"There have been several days when the wound care treatment was not done," the resident told inspectors on January 27. "I am just wondering why the nurses don't change the wounds."
The resident explained his wounds "are stage 4 and they are super big and drain a lot, and they are supposed to be changed every day." He said he didn't call to remind nurses 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 eight separate days in January alone: January 5, 7, 11, 12, 19, 21, 22, and 25.
The resident has stage 4 pressure ulcers on his right hip, right ischium, and sacrum. Stage 4 ulcers are the most severe category, extending through skin and fat into muscle and potentially bone. The resident's medical record shows he has paraplegia and intact cognitive function, scoring 15 out of 15 on a mental status assessment.
His care plan, initiated December 12 and revised December 15, specifically calls for "treatment per physician orders" to ensure his pressure ulcers "remain free of signs and symptoms of infection and wound will continue to heal without complications daily."
The facility's wound care coordinator, a licensed practical nurse, acknowledged the importance of following wound care orders exactly as prescribed. "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," she told inspectors.
She explained that staff nurses are responsible for completing wound care treatments when the dedicated wound care nurse isn't working. When wound care is administered, it's supposed to be documented in the patient's treatment administration record.
But those records show a pattern of missed treatments throughout January.
The facility has written guidelines acknowledging federal requirements for pressure ulcer care. The policy 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 resident's care plan also identifies him as being "at increased risk for impaired skin integrity related to wounds" and promises he "will not develop any skin integrity issues" unless "the disease process causes unavoidable deterioration."
Federal inspectors found no evidence that the missed treatments caused the wounds to decline or fail to heal. However, they determined the facility's failure to follow the prescribed treatment schedule "places the resident at risk for more than minimal harm."
The inspection was conducted January 30 following a complaint. Inspectors reviewed four residents with pressure ulcers out of a total sample of 17 residents and found this violation affected only the one resident who spoke up about missed treatments.
The resident's matter-of-fact description of waiting day after day for wound care that didn't come illustrates a basic breakdown in care coordination. Despite having cognitive abilities to understand his treatment needs and the severity of his condition, he was left to wonder why nurses weren't following his doctor's orders for daily dressing changes on wounds he described as "super big" and draining heavily.
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.