The cost of treating a hospital-acquired pressure ulcer (HAPU) places a significant burden on healthcare facilities. Associated expenses potentially include increased supplies, equipment, specialty beds, staffing, nutritional support, laboratory testing, and hospital length of stay. The quarterly HAPU data revealed an increased prevalence in our 25-bed intermediate care unit at Central DuPage Hospital at Winfield, Illinois. There were 6 occurrences of HAPU during fiscal year 2005 to fiscal year 2006, and 5 occurred during fiscal year 2006 to 2007. Based on these data, our unit quality council investigated contributory factors and reviewed current tools and standards of practice related to pressure ulcer prevention. Strategic plans were developed to reduce the incidence of HAPU. Follow-up monitoring revealed no HAPU occurrence from October 2006 through September 2007. Pressure ulcer prevention strategies proved effective in reducing incidence during a 1-year period and have been approved as standards of practice for the unit.