Our client, a 65-year-old man with dementia and quadriplegia, was admitted to a skilled nursing facility for rehabilitation following a fall and spinal surgery. Despite being entirely dependent on staff for care, he received inadequate monitoring, hygiene, nutrition, and wound prevention. Staff failed to perform skin assessments, follow wound care protocols, or inform the family of his condition. He was discharged home with a large, undiagnosed pressure ulcer, which rapidly worsened. He was later hospitalized, diagnosed with sepsis, and died shortly thereafter. This case settled confidentially for $725,000.00.