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
Staffing
Hours and turnover
RN hours / resident day
0.38
Registered nurse staffing
LPN hours / resident day
1.21
Licensed practical nurse staffing
Aide hours / resident day
1.87
Nurse aide staffing
Weekend hours
3.15
Weekend nurse staffing
RN turnover
100%
Annual RN turnover
Total nurse turnover
83%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
Other facilities in reach
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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
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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