Skilled Nursing Facilities Failed to Report Falls with Major Injury and Hospitalization

As described by the HHS Office of Inspector General (OIG), as part of a discharge assessment that is required for each resident who is hospitalized,

CMS calculates two nursing home quality measures from the MDS that reflect the percentage of residents who experienced a fall with major injury for each nursing home: 

• Long-stay measure: rate of falls with major injury among long-stay residents

• Medicare Part A SNF-stay measure: rate of falls with major injury among residents during Medicare Part A SNF stays (which are generally shorter)9 These measures are calculated from MDS items that record whether the resident experienced a fall during the episode of care and, if so, the severity of any injuries resulting from that fall.

HHS OIG, Nursing Homes Failed To Report 43 Percent of Falls With Major Injury and Hospitalization Among Their Medicare Enrolled Residents, OEI-05-24-00180, p. 2 (Sep. 2025). OIG writes that facilities should update the discharge assessment “when it becomes aware of the fall or aware that the severity originally reported was not accurate.” Report 3. OIG further explains that both measures are displayed on the Care Compare website and that the long-stay measure is one of the measures used to calculate the quality measure in the facility’s 5-star rating.

Editor:  Centers for Medicare & Medicaid Services (CMS), Design for Care Compare, Nursing Home Five-Star Quality Rating System: Technical Users’ Guide (Jul. 2025), describes the measures reported on the Care Compare website. One quality measure is “Percentage of residents experiencing one or more falls with major injury,” based on resident assessment information, as collected through the minimum data set (MDS). The Technical Users’ Guide describes this falls measure: “This measure reports the percentage of long-stay residents who have experienced one or more falls with major injury reported in the target period or look-back period (one full calendar year).”

In comments on proposed annual updates to Medicare reimbursement for skilled nursing facilities, the Center for Medicare Advocacy has repeatedly expressed concern with CMS’s reliance on MDS data in Care Compare, citing studies documenting inaccuracies in the falls measure. See “Proposed Annual Update to Reimbursement Rates for Skilled Nursing Facilities” (CMA Alert, May 15, 2025), and comments submitted June 9, 2026, citing Prachi Sanghav, Shengyuan Pan, Daryl Caudry, “Assessment of nursing home reporting of major injury falls for quality measurement on nursing home compare,” Health Services Research, p. 5.  2019;00:1-10, which found that only 57.5% of residents’ major injury falls that were identified in Medicare hospital admissions claims data were reported on residents’ assessment data.

Reviewing “nursing homes’ reporting of falls with major injury that resulted in Medicare-paid hospitalization among residents in MDS assessments completed in the 1-year period between July 1, 2022, and June 30, 2023,” id. 4, OIG found:

• “Nursing homes failed to report 43 percent of falls [18,369 of 42,236 falls] with major injury and hospitalization among Medicare-enrolled residents, as required, in Minimum Data Set assessments.” Id. 6.

• “Nursing homes with for-profit ownership, chain membership, and more beds failed to report falls most often.” Id.

Failure to report falls by facility ownership type

Id.

Failure to report falls by facility size

Id. 7.

Failure to report falls by facility location
National average = 43%

            Id.

There was wide state variation in failure to report falls:

• Washington, D.C., 64%; California, 61%; Nevada, 60%. Id.
• South Dakota: 21%; Vermont, 24%; North Dakota, 25%. Id.

“Nursing homes failed to report falls more often for younger residents, male residents, short-stay residents, and residents with only Medicare coverage.” Id. 8.

Failure to report falls by age of residents

      Id. 8.

Failure to report falls by residents’ length of stay, payment source

                       Id.

OIG finds that “Nursing homes’ failure to report falls on Minimum Data Set assessments leads to inaccurate fall rates on Care Compare.” Id. 9. Care Compare reported, inaccurately, that from July 1, 2022 through June 30, 2023, the average fall rate with major injury was 3.4% of long-stay residents. The actual fall rates cited by OIG may be low, since hospitalizations paid by payers other than Medicare and falls with major injury not resulting in a hospitalization were “outside the scope of this evaluation.” Id.

OIG finds that “Nursing homes with the lowest fall rates on Care Compare were the least likely to report falls that occurred,” suggesting that “those nursing homes’ low fall rates on Care Compare are driven by a failure to report falls rather than an actual low incidence of falls.” Id. 10.

Failure to report falls, by star ratings on Care Compare

           Id.

“Nursing homes with the highest star ratings were slightly less likely to report falls that occurred.” Id.

Failure to report falls, 5 star and 1-star facilities

                        Id.

A 5-star non-profit facility in New York with more than 200 beds had 13 falls with major injury and hospitalization reported only 3 of the falls. On Care Compare, it had a rate of 1.3% for falls with major injury and hospitalization (lower than the national average of 3.4%). Id.

OIG concludes that “using MDS assessment data alone is insufficient for quality measurement purposes given the current levels of provider under-reporting.” Id. 11. As interim measures, OIG recommends that CMS

• “Take steps to ensure the completeness and accuracy of the nursing home-reported Minimum Data set data used to calculate the quality measures for falls with major injury.” Id. OIG notes that CMS recently established an MDS data validation program for a subset of measures used in the SNF Value-Based Purchasing Program, beginning in fiscal year 2027. Id. 12. OIG suggests that CMS could compare MDS assessment responses with inpatient hospital claims data, as it did in this report. Id.

• “Explore whether approaches to improve the quality measures related to falls could similarly be used to improve the accuracy of other nursing home quality measures.” Id. 12. OIG encourages CMS to “consider opportunities to improve the reliability of other nursing home quality measures that are based solely on MDS assessments.” Id.

CMS concurred with both recommendations. Id. 14 and 20-23 (Appendix B). OIG describes a report by a Technical Expert Panel (Jul. 2025) that CMS had “convened to explore changes to the falls with major injury cross-setting quality measures.” Id. 14. OIG describes an even split in proposed approaches:

(1) adding falls reported in the MDS with no or minor injury, but with a diagnosis of major injury in claims or encounters; and (2) adding falls identified in the first approach, as well as falls with major injury identified solely in claims or encounters where both (a) an external cause of injury code indicates a fall and (b) a diagnosis code indicates a major injury (similar to the methods used in this report).

Id.

OIG described its Detailed Methodology, id. 15-17, and included two Appendices

• Appendix A: Nonreporting Rates by Nursing Home and Resident Characteristics. Id. 18-19.
• Appendix B: Agency Comments. Id. 20-23.

September 25, 2025 – T. Edelman