The resident, identified as R3 in inspection records, told investigators on January 27 that "there have been several days when the wound care treatment was not done." The patient has stage 4 pressure ulcers on the right hip, right ischium, and sacrum that "are super big and drain a lot, and they are supposed to be changed every day."
Treatment records show wound care was skipped on January 5, 7, 11, 12, 19, 21, 22, and 25 — more than a quarter of the days that month.
"I am just wondering why the nurses don't change the wounds," 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."
The resident scored 15 out of 15 on cognitive assessments, indicating full mental capacity to understand their medical needs.
V7, the facility's wound care coordinator and licensed practical nurse, acknowledged the treatment gaps during the inspection. She explained that staff nurses become responsible for wound care when dedicated wound care nurses aren't working, and that treatments must be documented in patient records when completed.
"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 told inspectors.
Stage 4 pressure ulcers represent the most severe category of bedsores, extending through skin and tissue down to underlying muscle and bone. The resident's care plan, initiated December 12 and revised December 15, specifically calls for "treatment per physician orders" to keep the wounds "free of signs and symptoms of infection" and ensure they "continue to heal without complications."
The facility's own guidelines emphasize evidence-based treatment protocols. An undated document titled "Guidelines for Prevention/Treatment of Pressure Injuries" states the facility will ensure residents with pressure ulcers receive "necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing."
Yet treatment administration records paint a different picture. Beyond the eight documented missed treatments in January, the pattern suggests systemic gaps in wound care delivery for residents dependent on nursing staff for basic medical needs.
The resident's medical history includes paraplegia and pressure ulcers of both specified and unspecified stages, conditions that require vigilant monitoring and consistent care to prevent deterioration. Pressure ulcers in paraplegic patients can lead to life-threatening complications including sepsis, osteomyelitis, and tissue death.
Federal inspectors classified the violation as causing minimal harm with potential for actual harm, noting no evidence of wound decline or failure to heal during the review period. However, the repeated treatment gaps place the resident at risk for infection, delayed healing, and wound progression.
The inspection, conducted as a complaint investigation on January 30, examined pressure ulcer care for four residents out of a total sample of 17. Only one resident experienced the documented treatment failures, though the facility's policies apply uniformly to all patients requiring wound care.
Southpoint Nursing & Rehab Center's wound care coordinator acknowledged that missed treatments could introduce bacteria and prevent proper wound monitoring. The resident continues waiting for consistent daily care while managing three severe wounds that drain heavily and require immediate attention to prevent life-threatening complications.
The facility has not yet submitted its plan of correction for the identified deficiencies.
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.