March 26, 2026

The Future of the Falls with Major Injury Quality Measure: What SNFs Need to Know

On March 26, 2026 by LeadingAge Minnesota

Falls with Major Injury (FMI) has long been one of the most closely watched quality measures in long-term care. It directly affects public reporting, survey scrutiny, and Five-Star Quality Ratings. However, a major shift is underway in how this measure is calculated.

CMS has released a respecified methodology that incorporates both Minimum Data Set (MDS) assessments and claims data, creating what is known as a hybrid quality measure. While this new methodology is already being implemented in some CMS programs, it has not yet been adopted in the Five-Star Quality Rating System.

Understanding what is changing—and when—will be critical for nursing homes preparing for the future of quality measurement.

Why CMS Is Changing the Measure

The primary reason for the re-specification is underreporting. Research reviewed by CMS found that a significant number of falls with major injury identified in hospital or emergency department claims were not being captured in MDS assessments. In fact, studies found that only about 57.5% of claims-identified fall injuries were reported in the MDS, indicating a substantial gap between clinical events and documented quality measure data.

To address this issue, CMS redesigned the measure so that fall-related injuries can be identified through multiple data sources, not just the MDS. This approach aims to provide a more accurate picture of actual resident outcomes.

What the Hybrid Measure Looks Like

The updated Falls with Major Injury measure uses a three-step identification process.

First, the traditional method remains in place. If a fall and major injury are documented on the MDS—specifically through Section J items indicating a fall and a major injury—the resident is included in the measure.

Second, CMS reviews claims data for injuries that occur after a fall recorded on the MDS. If a fall is documented in the assessment but the injury was not coded as major, CMS scans hospital, emergency department, or observation claims for diagnoses such as fractures or traumatic brain injuries. If these injuries appear in claims data, the event will still count in the measure.

Third, the measure can identify events entirely through claims data. If a hospital or emergency department claim contains both a fall external cause code and a qualifying major injury diagnosis code, the resident will be included in the numerator—even if the fall was never documented on the MDS.

This design makes the measure significantly more comprehensive and much harder to influence through documentation alone.

Expanded Definition of Major Injury

Another change in the respecified measure is the broader definition of what constitutes a major injury. CMS now includes a wide range of diagnoses such as traumatic fractures, joint dislocations, traumatic brain injuries, internal organ injuries, spinal cord injuries, crush injuries, and traumatic amputations. These are identified through ICD-10 diagnosis codes within claims data.

This expanded clinical definition further increases the likelihood that fall-related injuries will be captured through claims.

What Happens to the Rates

When CMS tested the hybrid methodology, the results showed a dramatic change in facility-level rates. Using MDS data alone, the average Falls with Major Injury rate was approximately 3.7%. When claims data were incorporated, the average rate increased to over 9%.

In addition, the percentage of facilities reporting zero fall injuries dropped significantly—from more than 11% of providers to less than 2%. This suggests that the hybrid methodology captures many events that previously went unreported in the MDS.

For providers, this means that future publicly reported rates may appear higher even if clinical performance remains the same.

When Will This Affect Five-Star?

At this time, the Five-Star Quality Rating System still uses the MDS-based version of the Falls with Major Injury measure. The hybrid methodology has been introduced within CMS technical specifications and Quality Reporting Programs but has not yet been formally adopted for the long-stay measure used in Five-Star.

CMS commonly introduces new measures first in reporting programs and testing environments before incorporating them into Care Compare or the Five-Star system. Based on past patterns, many experts anticipate that the hybrid falls measure could eventually transition into Five-Star in the coming years, although CMS has not announced a specific timeline.

What Nursing Homes Should Do Now

Even though the Five-Star measure has not yet transitioned to the hybrid model, facilities should begin preparing for the shift. Claims-based validation means that hospital and emergency department events will increasingly influence quality scores regardless of how they are documented on the MDS.

This places a greater emphasis on true fall prevention and clinical monitoring, rather than relying solely on documentation practices. Facilities should focus on strengthening fall risk assessments, environmental safety programs, interdisciplinary care planning, and post-fall review processes.

In addition, nursing homes should pay close attention to hospitalization and emergency department data, as these claims may soon play a much larger role in quality measurement.

Looking Ahead

The re-specification of the Falls with Major Injury measure represents a broader trend within CMS quality measurement strategy. Increasingly, CMS is moving toward claims-validated outcome measures that combine clinical documentation with real-world utilization data.

For skilled nursing facilities, this shift means that quality metrics will increasingly reflect actual resident outcomes across the continuum of care. Facilities that proactively strengthen clinical systems and fall prevention programs will be best positioned to succeed as these new measurement approaches evolve.