Stage 4 Pressure Ulcers at Congregate Living Facility

This was a case against a Congregate Living Facility in southern California. Ellroy was a 26-year-old paraplegic who required extensive nursing services on a 24-hr basis. The facility was so understaffed that even with only 6 beds, Ellroy spent night after night begging to be repositioned and turned. He developed several Stage 4 pressure ulcers. Upon transfer to a different home, Ellroy’s wounds healed.