The study found that full-thickness pressure ulcers develop in long-term care patients even under the best of care. These ulcers occurred even when residents were cooperative with their care and with a high prevalence of comorbid dementia, depression, and other psychiatric conditions. Most of the subjects studied were not at high risk for the development of a pressure ulcer according to Braden risk scoring. Conclusions from this study, however, must be tempered by the small sample size, which was due to the strict and multiple layers of assurance that high-quality care was being provided and due to the low prevalence of the condition. Consequently, study results are more descriptive than quantitatively conclusive. Still, the researchers believe that the presence of a single full-thickness pressure ulcer cannot and should not be used by itself as a measure of poor care. The overall pattern of care is more important than a single physical finding. Because of the multifactorial nature of pressure ulcers, the quality of care is only one determinant of the development and healing of ulcers; however, this study does not address the occurrence of multiple full-thickness pressure ulcers. Residents with multiple ulcers have been known to be victims of neglect. The study involved 63 top-performing skilled nursing facilities in Los Angeles/Orange Counties, greater Seattle, and Denver regions. The individuals examined were 24 elderly residents who received confirmed excellent care and developed full-thickness ulcers that emerged while they were facility residents. Data collected consisted of resident demographics, diagnoses, and medications; and characteristics of pressure ulcers. 6 exhibits; 51 references; and appended decisionmaking capacity assessment tool, Bates-Jensen Wound Assessment Tool, scoring of the pressure sore status tool, informed consent form, and Braden Risk Assessment