Grand Trace Health and Rehab: Pain Med Failure - MS
The resident, identified in inspection records only as Resident 169, came to Grand Trace on March 22, 2025, with diagnoses of neck pain and pain. His discharge instructions from the hospital included an order for Oxycodone HCL 20 mg, one and a half tablets every four hours as needed, totaling 30 mg per dose. The paperwork that should have preceded him, including the hard-copy prescriptions the pharmacy required before dispensing narcotics, had not been faxed ahead. It was processed only after he physically arrived.
Nobody completed a pain assessment when he came through the door.
The Weekend Night Supervisor, a registered nurse, confirmed she was on duty when Resident 169 arrived. She acknowledged she did not assess his pain at admission and that the package did not include hard-copy prescriptions. She said she contacted the Nurse Practitioner. She did not follow up.
The Nurse Practitioner said she was not informed about the resident's need for pain medication until Monday morning, March 24. That was when the hard-copy prescriptions were finally delivered. Oxycodone was administered for the first time on March 25, three days after admission.
By then, the resident had already spent a full weekend in pain, telling staff his pain level was 10.
Grand Trace has an Omnicell system, an automated medication dispensing cabinet used to provide backup medications when pharmacy delivery is delayed. The Licensed Practical Nurse who spoke with inspectors on March 25 said she was unsure whether oxycodone was stocked in it. The facility's own Nurse Consultant, interviewed two days later, was not unsure at all. She told inspectors that no resident should go without pain medication and that the situation should have been resolved on March 22, the morning he arrived, using exactly that system.
It was not resolved on March 22. It was not resolved on March 23. It was not resolved on March 24.
The Corporate Admissions and Marketing representative, reached by phone during the inspection, said she had no idea the resident had arrived at 4:45 in the morning. She did not know he had gone the entire weekend without his pain medications. She confirmed the admission paperwork and prescriptions had not been sent ahead of his arrival.
Federal inspectors classified the violation as causing actual harm.
What the inspection record describes is a chain of failures with no single point of accountability and no moment where anyone stopped and asked whether a patient in documented, severe pain had received anything for it. The night supervisor called the Nurse Practitioner and considered the matter handled. The Nurse Practitioner didn't learn about the problem until Monday. The admissions office didn't know he'd arrived in the middle of the night. The nurse on the floor two days later wasn't sure what was in the backup cabinet.
Resident 169 reported a pain level of 10 on March 24. That is the highest number on the scale. It is the number patients use when they have run out of other ways to describe what they are feeling.
His first dose of oxycodone came the following morning.
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.
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Last verified: October 31, 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 169, came to Grand Trace on March 22, 2025, with diagnoses of neck pain and pain.
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.