A Risk Strategist’s Perspective on
Avoiding Claims, Strengthening Compliance,
and Leading Change in Senior Living
I. Introduction: When Regulation Meets Risk
On October 1, 2025, the Centers for Medicare & Medicaid Services (CMS) implemented a critical update to the RAI User’s Manual (v1.20.1), redefining fall reporting standards across nursing homes nationwide. These revisions include new definitions of what constitutes a fall, refined injury categorizations, and changes to how these incidents must be reported through the MDS. While CMS characterizes these updates as technical coding clarifications, the implications extend far beyond the Minimum Data Set.
From where I sit—as a senior living defense attorney, litigation attorney, claims manager, and enterprise risk strategist—this regulatory shift is not simply about better documentation. It represents a reshaping of the compliance and risk landscape in long-term care. These changes are emerging against the backdrop of intensifying scrutiny, particularly following the Office of Inspector General (OIG)’s recent findings, which spotlighted significant inconsistencies and underreporting in how nursing homes document and address falls. Regulators are sending a clear signal: transparency, accuracy, and clinical accountability are no longer optional.
For operators, the risk isn’t just regulatory non-compliance—it’s the litigation exposure, grievance activity, and loss costs that follow when expectations are not aligned with documentation and care delivery. But this moment also offers an opportunity. With the right strategies in place, providers can use this inflection point to realign QAPI processes, improve physician collaboration, and embed a proactive culture of documentation that mitigates disputes before they begin.
This blog offers not just an overview of the new fall reporting rules—it provides practical, proactive strategies for navigating them with confidence.
II. Key CMS Fall Reporting Changes: What Providers Must Know Now
The new CMS updates to the RAI User’s Manual, effective October 1, 2025, go far beyond surface-level coding adjustments. These changes reshape how falls and injuries are categorized and introduce interpretive gray areas that can increase regulatory scrutiny, coding disputes, and litigation risk. Understanding the nuance behind the new rules is essential for providers looking to stay compliant—and reduce exposure.
A. New Fall Categories: External Forces Now Count
One of the most striking updates is the explicit inclusion of falls caused by “overwhelming external forces.” This includes being pushed by another resident, struck by a medication cart, or knocked over by environmental factors that previously may have been viewed as incidental.
Why it matters:
These events now qualify as reportable falls, even if they weren’t due to intrinsic resident factors like balance or gait. Providers can expect an increase in fall counts and potentially skewed Quality Measures (QMs) unless internal reporting systems and documentation are adjusted to reflect the new criteria.
B. Redefining “Pathologic” Fractures
CMS now distinguishes pathologic fractures—those caused by conditions such as osteoporosis or cancer—from traumatic fractures that result from a fall. When a fracture is confirmed to be pathologic through proper clinical documentation, it can be excluded from the “major injury” fall category on the MDS.
Documentation required:
This exclusion is only valid if supported by a physician’s note identifying the underlying pathology. Without timely and clear documentation, the fracture will default to “major injury”—increasing the facility’s risk profile.
C. Expanded Injury Definitions: Major Just Got Broader
The updated guidelines also expand what qualifies as a “major injury” in the context of falls. The new list includes, but is not limited to:
- Traumatic fractures
- Internal organ damage
- Dislocations and crush injuries
- Amputations
- Spinal cord injuries
- Head injuries with or without altered consciousness
Risk takeaway:
This broader scope means more incidents will fall into the highest-risk reporting category—again impacting QMs, grievance activity, and claims. The inclusion of vague terms like “organ damage” or “spinal cord injury” may also prompt surveyor interpretation and retrospective scrutiny in litigation.
D. The “Not Limited To” Clause: Regulatory and Legal Ambiguity
CMS uses “not limited to” language in multiple sections of the revised manual. This catch-all phrasing gives surveyors wide discretion to interpret whether an incident qualifies as a fall or major injury—even if not explicitly listed.
The legal risk:
This ambiguity opens the door to inconsistencies in interpretation, over-reporting, and post-survey disputes. It also creates a litigation risk where plaintiff attorneys may use evolving surveyor interpretations to challenge provider documentation or injury classification.
E. Other Notable MDS Adjustments
While the fall-related updates are most impactful, providers should also be aware of two additional documentation shifts:
- Section R (Social Determinants of Health) has been removed. However, discharge planning must still incorporate social and environmental needs—failure to do so could raise issues of neglect or non-compliance in transition-of-care litigation.
- A transportation assessment question has been moved to Section A and is now only applicable under specific Medicare PPS criteria, adding complexity to transportation-related risk analysis.
III. Why This Matters: Litigation, Loss Costs, and Strategic Risk
These CMS fall reporting changes aren’t just updates to definitions—they are recalibrations of risk across the senior living landscape. As a senior living defense attorney, claims manager, and enterprise risk strategist, I’ve seen firsthand how seemingly minor shifts in language can dramatically increase litigation exposure, regulatory vulnerability, and total cost of risk.
Let’s break down why these changes demand your full attention.
- Coding Is Now a Litigation Trigger
With the new RAI guidelines in effect, coding a fall incorrectly doesn’t just skew internal metrics—it becomes a public flag. Quality Measures like “Falls with Major Injury” now carry weight across multiple reporting programs, including:
- Five-Star Ratings
- SNF Quality Reporting Program (QRP)
- SNF Value-Based Purchasing (VBP)
A single misclassified fall can degrade your CASPER report and create a public record that invites regulatory action and legal scrutiny. It only takes one.
- Documentation Gaps = Citations and Claims
Inconsistent or vague documentation around fall incidents—especially fractures—can lead directly to:
- F-tags and clustered deficiencies during surveys
- Surveyor disagreement over “major injury” interpretation
- Litigation claims asserting negligence, poor supervision, or inadequate clinical oversight
Plaintiff attorneys are already leveraging regulatory ambiguity to build negligence narratives. Poor documentation is not just a clinical failure—it’s a legal vulnerability.
- Family and Regulatory Grievances Will Rise
The broader definitions and new reporting obligations will naturally increase the volume of falls being captured—even when care was appropriate. This visibility shift may trigger:
- More family complaints, especially when injuries are newly classified as “major”
- Increased ombudsman involvement and state-level grievance filings
- Higher demand for post-incident communication and care conferences
The absence of a strong communication protocol will exacerbate perceived failures, erode trust, and feed claims—even when care was appropriate.
- Legal Complexity Is About to Surge
With more fall incidents being flagged and categorized as “major injury,” legal defense becomes more complex and costly:
- More discoverable documentation to analyze, interpret, and defend
- Wider deposition scopes, especially around clinical decision-making and documentation standards
- Expanded use of plaintiff experts, including geriatricians, coders, and survey consultants
This shift also changes the underwriting landscape. Insurers, RRGs, and brokers are likely to:
- Heighten documentation expectations
- Reevaluate fall-related claims reserves
- Increase scrutiny on facility-specific coding practices
Risk is no longer reactive—it’s measurable, discoverable, and increasingly under a microscope.
- Pathologic Fractures: A New Flashpoint
One of the most consequential changes is CMS’s exclusion of pathologic fractures from the “major injury” fall category—but only if properly documented by a physician. This invites ambiguity that can easily lead to:
- Coding disputes with surveyors
- Retrospective audits
- Legal claims based on misclassification or under-documentation
When in doubt, the fracture will default to “major injury”—unless your team is proactively trained and aligned on physician documentation standards.
IV. Where It All Shows Up: Claims, Litigation, and Family Complaints
When CMS updates reporting rules, it doesn’t just affect compliance teams—it reshapes the entire ecosystem of risk, responsibility, and response. These new fall definitions and injury classifications have a direct, tangible impact on claims exposure, litigation strategy, and the tone of communication with families.
As someone who manages claims and defends senior living providers across the country, I’ve seen patterns emerge in real time. This isn’t theoretical—it’s already playing out in demand letters, complaints, and regulatory reviews.
- Claims Will Spike from Documentation Gaps
Expect to see a measurable increase in:
- Claims alleging mismanaged falls that don’t meet new documentation thresholds.
- Family accusations of negligence when injuries appear to be minimized or unacknowledged under the new criteria.
- Claims from “low harm” injuries being escalated due to classification as a “major injury” under vague or misunderstood definitions.
What used to be a low-risk fall is now coded differently—and carries much higher scrutiny.
- Public Data = Plaintiff’s Exhibit A
Plaintiff attorneys are sophisticated in how they use data from:
- CASPER Reports
- Five-Star Ratings
- State Surveys and Complaint Investigations
They mine fall-related quality measures and compare them against documentation produced in litigation. Any inconsistency—especially with a fracture—can become a narrative of:
- Willful misrepresentation
- Fraud
- Systemic neglect
- Failure to meet regulatory obligations
A single fall coded differently on the MDS than in the chart can spiral into a seven-figure demand.
- Surveyor Disputes May Become Legal Evidence
Disagreement between facilities and surveyors on fall classifications could now lead to:
- Immediate citations under F684 (Quality of Care) or F689 (Accidents)
- Survey findings that are discoverable in civil litigation
- Increased scrutiny on interdisciplinary assessment processes
Surveyors will rely on the “not limited to” language and the expanded injury definitions, while providers will be challenged to defend nuanced decisions about what is—and isn’t—a major injury.
The surveyor’s pen can now become a plaintiff’s weapon in court.
- Families Will File More Grievances—And Sue Faster
These expanded definitions and visibility into falls mean families are:
- More likely to question injury classifications
- More inclined to file grievances with state agencies
- More willing to escalate to litigation, especially in the absence of proactive communication or transparency
Even appropriate care won’t insulate a community from complaints if the documentation doesn’t explain the clinical judgment behind classification decisions.
In the eyes of the family, silence can feel like evasion.
V. Turning Risk Into Resilience: Strategic Shifts for the New Era
If the CMS fall reporting update teaches us anything, it’s that risk has evolved—and so must we. As definitions expand, documentation requirements deepen, and surveyor interpretations grow more discretionary, the stakes for providers are higher than ever.
But this is also a moment of opportunity. The providers who respond with systems—not just compliance checklists—will lead the way.
Here’s where the most resilient communities are focusing:
- Rewriting the Internal Playbook
- Re-educate your IDT and frontline teams on new definitions and injury classifications.
- Revise policies, incident forms, and EHR workflows to distinguish pathologic from traumatic events.
- Build interdisciplinary documentation habits that reduce interpretive risk and increase defensibility.
These aren’t just “regulatory updates.” They’re invitations to redesign internal culture—from reaction to readiness.
- Partnering Proactively
Smart providers are already aligning with their risk managers, clinical leaders, and legal advisors to get ahead of these changes. Whether it’s a one-time audit, quarterly QAPI review, or a more structured engagement, bringing together clinical, legal, and operational perspectives early is one of the strongest defenses available.
This isn’t about waiting for the lawsuit or the citation. It’s about engineering resilience before the fall happens—literally and metaphorically.
- Embedding Culture Change and Commitment
Sustainable risk mitigation isn’t just a matter of documentation—it’s a matter of culture.
More and more communities are adopting culture change frameworks and certification programs that elevate resident-directed care, align expectations early with families, and bake documentation integrity into daily operations. These models—like those integrated through the Guide Path Certification Program—don’t replace regulatory compliance; they ground it in relationships, trust, and communication.
- Laying the Groundwork for Better Conversations After Harm
Finally, one of the most promising evolutions in this space is the development of Communication and Resolution Programs (CRPs) tailored to senior living.
When something goes wrong—and eventually it will—how we respond makes all the difference. These programs emphasize timely disclosure, interdisciplinary analysis, and transparent engagement with residents and families. Done well, they can:
- De-escalate potential litigation
- Build trust with residents and families
- Align with QAPI and CMS expectations for collaborative care
- Improve quality outcomes over time
We’re currently designing a CRP Blueprint specifically for senior living, and we expect to introduce it in 2026. The goal? A scalable model that communities can adapt and implement to ensure their teams know how to have these conversations—and how to build systems that reduce the need for them in the first place.
VI. Final Thoughts: Lead With Strategy, Not Fear
CMS didn’t just rewrite a regulation. They reopened the conversation around falls, safety, trust, and care quality. That conversation now belongs to every provider.
The question isn’t whether surveyors, regulators, and litigators will interpret these new rules differently.
The question is: Will you be ready before they do?
Let’s Talk Strategy
If you’re rethinking your approach to fall documentation, regulatory preparedness, or enterprise risk systems, you’re not alone. These shifts in CMS policy are already prompting proactive providers to realign their strategies — not just to stay compliant, but to lead with clarity, confidence, and care.
At Adelman Firm, we work at the intersection of regulation, litigation, and innovation. We partner with senior living operators, insurers, and risk professionals to:
- Conduct fall reporting and documentation audits
- Align internal systems with evolving CMS guidance
- Build strategic responses to reduce exposure and cost
- Design culture-change initiatives that last
We welcome conversations — whether you’re looking for a thought partner, legal guidance, or a broader risk strategy.
Reach out to explore how we can support your team through this regulatory shift and beyond