Grand Trace Health and Rehab: Wound Care Failures - MS
Inspectors who arrived at the facility on March 17 and completed their review on March 21, 2025 found the failures through a records review of Resident 33, a long-term resident with severely impaired cognition who could not advocate for themselves. The resident had been admitted with a diagnosis that included osteomyelitis of the vertebra in the sacral and sacrococcygeal region, a bone infection in the same area where the Stage IV wound later developed.
A Stage IV pressure wound is the most severe classification. It reaches through the skin and underlying tissue to expose muscle, bone, or supporting structures. In a resident with a pre-existing bone infection in that region, the stakes of any lapse in care are not abstract.
The facility's own Electronic Treatment Administration Record showed no documentation that wound care treatments were provided on March 16 and again on March 22. Whether that means the treatments weren't done, or were done and never recorded, the inspection report does not resolve. What it does establish is that there is no evidence either way for two separate care days, and that the resident's wounds were severe enough that any gap carried real consequences.
Inspectors also reviewed the Electronic Medication Administration Record and found no documentation that pain medication was administered before wound care on March 26. Wound care on a Stage IV pressure injury is painful. For a resident with severely impaired cognition, the inability to clearly express or escalate pain makes the prior administration of medication more important, not less. The record shows it didn't happen, or at least that nobody wrote it down.
The resident's Braden Scale scores, a standardized tool used to predict pressure injury risk, had already flagged the danger. Scores recorded on February 20 came in at eight and 12. A score of eight falls in the "very high risk" category. A score of 12 is "high risk." The deep tissue injury to the left inner heel was identified as facility-acquired, meaning it developed after admission, on February 27.
The picture the records draw is of a resident whose vulnerability was documented and quantified, whose wounds were known and serious, and whose care still fell through on multiple occasions within a single month.
Resident 33 had been at Grand Trace for more than six years by the time inspectors arrived. The admission date on file is September 11, 2018. The January 2025 Minimum Data Set assessment, completed roughly two months before the inspection, confirmed severely impaired cognition. That assessment is a routine federal requirement, and it means the facility had recent, formal documentation that this resident could not reliably communicate distress or unmet need.
The harm finding in the inspection report is listed as actual harm, not potential. Inspectors did not characterize this as a near miss.
For a resident who cannot speak clearly for themselves, cannot track whether a nurse came by with medication, cannot remember whether a dressing was changed, the treatment record is the only account of what happened. On at least two days in March, that account was blank.
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 30, 2026 · Our methodology
GRAND TRACE HEALTH AND REHABILITATION in NATCHEZ, MS was cited for violations during a health inspection on March 27, 2025.
A Stage IV pressure wound is the most severe classification.
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.