Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grand Trace Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple unstageable pressure ulcers of both heels and the right ankle had physician orders and facility policies directing wound cleansing to minimize contamination and infection risk. During observed wound care, an RN repeatedly wiped over the open ankle and heel wounds using the same surface of gauze moistened with wound cleanser and did not wear a gown while treating one ankle, contrary to the facility’s clean dressing change and pressure injury management policies. The DON stated nurses were expected to follow infection control standards, and the Staff Development Coordinator noted the RN had just completed a wound care competency that required proper cleansing technique. In interview, the RN admitted wiping over the open wounds multiple times with the same side of the gauze, was unaware of the facility’s wound care protocols, and reported that no protocol had been provided.
A resident with moderate cognitive impairment, a history of stroke, dysphagia, aphasia, and multiple pressure ulcers required extensive assistance with toileting and perineal care. During observed incontinence care, a CNA used premoistened wipes to clean the resident’s genital and perineal areas but repeatedly wiped back and forth with visibly soiled surfaces instead of using a clean surface for each front-to-back stroke, and then used the same wipes on the rectal area and scrotum. This technique did not follow the facility’s incontinence care policy or the CNA’s documented competency instructions, which required cleaning the penis and scrotum with clean cloths and cleaning the anal area front to back without contaminating the perineal area. The DON and Administrator both stated they expected nursing staff to supervise care and ensure incontinence care was provided in a manner that would prevent infection, and the DON acknowledged that wiping back and forth with soiled wipes could lead to UTI.
A resident with multiple unstageable pressure ulcers and moderate cognitive impairment had an active order for Enhanced Barrier Precautions (EBP) related to wounds. Facility policies required wound care to be provided in a manner that prevents infection and cross-contamination, and EBP signage with required PPE was posted on the resident’s door. Despite this, an RN performed wound care to open ankle and heel wounds without donning a gown, even though PPE was available and the RN had recently completed wound care competency training. Leadership, including the DON and Staff Development Coordinator, confirmed expectations that staff follow current infection control standards and use appropriate PPE for residents on EBP.
A cognitively intact resident with a history of major depressive disorder was denied her right to receive visitors of her choosing when her regular visitor and friend was told by staff to leave the facility and was not allowed to stay or have the resident notified of his presence. The facility’s own Resident Rights policy states that residents may receive visitors of their choosing at times of their choosing, yet the IDON acknowledged she directed the friend to leave and confirmed staff did not inform the resident of the attempted visit, while the Administrator later stated he was unaware of the incident.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
The facility did not provide RN coverage for at least eight hours a day, seven days a week, as required. For eight days, no RN was present for a full 24-hour period. An LPN and the DON were counted toward RN staffing, with the DON often acting as both Charge Nurse and DON. The Nurse Consultant and Interim Administrator were unaware of the actual staffing practices, and the facility's census exceeded sixty during the period in question.
A resident with functional quadriplegia was repeatedly observed without an accessible call light, as the available push and touch button types could not be used due to paralysis. Despite being alert and oriented, the resident reported long wait times for assistance and informed multiple staff members of his inability to use the provided call lights. Staff interviews confirmed the call light was often out of reach, and no alternative system, such as a blow-call light, was provided.
A resident requiring total assistance with ADLs, including bathing and grooming, did not receive regular bed baths or shaving, as observed by surveyors and reported by the resident. The resident remained in bed with visible chin hair and a persistent urine odor in the room, and there was no documentation of care refusals. The facility's policy required staff to provide necessary ADL support, but this was not consistently done.
A facility failed to provide adequate nursing staff, resulting in high resident-to-CNA ratios and delays in essential care such as bathing, changing, and repositioning. A resident dependent on staff for personal care was observed unshaven and in a room with a strong urine odor, reporting missed showers. Staff interviews confirmed frequent staffing shortages, with CNAs and LPNs working extra shifts and residents experiencing extended wait times for care.
Improper Wound Cleansing Technique for Pressure Ulcers
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of pressure ulcer care and infection prevention for one resident with multiple pressure injuries. Facility policies on Pressure Injury Prevention and Management and Clean Dressing Change required cleansing wounds in a manner that decreases infection risk, including cleaning outward from the center of the wound and avoiding contamination of other skin surfaces or wound surfaces. The resident, admitted with diagnoses including aphasia, dysphagia, cerebral infarction, and unstageable pressure ulcers of both heels and the right ankle, had physician orders to cleanse the right lateral foot, right heel, and left heel pressure ulcers with wound cleaner, pat dry, and apply specified dressings once daily and as needed. The March Treatment Administration Record showed that a registered nurse documented providing these ordered treatments on the date of the survey observation. During direct observation of wound care, the RN cleansed the open pressure areas on the resident’s right ankle and heel by repeatedly wiping from above the open wound to below it using gauze moistened with wound cleanser, then using a new piece of gauze but again wiping multiple times over the open area with the same surface of the gauze. The RN then performed similar wound care on the left ankle without wearing a gown and again wiped over the open wound multiple times with the same surface of the wet gauze. This technique did not follow the facility’s written procedure to cleanse wounds in a way that avoids contaminating other skin or wound surfaces. The DON stated she expected nurses to follow current infection control standards, including cleaning away from open wounds and using clean surfaces of gauze for each contact. The Staff Development Coordinator reported that the RN had completed a wound care competency checkoff the same day, which included cleansing the wound without contaminating other surfaces. In an interview, the RN acknowledged wiping over the open wound multiple times with the same side of the gauze to remove discharge or slough, stated she was not aware of the facility’s wound care protocols, and said the facility did not provide a protocol to follow.
Improper Infection Control During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper infection control techniques during incontinence care for one sampled resident. Facility policy on incontinence care required that residents who are incontinent of bowel or bladder receive appropriate treatment to prevent infections, and the CNA competency checklist specified cleaning the penis in a circular motion from the tip using downward strokes, then cleaning the scrotal area with a fresh washcloth, and cleaning the anal area front to back without contaminating the perineal area. During an observed episode of incontinence care, CNA #1 used three premoistened disposable wipes to clean the resident’s penis and anterior perineal area front to back, resulting in visible soiling of the wipes, and then continued to wipe back and forth three more times without changing sides of the wipes or using new wipes. CNA #1 then discarded those wipes, obtained three new wipes, cleaned the resident’s rectal area back and forth three times, and then wiped the scrotum with the same soiled wipes. The resident involved had been admitted with diagnoses including aphasia, dysphagia, cerebral infarction, and unstageable pressure ulcers of both heels, and had a BIMS score indicating moderate cognitive impairment and four pressure ulcers at the time of a recent MDS assessment. The Kardex indicated the resident required extensive assistance with bed mobility and toileting, with staff responsible for cleaning the perineal area with each incontinence episode. Interviews revealed that CNA #1 did not verbally confirm awareness of the correct procedure or facility protocol for incontinence care when questioned. The DON stated she expected nurses to supervise resident care and CNAs to provide incontinence care in a manner that would prevent infection, including wiping only front to back one time with a clean surface of the cloth and ensuring each wipe was done with a clean surface, and confirmed that wiping back and forth multiple times with a soiled surface could lead to urinary tract infection. The Staff Development Coordinator reported that CNA #1 had previously completed a competency checkoff on incontinence care procedures, and the Administrator stated he expected nurses to supervise care and that incontinent residents would receive care in a manner to prevent infections.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement its infection prevention and control program by not using Enhanced Barrier Precautions (EBP) during wound care for a resident with multiple pressure injuries. Facility policies titled "Pressure Injury Prevention and Management" and "Clean Dressing Change," both revised on 11/07/25, stated the facility’s commitment to preventing pressure injuries, providing treatment and services to heal pressure ulcers/injuries, and decreasing the potential for infection and cross-contamination during wound care. The resident’s care profile contained an order dated 1/20/26 for EBP related to wounds. Despite this, on 3/31/26 at 12:40 PM, observation showed that an RN performed wound care on the resident’s open pressure sore on the right ankle and heel and a pressure area on the left ankle without donning a gown, contrary to EBP requirements and facility policy. Interviews further clarified the circumstances leading to the deficiency. The DON stated she expected nurses to provide all wound care according to current infection control standards and confirmed that the facility had an ample supply of PPE and expected staff to use appropriate PPE for residents on EBP. The Staff Development Coordinator reported that she provided monthly and as-needed in-service training, including orientation training with hand hygiene and PPE competency checkoffs, and that the RN involved had completed a wound care competency checkoff on 3/31/26. The RN acknowledged that the resident had pressure ulcers on both outer ankles, that EBP were in place for direct contact care, that signage on the resident’s door listed and depicted required PPE and interactions requiring PPE, and that she did not wear a gown during the wound care. Record review showed the resident was admitted on 8/05/25 with diagnoses including aphasia, dysphagia, cerebral infarction, and multiple unstageable pressure ulcers of both heels and the right ankle, and a Significant Change MDS dated 1/16/26 documented four pressure ulcers and a BIMS score of 9, indicating moderate cognitive impairment.
Failure to Honor Resident’s Right to Receive Chosen Visitors
Penalty
Summary
Surveyors identified a failure to honor a resident’s right to receive visitors of her choosing. The facility’s Resident Rights policy, revised 11/14/25, states that residents have the right to a dignified existence, self-determination, communication, and access to persons and services inside and outside the facility, including the right to receive visitors of their choosing at times of their choosing, subject only to the resident’s right to deny visitation and not infringing on other residents’ rights. Resident #1, admitted on 11/2/22 with diagnoses including Major Depressive Disorder, had a BIMS score of 15 on the 12/31/25 MDS, indicating she was cognitively intact. She reported that on the afternoon of 1/11/26 she was aware that her friend had been turned away by staff and was not allowed to visit her. In a telephone interview, the complainant, identified as Resident #1’s friend who had been visiting her several times each week without prior concern, stated that one afternoon in January 2026, between lunch and dinner, staff told him to leave the facility and refused to allow him to stay or to notify the resident that he was there. Resident #1 expressed that she hoped to see her friend again and stated that they had not done anything wrong and that they were both adults. The Interim DON confirmed that she was aware residents have the right to visitors of their choice and acknowledged that she was the one who asked the friend to leave the premises and that staff did not notify Resident #1 that she had a visitor. The Administrator reported he was not aware of this situation but affirmed that residents have the right to receive visitors of their choosing and that, if safety concerns exist, interventions such as supervision or designated visit locations could be used; however, no such measures were implemented in this case, and the visit was instead prohibited without informing the resident.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Ensure Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight hours a day, seven days a week, as required by regulations. Record review showed that for eight out of nineteen days reviewed, there was no documented RN coverage for a full 24-hour period. Interviews with staff revealed confusion regarding staffing requirements, with the DON being counted as both the RN and Charge Nurse, and an LPN being included on the staffing grid. The DON was the only RN present Monday through Friday, and another RN only occasionally served as Charge Nurse. The Nurse Consultant was unaware that the DON was being counted as Charge Nurse and believed that the DON and Staff Development Nurse could be counted toward RN coverage, regardless of the facility's census, which was confirmed to be over sixty during the days in question. The Interim Administrator, who had recently started at the facility, stated that he expected compliance with federal staffing regulations and the facility's own staffing assessment. Facility documentation indicated that staffing was based on census, acuity, and resident needs, with the facility assessment listing one RN DON among other nursing staff. However, the actual staffing practices did not ensure the required RN coverage, leading to the deficiency.
Failure to Provide Accessible Call Light for Resident with Quadriplegia
Penalty
Summary
The facility failed to ensure a resident's right to dignity and communication by not providing an accessible call light for a resident with functional quadriplegia. Multiple observations over several days showed the resident in bed without a call light within reach, and the available call lights (push button and touch button types) were not usable by the resident due to his paralysis. The resident repeatedly reported to staff that he could not use the provided call lights and experienced long wait times for assistance. Staff interviews confirmed that the call light was often found on the floor or out of reach, and that staff were unaware of alternative call light options suitable for the resident's needs. The resident was admitted with a diagnosis of functional quadriplegia and was alert and oriented, with documented contractures and paralysis. Despite this, staff did not assess or provide a call light system that accommodated his physical limitations. The resident stated he had previously used a blow-call light at other facilities, but this was not made available. Key staff, including CNAs, LPNs, and social services, were either unaware of the resident's inability to use the standard call lights or had not taken steps to address the issue, resulting in the resident being dependent on staff checks and occasional assistance from his roommate.
Failure to Provide Necessary ADL Assistance and Personal Hygiene
Penalty
Summary
A resident with diagnoses of muscle weakness, reduced mobility, and lack of coordination, who was assessed as requiring total assistance for bathing and showering, did not receive necessary services to maintain good grooming and personal and oral care. Observations over several days revealed the resident remained in bed with visible chin hair and reported not receiving regular bed baths or showers as previously provided. The resident expressed a desire to have her chin hair shaved and noted that no staff had asked about bathing or showering during the week. A strong and then faint odor of urine was noted in the resident's room on multiple occasions. Review of the resident's care plan indicated a need for substantial to maximal assistance with activities of daily living (ADLs), but there was no documentation of refusals of care. The facility's policy required encouragement of resident participation in ADLs and provision of assistance as necessary, but interviews and observations confirmed that the resident did not receive adequate support for personal hygiene and grooming during the period reviewed. The Corporate Nurse acknowledged awareness of these care concerns.
Insufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple days with inadequate CNA coverage for a census of 67 to 69 residents. Staffing schedules and grids revealed that on several occasions, only two or three CNAs were assigned per shift, resulting in high resident-to-staff ratios. Interviews with CNAs and LPNs confirmed that low staffing levels led to delays in providing essential care, such as changing, repositioning, and bathing residents. Staff reported working extra hours and shifts, with some staff members covering both day and night shifts due to shortages. One resident, who was cognitively intact and dependent on staff for bathing and showers, was observed lying in bed with visible chin hair and a strong odor of urine in the room. The resident stated she had not received a shower since the previous Thursday and used to receive bed baths three times per week. Multiple CNAs reported that when staffing was low, residents often had to wait longer than two hours to be changed or repositioned, and scheduled showers were sometimes missed due to the lack of a designated shower aide. Interviews with staff further revealed that the facility's staffing plan was not consistently followed, with frequent call-ins and reliance on staff from other roles, such as medical records, to cover nursing duties. The DON and staff developer were responsible for creating the nurse and CNA schedules, respectively, but ongoing shortages resulted in staff being called in for extra shifts and residents experiencing delays in care. Residents and staff both reported dissatisfaction with the timeliness and adequacy of care provided during periods of low staffing.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Natchez
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trend Health And Rehab Of Natchez, Llc | 0.2 mi | ★★★★★ | 1 | 0 |
| Natchez Rehabilitation And Healthcare Center | 1.1 mi | ★★★★★ | 4 | 1 |
| Camelot Leisure Living | 12.4 mi | ★★★★★ | 11 | 0 |
| Jefferson County Nursing Home | 22.3 mi | ★★★★★ | 0 | 0 |
| The Columns Rehabilitation And Healthcare Center | 27.3 mi | ★★★★★ | 1 | 0 |
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