same
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.9 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
2.9
0.3 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
95.7%
0.7 pts worse
|
93.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 90.7% · Q2 93.0% · Q3 95.8% · Q4 100.0% · 4Q avg 95.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.0%
3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
3.2%
1.2 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.7% · Q3 4.2% · Q4 4.3% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.7% |
1.6%
8.1 pts worse
|
11.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 9.1% · Q3 15.8% · Q4 5.1% · 4Q avg 9.7% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
6.1%
2.1 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.4% · Q3 4.9% · Q4 2.7% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.6% |
24.4%
3.8 pts better
|
19.6%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.6% · Q2 20.5% · Q3 14.3% · Q4 17.1% · 4Q avg 20.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.0% |
23.4%
5.4 pts better
|
16.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 18.8% · Q3 18.2% · Q4 22.2% · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.1% |
22.8%
4.3 pts worse
|
16.3%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.1% |
20.6%
5.5 pts worse
|
14.9%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 11.8% · Q3 34.2% · Q4 38.9% · 4Q avg 26.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.5%
About the same
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.0% · Q3 1.1% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.2% |
2.5%
2.7 pts worse
|
1.7%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 10.6% · Q4 9.3% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.3% |
21.4%
7.1 pts better
|
19.8%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 13.8% · Q3 6.5% · Q4 25.4% · 4Q avg 14.3% |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
6.9%
1.6 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 13.7% · Q3 7.5% · Q4 1.7% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.6% |
87.9%
0.3 pts worse
|
81.7%
5.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.2% · Q2 77.7% · Q3 87.5% · Q4 98.7% · 4Q avg 87.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
15.3%
6.2 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 9.7% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
2.6%
0.1 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.9% · Q3 2.5% · Q4 2.5% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.8% |
84.6%
7.8 pts worse
|
79.7%
2.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 36.4% |
27.9%
8.5 pts worse
|
23.9%
12.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 36.4% · Observed 35.5% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-24 · Fire 2024-04-24
7 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-08-10 · Fire 2022-08-10
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-09-04
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-10-01
E · Potential for more than minimal harm
2025-05-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-03-06
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-03-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-07
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-07
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-21
G · Actual harm
2024-04-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-04-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-04-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-04-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-21
D · Potential for more than minimal harm
2023-08-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-08-31
E · Potential for more than minimal harm
2022-08-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-10
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-09-20
Penalties and ownership
What sits behind the stars
$8,224
2024-04-24
Fine
Fine · fine $8,224
Fine
Ownership
Fglfc Holdco, LLC
5% Or Greater Direct Ownership Interest · Organization
Consulate Management Company Iii LLC
Operational/Managerial Control · Organization
Fc Investors Xxi LLC
5% Or Greater Indirect Ownership Interest · Organization
Grady, John
Contracted Managing Employee · Individual
Lavie Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Lehner, Timothy
Operational/Managerial Control · Individual
Lehner, Timothy
Corporate Officer · Individual
Lv Investment LLC
5% Or Greater Indirect Ownership Interest · Organization
Nspr Care Centers, LLC
5% Or Greater Indirect Ownership Interest · Organization
Nspr Operations I, LLC
5% Or Greater Indirect Ownership Interest · Organization
Nspr Operations Ii, LLC
5% Or Greater Indirect Ownership Interest · Organization
Williams, James
W-2 Managing Employee · Individual
Nearby options
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#2
Driftwood Nursing Center
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3-star overall rating with 4-star inspections with 3 recent health deficiencies
#3
Dunbar Village Terrace
Bay Saint Louis, MS
4-star overall rating with 4-star inspections with $8,021 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out
Supporting pages
City page
Best nursing homes in Pass Christian, MS
See how this facility ranks inside its city.
1 facilitiesCounty
Harrison County
County ranking page for nearby alternatives.
7 facilitiesChain
Consulate Health Care/Independence Living Centers/Nspire Healthcare/Raydiant Health Care
Chain page for the operating group.
36 facilities