The resident told federal inspectors on January 27 that there had been "several days when the wound care treatment was not done." The resident explained: "I am just wondering why the nurses don't change the wounds."
"My wounds are stage 4 and they are super big and drain a lot, and they are supposed to be changed every day," the resident said. "I didn't call to remind the nurse on duty because they can come anytime of the day and I just kept waiting. I am on medications, and I may fall asleep and the day went by."
Federal inspectors found that Southpoint Nursing & Rehab Center failed to follow its own treatment plan for the resident's three pressure ulcers — located on the right hip, right buttock area, and lower back. The facility's treatment records showed no wound care was provided on January 5, 7, 11, 12, 19, 21, 22, and 25.
The resident has a cognitive score of 15 out of 15, indicating full mental capacity to understand the missed treatments.
V7, the facility's wound care coordinator, told inspectors that the resident's pressure injuries were documented in the comprehensive care plan. When no wound care nurse was working, staff nurses were responsible for completing the treatments.
"It is important for wound care orders to be followed as ordered to ensure that the wound heals, to follow how the wound is progressing, prevention of decline, no introduction of bacteria or anything to the wound," V7 said.
The resident's medical record shows diagnoses including paraplegia and stage 4 pressure ulcer of the right hip. Stage 4 pressure ulcers are the most severe category, involving full-thickness tissue loss that can expose bone, tendon, or muscle.
The facility's care plan, initiated December 12 and revised December 15, states the resident's pressure ulcers "will remain free of signs and symptoms of infection and wound will continue to heal without complications daily through next review." The plan calls for "treatment per physician orders."
A second care plan entry acknowledges the resident is "at increased risk for impaired skin integrity related to wounds" and commits that the resident "will not develop any skin integrity issues through next review, unless the disease process causes unavoidable deterioration."
The facility's own guidelines for pressure injury treatment state it will "ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing."
Despite these written commitments, the treatment administration record shows the systematic failure to provide daily wound care throughout January. The missed treatments occurred sporadically across the month, with gaps of one to two days between some missed treatments and longer stretches including four consecutive days without care from January 19 through January 22.
Federal inspectors noted that while there was no evidence of decline or failure to heal during the inspection period, the missed treatments placed the resident at risk for more than minimal harm.
The resident's account suggests a pattern of passive waiting rather than advocacy — waiting each day for care that didn't come, not wanting to burden staff with reminder calls, sometimes sleeping through the day on medication while wounds that "drain a lot" went unchanged.
The inspection, completed January 30, found this violation among a sample of 17 residents, with four residents specifically reviewed for pressure ulcer care. Only one resident experienced the systematic missed treatments, but that single case revealed a breakdown in the facility's wound care protocols for its most vulnerable patients.
The facility's wound care coordinator confirmed that proper documentation should occur whenever wound care is administered or completed, yet eight days of missing treatments in a single month suggested either widespread documentation failures or actual missed care — both serious violations of federal nursing home standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Southpoint Nursing & Rehab Center from 2026-01-30 including all violations, facility responses, and corrective action plans.