The long-stay pressure ulcer quality measure (N045)

The long-stay pressure ulcer measure counts residents who have a Stage 2, 3 or 4 or an unstageable pressure ulcer on their target assessment. It is one of the long-stay MDS measures in the Five-Star quality rating, worth up to 100 points, and it is decided entirely by how Section M is coded on one assessment.

What it measures

The CMS name is “Percent of Residents with Pressure Ulcers (Long Stay),” CMS ID N045.02, and it is risk-adjusted.

If you remember a “high-risk” pressure ulcer measure, this is its replacement. The QM User’s Manual v16.0 (effective October 1, 2023) replaced “Percent of High-Risk Residents With Pressure Ulcers” (N015.03) with this measure, and Five-Star switched over in its January 2025 refresh. As the old name said, the old measure looked only at high-risk residents. N045 counts every long-stay resident and adjusts for risk instead.

State programs use it too. It is scored in the Ohio QIP, the Florida QIP, Component 4 of the Texas QIPP and the Indiana QIP.

What puts a resident in the numerator

A count of 1 or more in any of these six items on the target assessment:

Two things follow from that list:

• Stage 1 doesn’t count. M0300A isn’t in the measure.
• Present on admission doesn’t matter. The measure reads only the counts, not the “present on admission” items. An ulcer the resident arrived with counts the same as one that developed in the building.

Who is left out

• The target is an OBRA admission (A0310A = 01) or a PPS 5-Day (A0310B = 01).
• Any of the six items is dashed on the target and the resident isn’t already in the numerator.
• The target is dated before October 1, 2023.

There is no hospice or end-of-life exclusion. Hospice is handled in the risk adjustment instead.

When it clears

The measure is a snapshot of the target assessment, the resident’s latest qualifying assessment dated within 120 days of the end of the quarter (or of their discharge). Section M counts pressure ulcers present in the 7-day look-back, and a wound that closed inside that window isn’t counted:

So the resident leaves the numerator when the next target assessment is coded after every Stage 2 or worse ulcer has closed. Getting smaller doesn’t do it. A healing ulcer keeps its highest stage until it is closed:

Five-Star averages the four most recent quarters, so each quarter with the resident in the numerator stays in the rating until it rolls out.

Risk adjustment, in plain words

CMS predicts each resident’s chance of having a pressure ulcer from nine items on the same target assessment, and your rate is adjusted for the mix of risk among your residents. The nine:

• Needing substantial help or more, or not attempting, lying to sitting on the side of the bed (GG0170C)
• Any bowel incontinence (H0400)
• Peripheral vascular or arterial disease, or diabetes
• A low body mass index, 12 to 19, from height and weight
• Malnutrition or risk of malnutrition
• Dehydration (J1550C)
• A multidrug-resistant organism, pneumonia, septicemia or UTI
• Moisture-associated skin damage (M1040H)
• Hospice care

Accurate coding of these items matters too. A resident’s real diabetes or low BMI that is missing from the MDS lowers the rate CMS expects for your building.

Coding it accurately

The coding errors that move this measure put a wound in the wrong place, in either direction:

• A deep tissue injury is unstageable, not Stage 1. It goes in M0300G, and it counts.
• Code pressure only where pressure is the primary cause. A diabetic foot ulcer on the plantar surface, a venous or arterial ulcer, moisture-associated skin damage, and skin changes at the end of life (SCALE, also called Kennedy Terminal Ulcers) aren’t coded as pressure ulcers. Nor are mucosal ulcers from tubing or a urinary catheter.
• A scab isn’t eschar. A healing Stage 2 with a scab stays a Stage 2. Eschar that hides the depth makes it unstageable; if the wound bed is only partly covered and the depth can be seen, stage it.
• A reopened ulcer comes back at its worst stage, unless it now presents at a higher stage or is unstageable.
• A flap or graft closure turns it into a surgical wound. Once a pressure ulcer is surgically closed with a flap or graft, it is coded as a surgical wound, not a pressure ulcer, even if the flap fails.

What changed in the October 2026 RAI Manual

The RAI Manual v1.20.11, effective October 1, 2026, made two Section M changes that touch this measure. The first closes a question about modern wound products:

So a pressure ulcer treated with a skin substitute is still a pressure ulcer, still coded in M0300, and still in this measure. Its care goes in M1200E, pressure ulcer/injury care, not surgical wound care.

The second reverses the rule for an ulcer that was present on admission, healed, and then reopened. Under v1.20.1 it was still “present on admission” if it reopened at the same stage. Under v1.20.11 (page M-9), a pressure ulcer/injury documented on admission that closed and then opens again is not coded as present on admission. That doesn’t change this long-stay measure, which ignores present on admission. It does matter for the short-stay new-or-worsened pressure ulcer measure.

How Five-Star scores it

Long-stay pressure ulcers is one of the 100-point measures, scored in quintiles of the national distribution. Lower is better. Points come from your risk-adjusted four-quarter rate, using cut points set from 2023Q4–2024Q3 data:

SuperQM shows every long-stay resident with a Stage 2 or worse ulcer on their latest assessment, and which assessment will be the quarter’s target. See how it works.