Grand Trace Health And Rehabilitation
GRAND TRACE HEALTH AND REHABILITATION in NATCHEZ, MS — inspection on March 27, 2025.
Found 18 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
reported missing items to her.
She stated she searched for them and told the resident she could not
On 03/27/25 at 11:15 AM, during an interview with the Laundry and Housekeeping Supervisor (LHS),
without success.
When asked about the next step, she acknowledged that the incident should have been reported to the Director of Nursing (DON) or the Administrator, but she had not done so.
She stated that had she followed proper protocol, the items may have been replaced.
She acknowledged that the loss of personal items could cause distress to the resident.
On 03/27/25 at 11:28 AM, during an interview with the Administrator, he stated he had not been informed of the missing items. He confirmed that if it had been reported, the facility would have replaced the missing clothing.
255173 03/27/2025
Grand Trace Health and Rehabilitation 555 John R.
Junkin Drive Natchez, MS 39120
Significant Change in Status Assessment (SCSA) after a return from the hospital with a newly
one (1) of (20) sampled residents, Resident #33.
Findings include: A review of the facility's Minimum Data Set (MDS) policy, revision date 9/25/2017, revealed, .The center conducts initial and periodic standardized, comprehensive and reproducible assessments no later than every three months for each resident including, but not limited to, the collection of data regarding functional status, strengths, weaknesses and preferences using the federal and or/state required RAI (Resident Assessment Instrument) .
On 03/24/25 at 3:59 PM, Resident #33 was observed with enternal feeding flowing at 50 cc (cubic centimeters)/hour.
The head of the bed was elevated to 45 degrees.
The resident was lying in bed with eyes closed.
On 03/26/25 at 4:28 PM, during an interview with the Corporate Nurse, she stated she was aware that Resident #33 returned from the hospital with a sacral wound and a PEG tube.
On 03/27/25 at 12:04 PM, during an interview with Registered Nurse (RN) #1, who also serves as the MDS and Care Plan Nurse, she stated she forgot to complete a Significant Change in Status Assessment for Resident #33.
She explained that a significant change assessment is completed to notify staff of a resident's care needs and acknowledged it should have been completed when the resident returned from the hospital with a PEG tube and Stage IV sacral wound.
Record review of the re-entry MDS dated [DATE] revealed the resident returned from a short term general hospital but there was not a Significant Change MDS completed.
A record review of Resident #33's admission Record revealed an admission date of 09/11/18 with diagnoses including Osteomyelitis of vertebra sacral and sacrococcygeal region.
A record review of Resident #33's Physician Orders dated 03/14/25 revealed continuous Glucerna 1.5 at 50 ml(milliliters)/hour with 120 ml water flush every four hours, providing 1800 kcal (kilocalories), 100 grams of protein, and 910 ml of free water.
Orders also included PEG tube feedings twice a day for dietary support.
Wound care orders included cleansing the sacral wound with normal saline or wound cleanser, patting dry, applying normal saline wet-to-dry gauze, and covering with a bordered dressing.
A review of Resident #33's Annual MDS with an Assessment Reference Date (ARD) of 01/01/25 revealed severely impaired cognition.
255173 03/27/2025
Grand Trace Health and Rehabilitation 555 John R.
Junkin Drive Natchez, MS 39120
During the recertification survey, the facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who returned from the hospital with two significant changes.
Consultant, both explained that the facility and management expect PAS screenings to be completed
255173 03/27/2025
Grand Trace Health and Rehabilitation 555 John R.
Junkin Drive Natchez, MS 39120
Consultant, both stated that it is the facility's expectation that PASRR screenings be completed
255173 03/27/2025
Grand Trace Health and Rehabilitation 555 John R.
Junkin Drive Natchez, MS 39120
03/22/25, at 5:45 AM and stated he had experienced a difficult weekend and planned to leave the
weekend because the pharmacy did not deliver them. He stated that while the Duragesic patch was acceptable, he required his other medications, specifically Oxycodone. He reported that therapy staff said they would follow up on the medications, but he had not seen them again.
On 03/26/25 at 3:50 PM, during an interview with the Care Plan Nurse, she confirmed the presence of a pain care plan but stated it was the responsibility of the staff to follow the plan.
255173 03/27/2025
Grand Trace Health and Rehabilitation 555 John R.
Junkin Drive Natchez, MS 39120
care.
She also confirmed she did not follow wound care orders exactly as written.
On 03/26/25 at 3:53 PM, during an interview with LPN#1 responsible for wound care and infection
the care plan.
She stated orders are necessary to support wound healing and reduce complications.
She acknowledged a breakdown in communication regarding pain medication and accepted responsibility for the oversight.
On 03/26/25 at 3:53 PM, during an interview with the LPN #1, she admitted she did not follow the care plan when cleaning the resident's wound and acknowledged the care plan should always be followed.
On 03/27/25 at 12:04 PM, during an interview with Registered Nurse (RN) #1, who serves as the Minimum Data Set (MDS) and Care Plan Nurse, she emphasized that it is important for staff to follow the care plan, explaining its purpose is to ensure residents receive adequate and good quality care.
She stated all staff utilize the care plan to some extent.
A review of the admission Record revealed the facility admitted Resident #33 on 09/11/18 with diagnoses including Osteomyelitis of the vertebra, sacral, and sacrococcygeal region.
A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/01/25 revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident was unable to participate in the interview and had severely impaired cognition.
255173 03/27/2025
Grand Trace Health and Rehabilitation 555 John R.
Junkin Drive Natchez, MS 39120
During the recertification survey conducted on 03/07/2024, the facility failed to provide Activities of Daily Living (ADL) care to a dependent resident.
During an interview with the Central Supply staff on 03/27/25 at 2:30 PM, he stated the DON had misplaced the inventory list, possibly causing a delay in ordering supplies.
255173 03/27/2025
Grand Trace Health and Rehabilitation 555 John R.
Junkin Drive Natchez, MS 39120
03/17/25-03/21/25 revealed a facility-acquired deep tissue injury to the left inner heel on 02/27/25
indicating very high and high risk, respectively.
A review of the Electronic Treatment Administration Record (ETAR) revealed no documentation that wound care treatments were provided on 03/16/25 and 03/22/25.
A review of Resident #33's Electronic Medication Administration Record (EMAR) revealed no documentation that pain medication was administered prior to wound care on 03/26/25.
A record review of Resident #33's admission Record revealed an admission date of 09/11/18 with diagnoses including Osteomyelitis of vertebra sacral and sacrococcygeal region.
A review of Resident #33's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/01/25 revealed severely impaired cognition.
255173 03/27/2025
Grand Trace Health and Rehabilitation 555 John R.
Junkin Drive Natchez, MS 39120
Findings included: A review of the facility policy Equipment Change Schedule, dated 11/30/14, revealed: Policy: An equipment change schedule provides a schedule for changing disposable equipment at regular intervals as determined by manufacturer ' s recommendations and standards of practice.
Procedure: Equipment/When Changed .
Nasal Cannula, every seven (7) days or when contaminated .
On 03/24/25 at 12:58 PM, during an observation, Resident #18 was lying in bed.
Oxygen was flowing at two (2) liters per minute via nasal cannula.
The oxygen tubing was dated 02/10/24.
There was no signage posted on the door indicating oxygen was in use.
On 03/24/25 at 5:45 PM, during an interview and observation with the Licensed Practical Nurse (LPN)/Infection Preventionist (IP) in Resident #18 ' s room, she confirmed there was no oxygen-in-use signage on the door and that the tubing was dated 02/10/24.
She stated the tubing is supposed to be changed every Sunday on night shift and acknowledged the tubing may be nasty.
The tubing was discolored and cloudy.
The LPN/IP confirmed signage should be posted to make staff and visitors aware that oxygen was in use.
A review of Resident #18's admission Record revealed the resident was admitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD).
A review of Resident #18's Physician Orders revealed an order for oxygen at two (2) liters per minute via nasal cannula as needed for oxygen saturation less than 92% or dyspnea.
A review of Resident #18's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/10/25 revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete an interview.
255173 03/27/2025
Grand Trace Health and Rehabilitation 555 John R.
Junkin Drive Natchez, MS 39120
revealed the diagnoses of Neck Pain and Pain.
A record review of Resident #169's Discharge Instructions from (Proper Name of Acute Hospital)
and a half tablet to equal 30 mg.
On 03/25/25 at 9:30 AM, during an interview with Licensed Practical Nurse (LPN)#4, she confirmed the resident did not receive pain medications on 03/24/25 and reported pain levels of 10.
She stated the pharmacy had not yet delivered the narcotics due to the absence of hard-copy prescriptions.
She also stated the facility has an Omnicell system with backup medications but was unsure if Oxycodone was stocked in it.
On 03/27/25 at 11:50 AM, during an interview with the facility's Nurse Consultant, she stated that no resident should go without pain medication and that the issue should have been resolved on 03/22/25 using the facility's Omnicell system.
On 03/27/25 at 12:10 PM, during a phone interview with Corporate Admissions/Marketing, she confirmed she was unaware the resident arrived at 4:45 AM on 03/22/25 and did not know he went the entire weekend without pain medications.
She stated the admission paperwork and prescriptions were not faxed ahead and only processed once the resident physically arrived.
On 03/27/25 at 12:40 PM, during a phone interview with the Weekend Night Supervisor/Registered Nurse #2, she confirmed that the resident arrived at 4:00 AM on 03/22/25.
She did not complete a pain assessment upon admission and reported that the admission package did not include hard-copy prescriptions.
She contacted the Nurse Practitioner but did not follow up afterward.
On 03/27/25 at 1:10 PM, during an interview with the facility's Nurse Practitioner, she stated that she was only informed on Monday morning, 03/24/25, about the resident's need for pain medications.
She confirmed the hard-copy prescriptions were delivered on that date and Oxycodone was administered for the first time on 03/25/25.
255173 03/27/2025
Grand Trace Health and Rehabilitation 555 John R.
Junkin Drive Natchez, MS 39120
During the recertification survey, the facility failed to provide sufficient staffing to meet residents' care needs.
On 03/27/25 at 2:12 PM, during an interview with the Corporate Nurse (CN) and the Interim Nursing Home Administrator (INHA), the INHA stated he had been in the facility for three (3) weeks and was aware of the past survey results. He stated the facility had conducted QAPI meetings to address the repeated citations.
The CN acknowledged awareness of the repeated concerns and explained that they stemmed from the facility's noncompliance with regulations.
The CN stated the facility had held both QAPI and Performance Improvement Project (PIP) meetings related to these concerns and now conducts QAPI meetings monthly.
The CN also stated that the QAPI policy is reviewed annually.
255173 03/27/2025
Grand Trace Health and Rehabilitation 555 John R.
Junkin Drive Natchez, MS 39120
Findings included: A review of the facility's QAPI policy, with a revision date of 10/24/22, revealed The center and organization has a comprehensive data-driven Quality Assurance Performance Improvement Program that focuses on indications of the outcome of care and quality of life.
Important functional areas may include but are not limited to .c.
Resident Assessments .d.Quality of care .e.
Quality of Life .
Findings included: Record review of the facility policy titled Administering Medication, dated April 2019, revealed Medications are administered in a safe and timely manner and as prescribed . 25.
Staff follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications as applicable .
On 03/26/25 at 8:45 AM, during the administration of morning medications to Resident #169, Licensed Practical Nurse (LPN) #2 was observed entering the resident's room.
The resident asked to see the medications prior to taking them. At this time, the nurse poured the medications into her bare, ungloved hand, and the resident proceeded to take the medications after inspecting them.
On 03/26/25 at 8:55 AM, during an interview, LPN #2 confirmed she had placed the medications into her ungloved hand and stated she should have worn gloves during the exchange to prevent contamination.
She acknowledged it posed a risk of spreading infection to the resident, particularly since she had not performed hand hygiene before entering the room.
On 03/27/25 at 10:40 AM, during an interview with the Infection Prevention (IP) Nurse, LPN #1, she explained that the nurse should have worn gloves prior to handling the resident's medications.
She stated gloves are necessary to prevent spreading infections, including respiratory illnesses, to residents.
On 03/27/25 at 10:56 AM, during an interview with the Corporate Nurse, she stated the nurse should have either discarded the contaminated medications and replaced them with new, uncontaminated ones or worn gloves prior to handling them.
She explained that staff could transmit infections and bacteria to residents when medications are contaminated due to improper handling or lack of hand hygiene.
She stated it was her expectation that staff follow basic infection control guidelines during medication administration.
A record review of Resident #169's admission Record revealed the facility admitted the resident on 03/22/25 with diagnoses including Functional Quadriplegia, Generalized Anxiety Disorder, and Low Back Pain.
F-F641 - Significant Change Assessment
During the recertification survey, the facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who returned from the hospital with two significant changes.
F-F677 - ADL Care
During the recertification survey conducted on 03/07/2024, the facility failed to provide Activities of Daily Living (ADL) care to a dependent resident.
Findings included:
Record review of the facility policy titled Administering Medication, dated April 2019, revealed Medications are administered in a safe and timely manner and as prescribed . 25.
Staff follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications as applicable .
On 03/26/25 at 8:45 AM, during the administration of morning medications to Resident #169, Licensed Practical Nurse (LPN) #2 was observed entering the resident's room.
The resident asked to see the medications prior to taking them. At this time, the nurse poured the medications into her bare, ungloved hand, and the resident proceeded to take the medications after inspecting them.
On 03/26/25 at 8:55 AM, during an interview, LPN #2 confirmed she had placed the medications into her ungloved hand and stated she should have worn gloves during the exchange to prevent contamination.
She acknowledged it posed a risk of spreading infection to the resident, particularly since she had not performed hand hygiene before entering the room.
On 03/27/25 at 10:40 AM, during an interview with the Infection Prevention (IP) Nurse, LPN #1, she explained that the nurse should have worn gloves prior to handling the resident's medications.
She stated gloves are necessary to prevent spreading infections, including respiratory illnesses, to residents.
On 03/27/25 at 10:56 AM, during an interview with the Corporate Nurse, she stated the nurse should have either discarded the contaminated medications and replaced them with new, uncontaminated ones or worn gloves prior to handling them.
She explained that staff could transmit infections and bacteria to residents when medications are contaminated due to improper handling or lack of hand hygiene.
She stated it was her expectation that staff follow basic infection control guidelines during medication administration.
A record review of Resident #169's Admission Record revealed the facility admitted the resident on 03/22/25 with diagnoses including Functional Quadriplegia, Generalized Anxiety Disorder, and Low Back Pain.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.