In San Rafael and throughout Marin County, families frequently describe similar patterns when they call for help:
- A resident who seemed stable—then redness appeared on the heels, sacrum, hips, or back of the legs.
- Wound care that started late or changed repeatedly without a clear plan.
- Care teams who documented risk but couldn’t show consistent follow-through (for example, skin checks, turning schedules, or offloading devices).
- Communication gaps—family concerns were raised, but updates were delayed or incomplete.
Pressure ulcers don’t occur by accident. They usually follow a chain of missed prevention steps: turning/offloading not done on schedule, incomplete skin assessments, delayed response to early redness, or failure to adjust care when a resident’s condition changes.


