The new CMS emphasis on falls: What clinical nurse leaders need to know

In recent years, CMS has intensified its focus on falls and fall‑related injuries across multiple regulatory and quality frameworks in nursing homes. This shift reflects growing national concern over resident safety, underreporting of falls (as noted in this OIG report) and the need for more consistent quality measurement. Nurse leaders serve a critical role in leading system‑level improvements, shaping team performance and ensuring accurate documentation that aligns with evolving CMS expectations. Below are important points to understand.

1. Evolving MDS definitions: A new era of fall reporting

Beginning October 2025, CMS implemented significant changes to fall definitions in the Resident Assessment Instrument (RAI) Manual, affecting how facilities code and report fall events on the MDS.

Key updates include:

• Broader definition of a fall, now including:
  • Any unintentional change in position to the ground or a lower surface.
  • Falls caused by overwhelming external force (e.g., one resident pushes another).
  • Intercepted falls, where the resident would have fallen without self‑correction or staff intervention.
• Expanded definition of major injury tied to falls, now explicitly including:
  • Traumatic fractures, dislocations, internal organ injuries, head injuries, spinal cord injuries, crush injuries and amputations.
    • It is important to note that CMS did not provide further description of “head injury.” Although AHCA has requested clarification, members are encouraged to work with their medical directors to determine a consistent approach to coding injuries involving the head (i.e., lacerations, contusions, hematomas, concussions, etc.).
• Alignment of MDS fall definitions with ICD‑10 injury coding for improved cross‑setting consistency.

These changes reflect CMS’s intent to reduce under‑reporting and strengthen the reliability of nursing home quality data. However, in reality, the updated definitions may create additional confusion and, in some cases, regulatory risk.

2. Special Focus Facility (SFF) criteria: Falls now a key selection factor

In January 2026, CMS released major revisions to the SFF Program, marking a historic shift: states must now consider a facility’s prevalence of falls — rather than staffing levels — when selecting SFF candidates. Falls prevalence, as captured in the MDS Quality Measure (QM), is now a recommended factor for identifying SFF candidates with similar compliance histories. This shift underscores the increasing regulatory weight placed on accurate fall reporting and prevention, elevating fall performance from a clinical indicator to a compliance priority.

3. Quality programs: Updated measures and technical specifications

CMS has also updated the Falls with Major Injury (FMI) measure within its quality programs, including the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP).

Important updates include:

• CMS released a new Technical Specification Report (2025) for the Falls with Major Injury measure, incorporating cross‑setting expert panel feedback.
• The revised QRP measure now integrates Medicare fee‑for‑service claims with MDS data to identify falls with major injury occurring during SNF stays — enhancing accuracy through dual‑data verification.
• CMS continues refining fall‑related measures to improve public reporting accuracy, given documented gaps in provider‑reported MDS data.

Together, these actions signal CMS’s priority to ensure that fall‑related QMs reflect true resident experience and drive meaningful quality improvement.

Three strategies for improving nursing facility outcomes

Under these enhanced CMS expectations, nurse leaders can strengthen their facility’s performance by leading with these proactive strategies:

1. Strengthen interdisciplinary fall investigations and documentation

Because accurate MDS coding directly affects quality measures and SFF risk:

• Conduct a root‑cause analysis for every fall, examining patterns by shift, location, staffing and resident condition.
• Ensure documentation reflects:
  • Witness accounts
  • Injury classification supported by clinical assessment
  • Therapy and nursing alignment in charting
  • IDT justification of coding decisions

Why it matters: Accurate, consistent documentation prevents under‑reporting, supports correct MDS coding and reduces compliance risks.

2. Modernize and intensify fall prevention programs

With falls now influencing SFF selection and public reporting, fall prevention programs must be comprehensive and proactive. Recommended actions:

• Review fall prevention protocols with the medical director, therapy and pharmacy teams.
• Reassess resident mobility, medications and environmental hazards regularly.
• Train all staff — clinical and nonclinical — on fall‑risk indicators, response expectations and documentation accuracy.

Why it matters: Preventive interventions are now weighted more heavily in compliance evaluations, influencing both survey outcomes and facility reputation.

3. Use data transparently and proactively to drive performance

Leveraging fall‑related data offers a strategic advantage under the new CMS framework. Strategies include:

• Review MDS Facility‑Level QMs and compare trends to national benchmarks.
• Utilize iQIES reports to track fall prevalence and performance over time.
• Share findings with frontline staff and leadership to foster a culture of safety and accountability.

Why it matters: Proactive use of fall data reduces surprises during surveys and helps prevent facilities from being flagged for SFF consideration.

CMS’s enhanced focus on falls represents a significant shift across multiple regulatory domains — from MDS coding rules to SFF selection criteria and national quality programs. For nurse leaders, this creates both challenges and opportunities. By strengthening documentation standards, enhancing fall prevention programs and leveraging data, nurse leaders can lead their teams toward improved resident outcomes, regulatory compliance and overall facility performance.

Questions about fall prevention, MDS coding and reporting can be directed to IHCA’s VP of Regulatory Affairs, Brenda Irlbeck. This article is available as a guidance document in IHCA’s Resource Center. Find it here.