I echo your thoughts! Perhaps one of the reasons this man's bed sores became so advanced is because there was inadequate staffing and / or high rates of turnover? While it is easy to point the finger at the staff who were on-the-job during this man's admission, most situations such as this-- represent a complete breakdown amongst staffing. In this respect, blame is rightfully place on the facility as a whole.

With respect to your second concern, is it really fair to expect nursing home surveyors to inspect every patient--- head to toe? Again, accountability should be placed on the facility as a whole.