Grand Trace Health and Rehab: Wound Care Failures - MS
The inspection at Grand Trace Health and Rehabilitation, completed March 27, 2025, cited the facility for causing actual harm to a resident after a licensed practical nurse acknowledged she did not follow written orders during a wound treatment performed the day before inspectors arrived.
The resident, identified in inspection records as Resident 33, had lived at the facility since September 2018. Her diagnoses included osteomyelitis of the vertebra in the sacral and sacrococcygeal region, a bone infection that requires precise, consistent treatment to prevent it from worsening or spreading. A cognitive assessment conducted in January 2025 gave her a score of 3 on the Brief Interview for Mental Status scale, meaning she had severely impaired cognition and was unable to participate in her own interview with inspectors.
She could not describe what had been done to her wound. She could not say whether it hurt.
On the afternoon of March 26, inspectors spoke with LPN #1, the nurse responsible for wound care and infection prevention at the facility. The nurse confirmed that the wound care she had performed that day did not follow the physician's orders. She also confirmed she had not followed the care plan when cleaning the wound. She acknowledged a breakdown in communication regarding the resident's pain medication and accepted responsibility for the oversight.
She said orders are necessary to support wound healing and reduce complications.
That acknowledgment, offered plainly and without apparent dispute, is at the center of the deficiency. The nurse knew what the orders required. She knew what the care plan directed. She did neither.
The following morning, inspectors spoke with RN #1, who serves as the facility's Minimum Data Set and Care Plan Nurse. She told inspectors it is important for staff to follow the care plan, explaining that its purpose is to ensure residents receive adequate and good quality care. She said all staff utilize the care plan to some extent.
To some extent.
Osteomyelitis is not a condition that tolerates improvisation. Bone infections of the spine are serious and difficult to treat under the best circumstances. Wound care that deviates from physician orders, even once, can introduce bacteria, delay healing, or cause the kind of pain that a cognitively intact person would report immediately. Resident 33 had a BIMS score of 3. She was not in a position to tell anyone something had gone wrong.
The inspection record does not describe what specific steps were skipped or altered during the March 26 wound treatment. It does not detail the condition of the wound before or after. What it documents is that a nurse responsible for infection prevention confirmed she did not do what the physician ordered, did not follow the plan written to protect this specific resident, and identified a communication failure around pain medication as part of the same incident.
Inspectors classified the level of harm as actual harm, not potential harm. That distinction matters. It means the deviation from orders was not a near-miss or a paperwork problem. Something happened to Resident 33.
She had been a resident at Grand Trace for more than six years when inspectors arrived. She had a diagnosis that required careful, consistent wound management. She had a care plan written to protect her. And on March 26, 2025, the nurse assigned to her wound care set that plan aside.
Resident 33 could not tell inspectors what she experienced. The nurse told them instead.
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.
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Last verified: October 30, 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 as Resident 33, had lived at the facility since September 2018.
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.