Pressure ulcers are most likely when a resident is left on the same surface too long, repositioning doesn’t happen as ordered, or skin checks and wound monitoring are inconsistent. In San Francisco, families frequently report additional stressors that can affect care quality:
- High resident turnover and frequent transfers between hospitals and skilled nursing facilities.
- Staffing pressures that may increase the chance that turning schedules or skin checks slip.
- Difficulty tracking care instructions when multiple providers are involved (hospital discharge guidance, facility protocols, and resident-specific care plans).
Even when a facility has policies on paper, the real issue is whether those policies were followed for your family member.


