Bed Sores in Nursing Homes: Stages, Treatment, Kennedy Ulcers and When It Is Neglect
Published by Beverly Law
CDPH and CMS records · English y Español
A bed sore (pressure ulcer, pressure injury or decubitus ulcer) is damage to the skin and tissue from pressure, usually over the tailbone, hips or heels. Nurses grade it from stage 1 (red, unbroken skin) to stage 4 (muscle or bone exposed). Federal law says a nursing home resident should not develop one unless their condition made it unavoidable. In Los Angeles County, inspectors cited 31 facilities for 37 harm-level bed sore deficiencies from 2023 through October 30, 2026, and Cal Health Find lists 1,415 pressure sore complaints, 510 substantiated.
A bed sore is damage to the skin and the tissue under it caused by pressure, usually over a bony area. Doctors and nurses also call it a pressure sore, a pressure ulcer, a decubitus ulcer or, since the National Pressure Ulcer Advisory Panel (now the National Pressure Injury Advisory Panel, NPIAP) updated its terms in 2016, a pressure injury. They are the same thing.
Bed sores form when a person cannot shift their own weight, so the same spot carries pressure for too long and blood stops reaching the tissue. Friction (skin rubbing on bedding) and shear (skin pulled one way while the body slides the other, as when a resident slides down in bed) make it worse, and so do moisture from incontinence, poor nutrition and dehydration. The most common spots are the tailbone (sacrum and coccyx), the buttocks, hips and heels, and also the elbows, shoulder blades and the back of the head.
Nurses grade a bed sore by how deep the damage goes, using the NPIAP staging system (NPIAP staging poster):
Stage
What it looks like
Stage 1
Skin is intact but red, and the redness does not fade (blanch) when pressed. On darker skin it can look different. Purple or maroon skin is not stage 1; it may be a deep tissue injury.
Stage 2
Partial-thickness skin loss: a shallow open wound with a pink or red moist base, or an intact or broken blister filled with clear fluid. Fat is not visible.
Stage 3
Full-thickness skin loss: fat is visible in the wound, and there may be tunneling under the edges. Muscle, tendon and bone are not exposed.
Stage 4
Full-thickness skin and tissue loss: muscle, tendon, ligament, cartilage or bone is exposed or can be felt in the wound.
Unstageable
The base is covered by dead tissue (yellow or tan slough, or black eschar), so the depth cannot be seen. Once cleaned it turns out to be stage 3 or 4.
Deep tissue pressure injury
A persistent deep red, maroon or purple area, or a blood-filled blister, over intact or broken skin. The damage started deep, near the bone, and it can open into a stage 3 or 4 wound, or it may heal without opening.
A resident who lies on their back most of the day puts constant pressure on the sacrum and tailbone, which is why that is where most bed sores show up. A resident who sits in a wheelchair for hours loads the sit bones of the buttocks. Heels carry much of the weight of the legs in bed. A wound in any of these places on a resident who cannot move alone can be a sign the turning and offloading plan is not being followed, or is not enough.
Treatment starts with taking the pressure off: turning and repositioning on the schedule in the care plan (often every two hours), a pressure-redistributing mattress or cushion, and keeping the heels off the bed. The wound needs regular cleaning and dressing by a wound care nurse or physician, removal of dead tissue when present, and close watch for infection. Protein, calories and fluids matter, because a malnourished resident heals slowly. Some stage 4 wounds need surgery.
Ask for the stage in writing, the wound measurements, who is treating it, and the turning schedule. Measurements should be taken and charted regularly; a wound that keeps getting bigger is not responding to the plan.
Federal law sets the standard for every nursing home that takes Medicare or Medi-Cal: a resident must receive care to prevent pressure ulcers and must not develop one “unless the individual’s clinical condition demonstrates that they were unavoidable,” and a resident who has one must get the treatment and services needed to promote healing, prevent infection and prevent new ones (42 CFR 483.25(b)(1), inspected as federal tag F686).
In the inspection summaries on our facility pages that involve pressure ulcers, the patterns that come up most often are: turning or repositioning not done as the care plan required; a care plan that was not followed or not updated; the doctor or family not told about a new or worsening wound; wounds that reached stage 3, stage 4 or unstageable; and wounds that ended in infection or a hospital transfer. Untreated deep wounds can lead to bone infection and sepsis, which can be life-threatening.
A Kennedy terminal ulcer is a skin wound some patients develop near the end of life. It is named for Karen Lou Kennedy, who first noticed it with other staff at a Fort Wayne, Indiana, care facility in 1983 and published her findings in 1989 (Wound Management & Prevention). It typically appears suddenly, often within hours, usually on the sacrum or tailbone, and is often pear- or butterfly-shaped and red, yellow or black. It is generally seen in the final weeks of life and is considered unavoidable (WebMD).
If staff tell you a wound is a Kennedy ulcer, ask: Was the resident actively dying when it appeared? When was the skin last documented as intact? Did it appear within hours, or did it develop over days through earlier stages? Is there a turning record for the days before? A wound that developed slowly, or on a resident who was not near the end of life, does not fit the description.
We read the inspection record and the chart with you and tell you plainly whether there is a case. You pay no fees and no costs unless we win.
Talk to a Los Angeles nursing home abuse lawyer
Beverly Law represents residents and families in claims against nursing homes for abuse, neglect, bed sores, falls and fractures, sexual abuse, dehydration and malnutrition, medication errors and wrongful death. We start with the same public record shown on these pages, then request the resident’s chart and staffing records.
California’s Elder Abuse and Dependent Adult Civil Protection Act allows added remedies, including attorney fees, when neglect or abuse is proven to be reckless, oppressive, fraudulent or malicious (Welfare and Institutions Code section 15657). Filing deadlines can be as short as one year depending on the claim, so talk to a lawyer early. The consultation is free, in English or Spanish, and you owe no fees and no costs unless we win. Call (310) 552-6959.
Damage can begin within hours of unrelieved pressure in a frail resident, which is why turning schedules matter. Pressure injuries can develop over hours or days; a wound that appears suddenly, within hours, in a resident near the end of life may be a Kennedy ulcer.
Can a stage 4 bed sore heal?
Some do, but it often takes months of pressure relief, wound care, nutrition and sometimes surgery, and some never close. A stage 4 wound can also lead to bone infection or sepsis.
Are bed sores always a sign of nursing home neglect?
No, but most are preventable. Federal rules treat a new pressure ulcer as a failure unless the facility can show the resident’s condition made it unavoidable. Stage 3 and 4 wounds that develop in a facility deserve a close look at the turning and wound care records.
What does a bed sore lawyer do?
We get the chart, the turning and repositioning logs, staffing records and the facility’s own inspection history, have a wound care expert review them, and pursue the facility for the harm. You pay no fees and no costs unless we win.
How much does a nursing home abuse lawyer cost?
Beverly Law takes nursing home cases on contingency: the consultation is free and you owe no attorney fees and no costs unless we recover money for you.
Ask a question
Not ready to call? Write your question and someone on our team will answer. No cost, no commitment.
Important: This page reports findings from public records of the California Department of Public Health and the Centers for Medicare & Medicaid Services. A citation or deficiency is a regulatory finding by a government agency; it is not a court judgment and not proof of civil or criminal liability. Criminal defendants are presumed innocent unless proven guilty. Lawsuit allegations are claims, not findings. This page is general information, not legal advice, and reading it does not create an attorney-client relationship with Beverly Law. Attorney advertising. Prior results do not guarantee a similar outcome. Data as of: October 30, 2026.Methodology and corrections.
