Preventing Pressure Injuries in New SNF Admissions: The First Days

A resident arriving from the hospital has often spent days in bed or on a stretcher. They may be weak, poorly nourished, incontinent, or attached to tubes and devices, all before your team ever meets them.

That is why the first skin check and the first few days of care matter so much. They set the baseline and point the care plan toward the residents most at risk.

Why New Admissions Are a High-Risk Group

Many pressure injury risks show up together at admission: limited mobility, incontinence, poor intake, friction from being moved, and reduced sensation or awareness. A resident who cannot shift their own weight depends on staff to relieve pressure.

Medical devices add to the risk. The National Pressure Injury Advisory Panel (NPIAP) defines a pressure injury as localized damage to the skin and underlying soft tissue, usually over a bony prominence, "or related to a medical or other device." Oxygen tubing, splints, braces and catheters all deserve a look.

The Admission Skin Assessment

AHRQ's pressure ulcer prevention toolkit describes a comprehensive skin assessment as examining the entire skin for any abnormalities, by looking and touching, with emphasis on bony prominences. It typically checks temperature, color, moisture, turgor and skin integrity. AHRQ also stresses that it is "not a one-time event limited to admission" and should be repeated regularly.

A practical admission check includes:

• Sacrum, coccyx, buttocks and hips
• Heels, ankles and the backs of the knees
• Elbows, shoulder blades and the back of the head
• Ears, nose and any skin under or around devices
• Skin folds and areas exposed to moisture

The admission findings also feed the MDS. CMS's RAI Manual (version 1.20.11, in effect since October 1, 2026) for Section M (Skin Conditions) says that at admission, staff code based on the first skin assessment done on or after admission, as close to admission as possible. A complete first look gives an accurate record of what was present on arrival.

Using the Braden Scale Wisely

The Braden Scale scores six areas: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. AHRQ notes that total scores range from 6 to 23, lower scores mean higher risk, and scores of 18 or less generally indicate risk. Your facility may set its own threshold.

A score is a starting point. AHRQ advises combining it with other risk factors and clinical judgment, and says "any area of risk should have a corresponding care plan regardless of the overall risk assessment scale score." A resident who scores 19 but has a pink coccyx still needs attention.

Repositioning, Support Surfaces and Nutrition

Prevention steps come from the resident's care plan, written by the interdisciplinary team and approved by providers as your facility requires. Common elements include:

• Repositioning on the schedule the care plan sets, with attention to heels and to residents who cannot move on their own
• Support surfaces such as pressure-redistributing mattresses or cushions, as ordered or care-planned
• Moisture management and prompt incontinence care
• Nutrition and hydration, which is one of the six Braden areas; residents with poor intake are often referred to the dietitian under facility process

Federal rules at 42 CFR 483.25(b)(1) require that, based on the comprehensive assessment, a resident receives care consistent with professional standards to prevent pressure ulcers, and does not develop them unless their clinical condition shows they were unavoidable.

Staging Basics Every Nurse Should Know

The NPIAP staging system, updated in 2016, describes these categories:

• Stage 1: Intact skin with non-blanchable redness. It "may appear differently in darkly pigmented skin," and changes in warmth, firmness or sensation may come before visible changes.
• Stage 2: Partial-thickness skin loss with exposed dermis, or an intact or ruptured serum-filled blister.
• Stage 3: Full-thickness skin loss with fat visible in the wound.
• Stage 4: Full-thickness loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone.
• Unstageable: Full-thickness loss where slough or eschar hides the extent of damage.
• Deep tissue pressure injury: Persistent non-blanchable deep red, maroon or purple discoloration, or a blood-filled blister.

CNAs do not stage wounds, but they do need to know what to report. Staging and treatment belong to licensed nurses and providers. For MDS coding, the RAI Manual tells staff not to reverse or "back stage" a healing ulcer.

Documenting and Reporting Changes

Skin that looked fine yesterday can look different today. Clear, fast communication is what turns an early finding into early action:

• CNAs report any new redness, blister, open area, dark spot, or pain during care to the charge nurse right away.
• The nurse assesses, documents location, size and appearance, and notifies the provider and family per facility policy.
• The care plan is updated so every shift knows what changed.

Quick Checklist

• Confirm every new admission gets a full head-to-toe skin check on arrival, including under devices.
• Review admission Braden scores in morning meeting and make sure each risk area has a care plan item.
• Spot-check that support surfaces and repositioning in the care plan are actually in place at the bedside.
• Flag residents with poor intake for dietitian review per your process.

A daily screen of new admissions, like the one Keystone provides, can help teams see which residents carry several of these risks at once so the care team can act sooner.

This article is general education for skilled nursing teams. Follow your facility's policies and the direction of your medical director and providers.