When a resident develops a bedsore, it often reflects breakdowns in day-to-day care—not a single bad moment. Common failure points we investigate include:
- Turning/repositioning not happening on schedule
- Skin checks not performed consistently or not documented when changes appear
- Hygiene and moisture control missed (especially for incontinence)
- Nutrition and hydration not adjusted when risk rises
- Wound care delayed after early redness or non-blanching discoloration
In California, facilities are expected to follow accepted standards of care and their own resident-specific care plans. If those steps were not carried out, that’s where liability may begin.


