The resident told federal inspectors there had been "several days when the wound care treatment was not done" and questioned "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 during the January 27 inspection. "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."
Treatment records show nurses skipped the resident's wound care on January 5, 7, 11, 12, 19, 21, 22, and 25.
The resident has three pressure ulcers on the right hip, right buttock area, and tailbone. Stage 4 pressure ulcers are the most severe category, extending through skin and fat into muscle and potentially reaching bone.
Federal inspectors found the facility's own policy acknowledges the importance of consistent wound care. The document states the facility 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."
The wound care coordinator, a licensed practical nurse identified as V7, told inspectors the resident's pressure injuries were documented in the comprehensive care plan. She said when wound care is completed, it should be recorded in the treatment administration record.
"Staff nurses are responsible for completing the wound care treatment orders when there is no wound care nurse working," V7 told inspectors.
She explained why consistent treatment matters: "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."
The resident's care plan, initiated December 12 and revised December 15, calls for "treatment per physician orders" for the pressure ulcers on the right hip area, right buttock, and tailbone.
The plan 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."
A separate section of the care plan acknowledges the resident is "at increased risk for impaired skin integrity related to wounds" and calls for administering "wound care treatments per MD orders."
The resident scored 15 out of 15 on a cognitive assessment, indicating intact mental capacity to understand and report on their care.
Federal inspectors noted the resident showed no evidence of decline or failure to heal despite the missed treatments, but concluded the lapses "place the resident at risk for more than minimal harm."
Stage 4 pressure ulcers develop when prolonged pressure cuts off blood flow to tissue. They typically occur in people who cannot change positions independently, such as those with paralysis. Without proper care, the wounds can become infected, potentially leading to sepsis or bone infection.
The facility's policy document acknowledges following "evidence-based recommendations for the prevention/treatment of pressure injuries" and compliance with federal regulations requiring necessary treatment to promote healing and prevent infection.
The inspection was conducted in response to a complaint. Federal records show this was the only resident among four reviewed for pressure ulcer care who experienced treatment lapses, though inspectors examined wound care practices across a sample of 17 residents total.
The resident's medical record lists diagnoses including paraplegia and pressure ulcers of the tailbone and right hip at stage 4 severity.
Inspectors classified the violation as causing minimal harm or potential for actual harm, noting no evidence the wounds worsened during the period when care was skipped.
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.