Pressure ulcers don’t typically appear out of nowhere. They usually develop when a resident’s risk level isn’t matched with consistent prevention—especially when residents require more hands-on assistance.
Common patterns we investigate include:
- Turning and repositioning gaps during shift changes or busy staffing periods
- Inconsistent skin checks (for example, assessments not happening at the frequency required by the care plan)
- Delays in wound response, such as waiting to escalate treatment after redness or non-blanchable areas are noticed
- Mobility and nutrition shortfalls, including reduced intake or difficulty coordinating care between nursing staff and clinicians
In many cases, family members first notice the issue when they arrive for a visit and see something that wasn’t there the day before—or when discharge paperwork suddenly reflects a wound that never seemed to be addressed.


