Dr. Levine is a nationally recognized expert in wound care and pressure ulceration. and has published and spoken widely on this topic. He is a Board Member of the National Pressure Ulcer Advisory Panel (NPUAP). Dr. Levine's Pocket Guide to Pressure Ulcers co-authored by Elizabeth Ayello RN and published by the New Jersey Hospital Association is in its 4th printing and has sold over 30,000 copies.

I received so many inquiries about resources for skin assessment in the nursing home that I devoted this blog post to providing links and downloads useful to wound care clinicians.  Below you can access PDFs which contain important information related to skin, pressure ulcer, and wound assessment that will be helpful to nurses, doctors, medical directors, inservice directors, MDS coordinators, and anyone else interested in this very important topic.  As you probably know, the revised Resident Assessment Instrument (RAI) version 3.0 along with Minimum Data Set (MDS) 3.0 will be going into effect for Medicare certified skilled nursing facilities across America beginning October 1, 2010.

The RAI Manual chapter for MDS 3.0 Section M: Skin Conditions can be downloaded from this link.  It contains complete guidelines for completion of the skin assessment section.  This is a large file (almost 2 MB) and is current as of May 25, 2010:

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The data entry pages for MDS 3.0 Section M: Skin Conditions can be downloaded from this link:

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For those who need information on Guidance for Surveyors on pressure ulcers and skin care, the entire text of F Tag 314 can be downloaded from this link:

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As a study aid, I compiled a list of subsections from Section M: Skin Conditions.  I recommend that this list be memorized by all wound care clinicians in nursing homes who must prepare data for entry into the MDS:

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For clinicians who are looking for a resource on avoidable vs unavoidable pressure ulcers, download this article.  This research study was done in hospitals but may provide a conceptual framework for determining when a pressure ulcer is unavoidable:

For clinicians who need a pictorial resource for staging of pressure ulcers and wound identification, you can purchase a copy of my Document Dermis™ Pocket Guide to Pressure Ulcers: How to Classify, Stage, and Document Pressure Ulcers and Other Common Wounds, co-authored with Elizabeth A. Ayello RN, PhD. Copies can be purchased directly from the New Jersey Hospital Association (NJHA) website. To read more about the Document Dermis™ Pressure Ulcer Guide click here.   

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To read all blog posts related to MDS 3.0 click here.

To read all blog posts about the Document Dermis™ Pressure Ulcer Guide click here.



  • Billie Jo Schwerin
    03/17/2011, 8:32 am  Reply

    I was recently attended a seminar that covered staging and documentation of wounds, types, and assessment. The speaker said that a blood blister is a stage II but we must say that it is blood filled, and for the MDS, it is a IV. I was under the impression that a blood blister is nowan unstageable wound, and for the MDS, it is still an unstageable until we can see the base of the wound and give it a numerical stage. I am now very confused, please help!! Thank you

    • 03/17/2011, 10:36 am

      Thank you for your comment, this is a constant source of confusion for wound classification. The rule is as follows. If a blister is clear, and you examine the periphery of the wound and there is nothing that would suggest infection or other injury, this is a STAGE 2. If the blister is blood filled, it is to be classified as a SUSPECTED DEEP TISSUE INJURY (SDTI). Once the SDTI evolves it can be staged. For example it can evolve into an eschar, which is UNSTAGEABLE, or it can peel off leaving partial thickness skin break, or STAGE 2.

      Be alert if the blister gets inflamed and filled with pus and yellow drainage, as this means that it is infected and needs immediate evaluation by a physician for possible debridement and antibiotics. Blisters of the lower extremity in older folks can also be caused by an autoimmune disease, bullous pemphigoid.

      Any blister of the lower extremities raises the possibility of underlying vascular disease, and the caregivers should consider non-invasive studies including ankle-brachial index (ABI) and pulse volume recordings (PVR). See my blog post on this topic:

      This topic is also addressed in my CMS lecture which is posted here:

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Dr. Jeffrey M. Levine has authored numerous articles on topics related to healthcare of the elderly. These include medical history, prevention and treatment of chronic wounds such as pressure ulcers, elder neglect and abuse, and physical restraints. He has also edited a book on legal and regulatory aspects of nursing homes.