The resident, identified as R3 in the inspection report, told investigators on January 27 that wound care treatments had been skipped on several days. "I am just wondering why the nurses don't change the wounds," the resident said. "My wounds are stage 4 and they are super big and drain a lot, and they are supposed to be changed every day."
R3 has three pressure ulcers — on the right ischium, right trochanter and sacrum — that require daily treatment under physician orders. The resident's treatment administration record shows wound care was not provided on January 5, 7, 11, 12, 19, 21, 22 and 25.
"I didn't call to remind the nurse on duty because they can come anytime of the day and I just kept waiting," R3 told inspectors. "I am on medications, and I may fall asleep and the day went by."
The facility's wound care coordinator, identified as V7, acknowledged that staff nurses are responsible for completing wound care treatments when no wound care nurse is working. The coordinator emphasized that following wound care orders is "important 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."
R3's care plan, initiated December 12 and revised December 15, specifically calls for "treatment per physician orders" for the pressure ulcers. The plan states the goal is for the wounds to "remain free of signs and symptoms of infection and wound will continue to heal without complications daily."
Stage 4 pressure ulcers represent the most severe form of these wounds, extending through skin and tissue to expose muscle, tendon or bone. They typically develop in residents who cannot reposition themselves, like those with paraplegia.
The resident scored 15 out of 15 on a cognitive assessment, indicating intact mental capacity to understand and report on their care needs.
Despite the missed treatments, inspectors noted there was "no evidence of decline or failure to heal" in the resident's condition. However, they determined the facility's failure to follow the treatment plan "places the resident at risk for more than minimal harm."
Southpoint's own policy guidelines acknowledge federal regulations requiring that 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."
The facility operates at 1010 West 95th Street in Chicago. The inspection was completed January 30 following a complaint. Inspectors reviewed four residents with pressure ulcers from a total sample of 17 residents and found the treatment failures affected only R3.
The missed treatments occurred despite R3's care plan specifically documenting increased risk for impaired skin integrity and stating the resident "will not develop any skin integrity issues through next review, unless the disease process causes unavoidable deterioration."
R3 continues to wait each day, never knowing if the wound care will come.
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.