Grand Trace Health and Rehabilitation: Oxygen Tubing Left Unchanged for 13 Mo...
The date written on the tubing was February 10, 2024. Inspectors observed it on March 24, 2025. By the facility's own written policy, nasal cannula tubing is to be replaced every seven days.
The tubing was discolored and cloudy.
The resident, identified in inspection records only as Resident 18, was receiving oxygen at two liters per minute through a nasal cannula, on a physician's order tied to a diagnosis of COPD. The order called for supplemental oxygen when the resident's blood oxygen saturation dropped below 92 percent or when the resident experienced difficulty breathing. A cognitive assessment indicated the resident was unable to complete an interview.
There was no sign on the door indicating oxygen was in use.
When a Licensed Practical Nurse who also served as the facility's Infection Preventionist was brought into the room that evening, she confirmed both findings. The tubing was dated February 10, 2024. The door had no oxygen-in-use signage. She told inspectors the tubing is supposed to be changed every Sunday on night shift.
Then she said the tubing "may be nasty."
The facility's Equipment Change Schedule policy, last dated November 2014, is unambiguous. Nasal cannula tubing is to be changed every seven days, or sooner if contaminated. More than fifty-two weekly changes had come and gone since the date written on that tubing. None of them happened.
The missing door signage compounded the problem. The LPN confirmed that the sign exists to alert staff and visitors that oxygen is in use, a precaution with direct safety implications. Without it, anyone entering the room, a housekeeper, a visitor, a maintenance worker, would have no way of knowing a flammable gas was flowing.
Inspectors reviewed the resident's physician orders, admission records, and a Minimum Data Set assessment completed in January 2025. The clinical picture was consistent: a resident dependent on supplemental oxygen, cognitively unable to advocate for equipment changes, and relying entirely on staff to follow the protocols in place.
The infection preventionist is, by role, the person in a nursing facility responsible for ensuring that practices like equipment replacement schedules are followed to reduce the risk of infection. At Grand Trace, that position was held by the same nurse who confirmed, standing in the resident's room, that the tubing dated to the prior February and that it might be nasty.
Inspectors classified the violation as causing minimal harm or the potential for actual harm. The deficiency affected one of four residents observed with oxygen in use during the survey.
The facility's plan of correction was not included in the inspection report. For information on corrective steps taken, CMS directs the public to contact the nursing home or the state survey agency directly.
What the inspection does not answer is how many Sundays the night shift skipped the change, and whether anyone noticed the date on the tubing before a federal inspector walked into the room and wrote it down.
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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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
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 date written on the tubing was February 10, 2024.
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.