High-Risk Pressure Ulcer Quality Measure — Calculation and Facility Benchmarking

To understand the high-risk pressure ulcer quality measure, clinical risk must be considered separately from the rules that turn MDS coding into a public score. As CMS broadens the long-stay measure beyond high-risk residents, accurate documentation and current national benchmarking become inseparable. Together, they help nursing home operators see how to manage their risk and improve their standing on Care Compare.

What the pressure ulcer quality measures are and what they cover

CMS uses two distinct pressure ulcer measures that cover different populations and observation windows. The short-stay measure is “Percentage of SNF residents with pressure ulcers/pressure injuries that are new or worsened.” Its data collection period begins 10/01/2024 and runs through the following year, and it is also used in the SNF Quality Reporting Program. The long-stay measure is “Percentage of long-stay residents with pressure ulcers,” with an annual data collection period running through early 2026. Both measures are part of the Five-Star Quality Measure domain and appear on Care Compare.

The distinction is between change during a stay and prevalence at an assessment. The short-stay measure counts Stage 2–4 ulcers that are new or worsened between admission and discharge. The long-stay measure counts qualifying pressure ulcers present at the time of the qualifying assessment. The former therefore depends on a comparison across assessments, while the latter describes the resident’s status at a particular assessment. They are separate measures, with different documentation requirements, rather than interchangeable versions of one pressure ulcer rate.

The structural shift from "high-risk" to all residents in the long-stay measure

The prior long-stay measure used high-risk classification to decide which residents it would count. The relevant criteria included bed mobility limitation, comatose status, or malnutrition. A resident documented as not meeting those criteria could remain outside the numerator even when a pressure ulcer was present. Under N045.01, any long-stay resident with a qualifying pressure ulcer on a qualifying assessment can enter the numerator, regardless of risk tier. CMS has therefore retired a classification boundary.

That broader scope changes how facilities interpret their exposure. The change has the greatest effect on facilities that admitted many high-acuity residents and relied on risk classification to limit which residents the measure counted. Those facilities can no longer interpret an absence of high-risk classification as protection from numerator inclusion. The change reflects CMS’s position that skin integrity is a universal care expectation, rather than one confined to residents classified as high-risk.

How the numerator, denominator, and risk adjustment are constructed

The short-stay score is a rate built from eligible stays. Its numerator includes Type 1 SNF stays in the denominator whose discharge assessment indicates one or more new or worsened Stage 2–4 pressure ulcers compared with admission. When a resident has multiple stays in the 12-month target period, all stays are included. The unit of inclusion is therefore the stay, which makes the admission-to-discharge comparison central to calculation. For the long-stay measure, the relevant population is qualifying long-stay residents, with numerator inclusion based on qualifying ulcer prevalence at the assessment.

Risk adjustment then accounts for the population’s documented risk profile. CMS’s resident-level expected score estimates the likelihood that a resident meets QM criteria using covariates including mobility scores, prior pressure ulcer stage, malnutrition, and comorbidities. The facility-level score is adjusted for that specific population profile. Under-documenting acuity at admission can therefore remove risk-adjustment credit that would otherwise buffer the score if a wound worsens. Accurate admission coding has a direct quality and financial interest, rather than serving only as background clinical information.

CMS’s SNF QRP Manual V7.0 became effective October 1, 2025, and CMS released V8.0 on September 11, 2026 as the most current specification document. Within MDS Section M, M0300B–D capture Stage 2–4 pressure ulcer presence. However, CMS’s adaptation of NPUAP staging guidelines does not perfectly match every clinical staging definition, so MDS coding must translate clinical terminology according to RAI manual instructions. Imprecise translation can distort numerator and denominator construction. For example, a nurse without skin history may assess a reopened Stage 4 ulcer as Stage 2 and code it as not present on admission, inflating the short-stay numerator while understating severity and impairing care planning.

How the Five-Star system converts a raw QM score into a public rating

CMS groups facilities into quintiles on the national distribution for each measure and converts performance into points. The lowest-performing quintile earns the fewest points, the highest-performing earns the most, and the middle quintiles receive intermediate values. Both pressure ulcer measures contribute to the MDS-based measures in the Five-Star QM domain. Their effect on public standing therefore depends on the points they contribute to the pooled QM score.

The Five-Star Technical Users’ Guide for September 2026 states that, as of July 2026, an overall QM score of 1,494 to 2,300 points earns a 5-star QM rating. That domain rating also has a direct one-star lever on the overall composite. A 5-star QM domain adds one star, while a 1-star QM domain subtracts one. The guide’s September 2026 revision note also adds a trophy icon as a new part of the rating shown to the public. These developments make it important to distinguish the underlying pressure ulcer rate, its contribution to QM points, and the rating ultimately presented on Care Compare.

Why the July 2026 threshold reset means a stable score can still lose ground

Those rating thresholds are not fixed benchmarks. CMS raises them from time to time as national performance improves, so a facility whose performance stays the same can still lose its rating. The July 2026 refresh increased QM rating thresholds by one-half of the average improvement in QM scores measured from January 2025 through April 2026. CMS applied the QSO 19-08-NH methodology to make that adjustment. The mechanism is intended to prevent score inflation as the industry improves, rather than to judge facilities only against their own past performance.

A facility just above a quintile cutpoint can fall below a shifted boundary without any change in its pressure ulcer rate. That measure-level comparison and the reset of aggregate QM rating thresholds both make a trailing record insufficient for operational benchmarking. Facilities need a forward-looking view of their position in the current national distribution, particularly when their scores sit near a boundary. Facilities need to assess whether the rate improved enough to preserve its contribution to the rating.

How pressure ulcer citations feed the survey track and state-level deficiency reporting

Pressure ulcer findings also have consequences outside the QM domain. Beginning September 2026, a facility needs a five-star overall rating to meet one of several eligibility criteria for CMS’s risk-based survey approach. Those criteria include at least a three-star staffing rating, a health inspection score at or below the state 50th percentile, accurate data, no recent ownership changes, and no citations for actual harm or substandard quality of care in the last survey cycle. A pressure ulcer citation at actual harm, immediate jeopardy, or substandard quality of care level directly disqualifies a facility from the lighter-touch track. This is a separate regulatory consequence from the points assigned to a pressure ulcer QM.

CMS also added a 2025 composite measure that rates state survey agencies on items including deficiencies per bed and the percentage of surveys that identify J, K, or L scope and severity. Severe pressure ulcer findings thus help hold states accountable as well as affect a facility’s inspection results. Advocacy groups have raised concerns that the new survey track underweights high pressure ulcer rates as indicators of potential substandard care. That policy debate does not diminish the importance of the underlying findings.

The survey domain is the only Five-Star domain that is state-specific. Overall survey scores differ widely between states, and the same clinical scenario may lead to a harm-level pressure ulcer citation in one state but not another. For the survey domain, this makes comparisons between peer facilities in different states unreliable. National QM benchmarking and state-level survey benchmarking answer different questions. Treating them as one comparison obscures the distinct sources of regulatory exposure.

Why the resident population most likely to develop pressure ulcers is the same population hardest to exclude from the measure

The clinical drivers of pressure ulcers also explain why high-acuity populations create sustained QM exposure. Prolonged immobility reduces tissue perfusion, malnutrition impairs skin integrity, and residents who are comatose or have low mobility cannot self-reposition. These conditions drive wound development and inform the MDS covariates used in risk adjustment. Yet adjustment does not exclude a qualifying wound from the broader long-stay numerator. Prevention and documentation therefore deal with the same risk to the resident in both care and compliance.

Risk adjustment also has limits as a description of unusually high-acuity populations. Research on the Waterlow, Braden, and Norton scales has found that their predictive properties vary widely between studies. CMS’s covariate-based adjustment draws from these same instruments, making it an imperfect buffer for high-acuity outliers. Thorough admission documentation and continuous monitoring help protect the score when risk adjustment provides an imperfect buffer. Suboptimal mattresses or seating cushions compound resident-level risk and remain within facility control, making them a logical first operational target.

The Teays Valley Center / Genesis case in West Virginia illustrates the connection between the two measures. A quality study looked at whether a digital skin and wound management system could improve both long-stay high-risk prevalence and short-stay new-or-worsened performance. The study’s question tied one operational intervention to both QM categories. It supports treating wound management as a shared clinical process across the two reporting windows, without collapsing their different calculation rules.

What coding errors and documentation gaps do to QM scores in practice

Documentation failures make that shared process vulnerable in ways that are both measurable and auditable. MDS Section M errors can inflate a numerator, misrepresent wound severity, and leave care planning based on an incorrect baseline. A discrepancy is therefore not confined to the submitted measure. It can separate the coded record from the clinical information needed to understand the resident’s condition.

The Office of Inspector General’s 2025 audit found that one nursing and rehabilitation center failed Medicare documentation and coding requirements on nearly all sampled claims. The estimated overpayment was in the tens of millions of dollars. That finding establishes the financial scale of documentation and coding divergence, although it does not establish that pressure ulcer coding alone caused the overpayment. For pressure ulcer management, the relevant issue is whether the structured assessment faithfully captures the clinical record. Research using bigram analysis of clinical notes provides a bridge to addressing that issue by identifying language patterns corresponding to known pressure ulcer risk factors.

How continuous monitoring of existing clinical documentation closes the gap between what nurses document and what MDS coding captures

Bigram analysis shows that the language used in routine clinical notes has patterns linked to pressure ulcer risk. The operational gap is therefore one of extracting information from existing notes. Continuous analysis of existing notes against QM criteria can identify staging inconsistencies, documentation gaps, and developing skin integrity concerns in those notes before an assessment, survey, or audit identifies them.

Machine learning research using electronic health records has also shown that it may be possible to better predict pressure ulcer risk while reducing nursing workload. A dynamic daily risk model that is explainable and robust enough for clinical implementation remains an active research goal. That distinction matters because identifying useful signals is not the same as establishing a fully implemented clinical prediction system. The research supports using this information sooner, while it would otherwise remain unstructured. It gives clinical and MDS teams a clearer view of the same resident record.

The same monitoring layer can support acuity documentation at admission and later scrutiny of wound coding. It connects the information that shapes risk adjustment upstream with the records needed to defend the QM score downstream. The resulting clarity rests on a precise alignment between what nurses document, what MDS coding captures, and what the measure counts.