CMS Tightens Nursing Home SFF Picks Over Falls - National

WASHINGTON, D.C. — The Centers for Medicare & Medicaid Services announced revisions to its Special Focus Facility program this week, directing state survey agencies to prioritize resident fall rates when selecting nursing homes for enhanced oversight, according to a federal memo issued Wednesday.

The policy change follows findings from the Office of Inspector General indicating that nursing homes failed to report 43 percent of falls resulting in major injury and hospitalization among Medicare-enrolled residents during assessments, as reported in a September 2025 OIG study. The revised guidance replaces previous language emphasizing staffing levels with new criteria centered on fall prevalence at candidate facilities.

Under the updated selection process, state survey agencies will consider a facility's prevalence of falls when choosing nursing homes from the Special Focus Facility candidate list, according to the CMS memo. When two facilities demonstrate similar compliance histories, regulators may now prioritize the facility with higher fall rates for SFF designation. The shift aims to accelerate improvement and increase accountability for facilities that continue putting residents at risk, according to the federal agency.

The revisions build upon program updates finalized between 2022 and 2023. Federal regulators stated the changes are designed to protect and improve quality of care for residents living in facilities with persistent compliance problems.

"CMS is informing State Survey Agencies to consider a facility's prevalence of falls when selecting SFFs from the SFF candidate list," the memo states, marking a departure from previous guidance that referenced staffing levels data.

Alicia Cantinieri, managing director of clinical reimbursement and regulatory compliance at Zimmet, noted that the agency relied on the Long-Stay Prevalence of Falls measure rather than more specific data tracking falls with injury. The prevalence measure is broad, encompassing any fall including intercepted falls and those from overwhelming external force, regardless of whether injury occurred.

Federal regulations collect more detailed information through specific minimum data set items that track falls with injury and falls with major injury, according to Cantinieri. These data points provide a more precise picture of resident harm than the general falls measure, she told Skilled Nursing News.

"I am surprised to see that CMS used the prevalence of falls measure rather than data from Falls with Injury (Except Major) and Falls with Major Injury," Cantinieri stated.

Program Structure Changes

The revised program includes several procedural modifications affecting how facilities enter and exit heightened oversight. Nursing homes will now be identified as SFF candidates based on their last two standard health survey cycles, according to the memo, a reduction from the previous requirement of three cycles.

State survey agencies will select new facilities from the latest candidate list, which CMS typically updates monthly with five to thirty nursing homes per state. Currently, 88 facilities are designated as Special Focus Facilities. These facilities will undergo surveys at least every six months, with Life Safety Code and Emergency Preparedness surveys conducted annually, according to the federal guidance.

When a new SFF designation receives approval, state survey agencies must notify the facility. Under the revised timeline, facilities have five business days from receiving notice to submit contact information for all accountable parties.

The revisions may shift which facilities reach the candidate list and receive SFF designation based on fall prevalence rather than staffing metrics used in prior guidance, according to Cantinieri. State agencies use health inspection scores alongside the prevalence of falls criterion when making determinations.

Graduation Requirements

Facilities can graduate from the Special Focus Facility program after achieving two consecutive standard health surveys with twelve or fewer deficiencies at severity level E or below, according to program requirements. Graduation is prohibited if any survey shows deficiencies at level F or higher, Life Safety Code or Emergency Preparedness deficiencies at level G or higher, thirteen or more total deficiencies, or pending complaint surveys triaged as Immediate Jeopardy or Non-IJ High priority.

Federal regulations require facilities to have returned to substantial compliance across all surveys before graduation from the program. The monitoring period guidelines remain unchanged from previous program iterations.

The shift in selection criteria reflects growing federal concern about fall safety in nursing homes. Falls represent a leading cause of injury and hospitalization among long-term care residents. Federal oversight programs use fall data collected through the minimum data set, which facilities submit as part of resident assessments.

The Office of Inspector General findings that prompted the policy change highlighted significant gaps in fall reporting. The 43 percent underreporting rate for serious falls raised concerns about the accuracy of quality measures used to evaluate facility performance and inform consumer choice.

Resources for Families

Families concerned about fall safety or quality of care at nursing homes can contact the National Long-Term Care Ombudsman Resource Center at 1-800-677-1116. The ombudsman program provides advocacy services for residents and assists families in addressing care concerns.

Additional resources and facility quality information are available through Medicare's Care Compare website, which provides inspection results, staffing data, and quality measures for all Medicare and Medicaid-certified nursing homes nationwide.

Residents and families can also file complaints about suspected care deficiencies with state survey agencies, which conduct inspections and enforce federal regulations at nursing homes. Contact information for state survey agencies is available through state health departments.