Bed sores in nursing homes: stages and what to do

The sacrum, the heels and the hips carry most of a bedbound resident's weight, and skin over those bones can begin to die within two to six hours of unrelieved pressure. That is the uncomfortable arithmetic behind bed sores. Families usually find the first one by accident, during a July visit when a sheet slips or a resident shifts in a chair, and the redness over a hip does not fade when pressed. By then the question is no longer whether the facility noticed, but what it recorded and when. Bed sores, known clinically as pressure injuries or pressure ulcers, are one of the few quality problems in long-term care with a clear regulatory standard attached, a clear staging system, and a clear prevention protocol that costs almost nothing to follow. This guide explains the stages, the summer risk factors, the federal rules a facility must meet, and the practical steps that turn a family observation into a documented care change.

What a bed sore actually is, and why bony areas fail first

A pressure injury is localized damage to skin and the soft tissue underneath, almost always over a bony prominence. Pressure squeezes the small blood vessels that feed the tissue, oxygen stops arriving, and cells begin to die. Shear makes it worse: when the head of a bed is raised above 30 degrees, the skeleton slides down while the skin stays gripped to the sheet, tearing tissue at deeper layers before the surface shows anything. The most common sites in nursing homes are the sacrum and tailbone, the heels, the greater trochanter at the hip, the elbows, the shoulder blades and the back of the head. Heels are the site families miss most often because they sit inside socks and under blankets. MedlinePlus explains the basic biology of pressure sores in plain language, and the clinical detail is summarized in the StatPearls review of pressure injury. The important point for families is that the visible wound is usually smaller than the damage beneath it.

The four stages, plus the two categories that are not numbered

Staging describes depth of tissue loss, and it is the language every clinician and surveyor uses. It is not a severity scale in the way families expect, and it does not run in a straight line. A wound is staged at its deepest point at the time it is assessed, and once a stage 3 wound begins to heal it is described as a healing stage 3, never downgraded to a stage 2. Getting the vocabulary right matters because it changes what you can ask for. A stage 1 area justifies an immediate offloading change. A stage 3 or 4 wound justifies a wound care specialist referral, a nutrition review and, in most facilities, notification of the physician and the family within hours.

How each stage is described in a chart

Stage 1 is intact skin with a persistent red or purple area that does not blanch when you press it. Stage 2 is partial-thickness loss, an open shallow wound or an intact fluid-filled blister, with a pink or red base and no visible fat. Stage 3 is full-thickness loss where fat is visible, the wound may have undermined edges, and healing takes months. Stage 4 exposes muscle, tendon, cartilage or bone, and carries a high risk of osteomyelitis and sepsis. Two categories sit outside the numbers. An unstageable injury is covered by dead tissue, so depth cannot be judged until the slough or eschar is removed. A deep tissue pressure injury shows as a maroon or purple intact area or a blood-filled blister and often signals damage that will open later. Documented staging matters because a facility must record the stage at discovery, and any stage that develops after admission is scrutinized as potentially avoidable.

Why late July and August quietly raise the risk

Summer conditions attack skin integrity from several directions at once. Heat increases sweating, and moisture trapped between skin and a mattress or brief causes maceration, which lowers the pressure and time needed to break skin. Fluid intake often drops in residents with dementia who no longer feel thirst, and dehydration reduces tissue perfusion and skin turgor. Appetite falls in hot weather, and protein intake falls with it, removing the raw material for repair. Staffing is thinner across July and August because of vacation cover and agency turnover, so repositioning rounds slip. Facilities that ran a cooling plan during the heat events described in our post on nursing home summer heat safety usually also tighten skin checks, but many do not connect the two. Ask specifically whether skin inspection frequency was increased during heat advisories. The answer tells you a great deal about how the facility thinks about risk.

What federal rules require, and what CMS Tag F686 means

Under 42 CFR 483.25, a resident who enters a facility without pressure ulcers must not develop them unless the individual's clinical condition made them unavoidable, and a resident who has one must receive necessary treatment and services to promote healing, prevent infection and prevent new ulcers from forming. Surveyors cite this as Tag F686. The word that carries all the weight is avoidable. To defend an injury as unavoidable, the facility must show it evaluated the resident's risk, defined and implemented interventions consistent with the resident's needs and recognized standards of practice, monitored and evaluated the impact of those interventions, and revised them as needed. The full surveyor guidance appears in Appendix PP of the CMS State Operations Manual, and the underlying regulation text is in the eCFR version of 42 CFR part 483. Those four requirements are the checklist a family should hold the care plan against.

The prevention protocol that should already be running

Effective prevention is unglamorous and well established. Risk is scored on admission and after any change of condition, usually with the Braden Scale, which rates sensory perception, moisture, activity, mobility, nutrition and friction. A lower score means higher risk, and the score is supposed to drive the plan rather than sit in a file. Every intervention below should already appear in the care plan of any resident who is bedbound, uses a wheelchair for most of the day, has diabetes or vascular disease, is incontinent, or has lost weight recently. If a family member fits that description and the care plan lists none of them by name, that gap is the conversation to have.

The interventions worth asking about by name

Repositioning on a set schedule, commonly every two hours in bed and every hour in a chair, adjusted to the resident's tolerance and skin response. A pressure-redistributing support surface, meaning a high-specification foam or alternating air mattress rather than a standard institutional mattress. Heel offloading, which usually means a pillow lengthwise under the calves so the heels float clear of the bed entirely. Moisture management, including prompt continence care, breathable briefs and barrier cream on at-risk skin. Nutrition and hydration support, with protein and calorie targets set by a dietitian and reviewed when weight drops. Daily skin inspection at bathing or care time, with findings recorded, not just observed. The AHRQ long-term care patient safety resources collect the tested versions of these protocols, and the National Institute on Aging guidance on skin care and aging explains why older skin tears and heals differently.

How to inspect skin yourself during a visit, without overstepping

You do not need clinical training to be useful here. Ask the nurse whether now is a good time to help with repositioning, then look while the resident is being turned. Check the tailbone, both heels, both hips, the elbows and behind the ears where oxygen tubing sits. Press gently on any red area for three seconds and watch whether the colour returns. Redness that stays is a stage 1 injury and should already be on the chart. Feel for warmth, a boggy soft texture or an area that is firmer than the skin around it, because those are early deep tissue signs. Note any smell, drainage on linen or a dressing with an old date written on it. If you find something, do not clean it, uncover a dressing or apply anything yourself. Photograph it with the date visible if the resident or representative consents, tell the charge nurse in the moment, and follow up the same day in writing.

What to do in the first 72 hours after you find a sore

Speed and paper are what change outcomes. On day one, report the finding verbally to the charge nurse and send a short email to the director of nursing that states what you saw, where, and when. Ask for three things in that email: the wound assessment including stage, measurements and photograph; the repositioning and skin inspection records for the past 14 days; and confirmation that the physician has been notified. Under resident rights rules the record must be available to examine within 24 hours, and copies within two working days, as covered in our guide to nursing home resident rights. On day two, request a care plan meeting and ask whether a wound care specialist or nutrition review has been ordered. On day three, if the wound is stage 3 or higher, was not previously documented, or the records show gaps in repositioning, contact the state long-term care ombudsman. Our walkthrough on filing an ombudsman complaint that gets action explains what to expect from that call.

Reading the data before you choose a facility

Pressure ulcers are a reported quality measure, which means you can screen for them before admission rather than discover the problem later. Medicare publishes the percentage of high-risk long-stay residents with pressure ulcers, alongside staffing hours and inspection results, on Medicare.gov Care Compare. Read that number next to registered nurse hours per resident day, because repositioning fails first where staffing is thin. Then read the most recent inspection report and search it for F686, F684 and F695. A facility with a clean pressure ulcer measure and no skin-related citations across two survey cycles is telling you something real about its routines. On this site you can compare star ratings, staffing and inspection history for homes in your area, then shortlist two or three for a tour using our nursing home tour checklist. Ask the administrator directly what the facility's current pressure injury rate is and how many of those were acquired in house. A confident answer with a number attached is a good sign. A vague answer is also an answer.

When a bed sore becomes a neglect issue

Not every pressure injury is neglect. Residents at the end of life, residents with severe vascular disease and residents who consistently refuse repositioning can develop wounds despite good care, and the record should show that pattern clearly. Neglect looks different. It looks like a stage 3 wound that appears in the chart for the first time on the day the family asks about it. It looks like repositioning records with identical entries every two hours across three shifts, including at times when the resident was known to be at dialysis. It looks like a dressing dated a week earlier, or weight loss of ten pounds with no dietitian note. When the pattern points that way, treat it as the wider neglect problem it usually is and read the indicators in our guide to warning signs of nursing home neglect and our post on signs of elder abuse families miss. Resident advocacy groups such as the National Consumer Voice for Quality Long-Term Care publish family materials on documenting care failures, and the state survey agency is the body that can act on them.

The short version families can act on this week

Bed sores are a timing problem more than a medical mystery. Pressure that is never relieved will damage tissue, and every hour without a turn narrows the margin. If someone you love is bedbound or uses a wheelchair for most of the day, ask this week for three specific things: the current Braden score, the written repositioning schedule, and the date of the last documented skin inspection. Then look at the heels yourself on the next visit. Families who ask those questions early are the reason many wounds never reach stage 2. If the answers are unclear, or the facility's pressure ulcer measure sits above the state average, it is worth knowing what else is available nearby. Search and compare nursing homes on this site by rating, staffing and inspection history, and take the shortlist into a tour with the questions above written down.

More from the blog

Industry analysis

The 2026 nursing home staffing crisis: what families actually need to know

Costs & funding

The hidden costs of nursing home care: 9 fees nobody mentions on the tour