Natchez, MS

Grand Trace Health And Rehabilitation

1-star overall rating with 1-star inspections with $48,153 in total fines with 18 recent health deficiencies

555 John R. Junkin Drive, Natchez, MS

(601) 442-4396

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Consulate Health Care/Independence Living Centers/Nspire Healthcare/Raydiant Health Care

Operator or chain grouping

Approved since

1994-03-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

36 facilities

Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.26

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.05

Licensed practical nurse staffing · state 1.10 · national 0.87

Aide hours / resident day

1.89

Nurse aide staffing · state 2.48 · national 2.35

Total nurse hours

3.20

All reported nurse hours · state 4.21 · national 3.89

Licensed hours

1.31

RN + LPN hours · state 1.73 · national 1.54

Weekend hours

3.06

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.19

Weekend registered nurse coverage · state 0.37 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

0.34

CMS adjusted RN staffing hours

Adjusted total hours

4.21

CMS adjusted total nurse staffing hours

Case-mix index

1.04

Higher values indicate more complex resident acuity

RN turnover

83%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

68%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,165

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

24.60

Composite VBP score used to determine payment impact.

Payment multiplier

0.9835

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Baseline 5.55% · Performance 8.77% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

4.61

Baseline 43.48% · Performance 44.83% · Measure score 4.61 · Achievement 4.61 · Improvement 0

Adjusted total nurse staffing

2.77

Baseline 3.21 hours · Performance 3.86 hours · Measure score 2.77 · Achievement 2.77 · Improvement 2.06

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.56%	10.72% 0.2 pts better	No Different than the National Rate · Eligible stays 48 · Observed rate 8.33% · Lower 95% interval 6.91%
Discharge to community	36.63%	50.57% 13.9 pts worse	No Different than the National Rate · Eligible stays 26 · Observed rate 15.38% · Lower 95% interval 21.54%
Medicare spending per beneficiary	1.15	1.02 0.1 pts worse
Drug regimen review with follow-up	97.62%	95.27% 2.4 pts better	Numerator 41 · Denominator 42
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 42
Discharge self-care score	56.67%	53.69% 3 pts better	Numerator 17 · Denominator 30
Discharge mobility score	43.33%	50.94% 7.6 pts worse	Numerator 13 · Denominator 30
Pressure ulcers or injuries, new or worsened	2.38%	2.29% 0.1 pts worse	Numerator 1 · Denominator 42 · Adjusted rate 2.97%
Healthcare-associated infections requiring hospitalization	8.76%	7.12% 1.6 pts worse	No Different than the National Rate · Eligible stays 25 · Observed rate 16% · Lower 95% interval 4.62%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 61
Staff flu vaccination coverage	24.59%	42% 17.4 pts worse	Numerator 15 · Denominator 61
Discharge function score	70%	56.45% 13.5 pts better	Numerator 21 · Denominator 30
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.7	2.4 0.7 pts better	1.9 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.0 · Expected 2.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.3	2.9 0.6 pts better	1.8 0.5 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.6 · Expected 1.9 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	95.1%	95.7% 0.6 pts worse	93.4% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 88.7% · Q2 93.7% · Q3 98.5% · Q4 100.0% · 4Q avg 95.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	97.1%	97.0% 0.1 pts better	95.5% 1.6 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1%
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	3.2% 3.2 pts better	3.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.0%	1.6% 0.6 pts better	11.4% 10.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.1% · 4Q avg 1.0%
Percentage of long-stay residents who lose too much weight	8.2%	6.1% 2.1 pts worse	5.4% 2.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 13.8% · Q3 5.5% · Q4 0.0% · 4Q avg 8.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	28.8%	24.4% 4.4 pts worse	19.6% 9.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 28.3% · Q3 27.9% · Q4 30.2% · 4Q avg 28.8%
Percentage of long-stay residents who received an antipsychotic medication	33.5%	23.4% 10.1 pts worse	16.7% 16.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 32.5% · Q2 35.6% · Q3 31.8% · Q4 34.2% · 4Q avg 33.5% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	15.3%	22.8% 7.5 pts better	16.3% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 7.2% · Q3 29.7% · Q4 4.1% · 4Q avg 15.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	18.6%	20.6% 2 pts better	14.9% 3.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 15.1% · Q3 31.6% · Q4 13.7% · 4Q avg 18.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.8%	1.5% 0.7 pts better	1.0% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.4% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	2.5% 2.5 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	26.2%	21.4% 4.8 pts worse	19.8% 6.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 27.0% · Q3 23.9% · Q4 39.3% · 4Q avg 26.2%
Percentage of long-stay residents with pressure ulcers	8.0%	6.9% 1.1 pts worse	5.1% 2.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 4.8% · Q3 11.9% · Q4 5.5% · 4Q avg 8.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	91.0%	87.9% 3.1 pts better	81.7% 9.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 86.1% · Q2 89.3% · Q4 96.9% · 4Q avg 91.0%
Percentage of short-stay residents who had an outpatient emergency department visit	14.1%	15.3% 1.2 pts better	12.0% 2.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 14.1% · Observed 17.2% · Expected 13.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	7.1%	2.6% 4.5 pts worse	1.6% 5.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 9.5% · 4Q avg 7.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	92.3%	84.6% 7.7 pts better	79.7% 12.6 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 92.3%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.9%	27.9% 3 pts better	23.9% 1 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 20.7% · Expected 19.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-27 · Fire 2025-03-27

18 health deficiencies

Top issue: Resident Assessment and Care Planning (7 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-03-07 · Fire 2024-03-07

10 health deficiencies

Top issue: Resident Rights (5 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2022-01-20 · Fire 2022-01-20

7 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2022-01-20

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2022-02-11

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-08-27

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-10-07

G · Actual harm 2025-03-27

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-04-24

G · Actual harm 2025-03-27

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-04-24

G · Actual harm 2025-03-27

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2025-04-24

F · Potential for more than minimal harm 2025-03-27

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2025-04-24

E · Potential for more than minimal harm 2025-03-27

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-04-24

E · Potential for more than minimal harm 2025-03-27

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-04-24

E · Potential for more than minimal harm 2025-03-27

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-04-24

E · Potential for more than minimal harm 2025-03-27