South River Rehab: Wound Care Gaps Miss Ulcers - MD
A resident at South River Rehabilitation and Wellness Center developed two unstageable pressure ulcers on the buttocks, and the family learned about them not from nurses or doctors, but from the course of a complaint investigation. "No one updated us about his/her new wound," the family member told a surveyor on May 26.
The family also said the resident had no buttock wound during the most recent hospital stay. The wounds appeared on the facility's watch.
Federal inspectors cited South River on May 28, 2026, following a complaint survey that examined the wound care provided to one resident, identified in records only as Resident #1. What they found was a pattern of gaps: missing assessments, conflicting internal records, and a wound specialist who went weeks at a stretch without evaluating a resident whose skin had been breaking down since the day of admission.
Resident #1 arrived at South River with pressure ulcers already documented on the sacrum, coccyx, and groin. The nursing admission evaluation, dated January 8, noted all three wounds. Then, for the nine days that followed, the contracted wound care nurse practitioner, who visits the facility twice a week, left no record of ever assessing them. The resident was transferred to the hospital on January 17. There is nothing in the medical record to show the wounds were evaluated by a specialist in the interval between admission and that transfer.
After the resident was readmitted, the wound NP assessed the resident on January 27 and again on February 10. The first week of February has no wound care records at all.
By the time inspectors reviewed the chart on May 28, the wound NP had documented two new findings from a May 1 visit: a left buttock unstageable pressure ulcer measuring 4 by 4.5 centimeters, and a right buttock unstageable pressure ulcer measuring 1.5 by 2.5 centimeters. Unstageable wounds are among the most serious classifications, indicating tissue damage deep enough that the full extent cannot be determined without removing the dead material covering it.
The week before that May 1 assessment, there had been no specialized wound evaluation at all.
The facility's own internal skin assessments made the picture stranger. On April 29, staff recorded "no new skin area noted." On April 30, they noted "a non-pressure new area." On May 7, after the NP had already documented two unstageable ulcers, the internal record read "no new skin issue noted." The inspectors reviewed these entries alongside the wound NP's findings. The two sets of records do not reconcile.
The Director of Nursing, interviewed the afternoon of May 26, explained how the wound care system is structured. A contracted company sends a nurse practitioner to the facility twice a week: Thursdays for new admissions, Tuesdays for residents with existing wounds. The facility also has a dedicated internal wound care nurse.
With that staffing in place, the gaps are harder to explain, not easier.
The DON reviewed Resident #1's medical records alongside the surveyor. According to the inspection report, she validated the findings and acknowledged the lack of required wound assessments. She did not dispute what the record showed.
Resident #1 had been transferred to the hospital and readmitted multiple times across the months covered by the inspection. Each transition is a moment when wound documentation matters most, when skin that has been under pressure can deteriorate quickly, and when a new care team needs an accurate picture of what they are inheriting. The record shows those moments passed without the specialist assessments that should have accompanied them.
The family, who had been asking questions about wound care long before the surveyor arrived, said they were never told a new wound had developed. They found out the way families in these situations often do: too late, through a process that began with a complaint.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for South River Rehabilitation and Wellness Center from 2026-05-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
South River Rehabilitation and Wellness Center in EDGEWATER, MD was cited for violations during a health inspection on May 28, 2026.
"No one updated us about his/her new wound," the family member told a surveyor on May 26.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.