Families in Hollister sometimes describe a similar pattern: things seemed fine, then suddenly the resident’s skin looked worse—sometimes over a weekend, during a staffing shortage, or after a transfer between units.
Pressure ulcers don’t appear out of nowhere. They typically develop when a resident is at risk (limited mobility, impaired sensation, incontinence, frailty, recent surgery) and the facility fails to:
- carry out the care plan’s turning/repositioning schedule
- perform and record skin checks at the intervals required by the resident’s risk level
- respond promptly when early warning signs appear
- maintain consistent wound care and escalation procedures
California care obligations require facilities to provide reasonable care under the circumstances. In real cases, the dispute usually isn’t “did the sore exist?”—it’s whether the facility acted in time and documented what it did.


