Sallie Eula Spencer entered Paris Health in June 2001, following a brief hospitalization for pneumonia and suspected stroke. She also suffered from diabetes and a peptic ulcer. Because of understaffing, nurses and aides failed to provide Spencer with timely pressure relief and incontinence care to prevent the progression and promote the healing of a Stage I sore on her coccyx. Ms. Spencer was found on several occasions with dried feces in her coccyx bandage and lying in sheets stained by dried urine and fecal matter.