Grand Trace Health and Rehab: Assessment Failure - MS
The resident, identified in inspection records only as Resident #33, has lived at the Natchez facility since September 2011. She has severely impaired cognition and a diagnosis of osteomyelitis, a bone infection, in the sacral and sacrococcygeal region. When she came back from the hospital in March 2025, she came back fundamentally changed: dependent on a PEG tube for all nutrition and carrying an open wound at the deepest classification the staging system has.
Nobody completed a Significant Change in Status Assessment.
That assessment exists for one specific purpose: to tell staff what a resident now needs. When a resident's condition shifts sharply, the assessment triggers updated care planning across the facility. Without it, the people providing daily care, the aides, the floor nurses, the dietary staff, are working from an outdated picture of who that person is and what her body requires.
On March 27, 2025, inspectors sat down with the registered nurse who serves as both the MDS coordinator and the care plan nurse. She told them she forgot. She acknowledged the assessment should have been completed when Resident #33 returned from the hospital. She acknowledged it would have notified staff of the resident's care needs. She offered no other explanation.
The corporate nurse, interviewed the day before, confirmed she already knew about the wound and the feeding tube. She had been aware. The assessment still had not been done.
By the time inspectors observed Resident #33 on March 24, the resident was lying in bed with her eyes closed, receiving continuous tube feedings of Glucerna at 50 milliliters per hour. The head of the bed was elevated to 45 degrees. Her physician orders, dated March 14, called for 1,800 calories a day delivered through the PEG tube, along with water flushes every four hours. Her sacral wound required cleansing with saline, wet-to-dry gauze, and a bordered dressing.
A Stage IV pressure wound means the tissue has broken down past the skin, past the fat beneath it, past the muscle, down to bone or tendon. In a resident with documented bone infection in that same region, the wound was not an isolated problem. It was a development in an already compromised site, in a woman who could not speak for herself or direct her own care.
The facility's own MDS policy, last revised in September 2017, requires comprehensive assessments that capture a resident's functional status, strengths, weaknesses, and preferences. The re-entry MDS completed when Resident #33 returned from the hospital noted she had come back from a short-term general hospital stay. It did not include a Significant Change assessment. Nothing in the record did.
Inspectors classified the violation as having minimal harm or potential for actual harm, the lower end of the deficiency scale. The finding covered one of 20 sampled residents.
What the classification does not capture is the specific situation of a woman with severe cognitive impairment, a new surgical feeding tube, and a wound that had reached bone, being cared for by a team that had never been formally updated on any of it, because the nurse whose job it was to do that updating forgot.
Resident #33 was still receiving tube feedings when inspectors left. Her sacral wound was still being dressed. The assessment that should have told her caregivers what she needed, and formalized a plan around her changed condition, remained incomplete.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grand Trace Health and Rehabilitation from 2025-03-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 29, 2026 · Our methodology
GRAND TRACE HEALTH AND REHABILITATION in NATCHEZ, MS was cited for violations during a health inspection on March 27, 2025.
The resident, identified in inspection records only as Resident #33, has lived at the Natchez facility since September 2011.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.