The Centers for Medicare & Medicaid Services (CMS) issued a revised memo Wednesday to strengthen the Special Focus Facility (SFF) program, directing state survey agencies to place greater emphasis on resident falls when choosing new SFFs.

At the center of the revisions is a shift in how facilities are selected for the SFF program. The CMS memo notes that when facilities have similar compliance histories, those with higher fall rates may be prioritized for SFF designation. CMS cited Office of Inspector General (OIG) findings highlighting the seriousness of falls and improving fall safety as a key driver of this change.

In September 2025, OIG issued a report noting that during resident assessments, nursing homes failed to report 43% of falls with major injury and hospitalization among Medicare-enrolled residents.

The memo builds on earlier reforms finalized in 2022 and 2023 and is aimed at accelerating improvement, curbing repeat noncompliance, and increasing accountability for facilities that continue to put residents at risk.

“Building upon the 2022 program updates, CMS is revising the SFF program to protect and improve the quality of care that residents living in these facilities receive,” the federal agency noted in the memo. “CMS is informing State Survey Agencies (SAs) to consider a facility’s prevalence of falls when selecting SFFs from the SFF candidate list.” The memo had previously noted “staffing levels data” but replaced that with falls prevalence at facilities.

Alicia Cantinieri, managing director of clinical reimbursement and regulatory compliance at Zimmet, said she was surprised that CMS relied on the overall prevalence of falls measure rather than more detailed data on falls that result in injury to make the revisions.

“The fact that the criterion is the prevalence of falls is interesting,” Cantinieri said.

The Long-Stay Prevalence of Falls is a survey measure that is a broad one, she noted. It includes any fall, including intercepted falls and those resulting from overwhelming external force since admission, at readmission, or the most recent OBRA or PPS assessment, regardless of whether an injury occurred, she explained.

While there is no standalone quality measure for falls with injury other than major injury, CMS does collect that information through specific minimum data set (MDS) items – J1900B and J1900C – which track falls with injury and falls with major injury, Cantinieri told Skilled Nursing News. She noted that these data points, outlined in CMS compliance guidance, provide a more precise picture of resident harm than a general falls measure.

“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,” she said.

SFF candidates list changes

In addition to adding falls prevalence data as criteria for SFF selection, CMS outlined some other changes to the program. Namely, if a survey agency is considering two SFF candidates with a similar compliance history, CMS is now recommending selecting the facility with the higher prevalence of falls among the resident population. Furthermore, nursing homes will be identified as SFF candidates based on their last two standard health survey cycles, a change from three such cycles previously.

State survey agencies will select new SFFs from the latest CMS-issued candidate list, typically updated monthly, with 5 to 30 nursing homes per state. Currently, 88 SFFs are on the list, and CMS will conduct surveys at least every six months (a minimum of two per year), with Life Safety Code and Emergency Preparedness surveys conducted at least annually, the memo noted as part of the revisions.

Once CMS approves a new SFF, the state survey agency must notify the facility. The CMS memo now states that the facility then has five business days from receiving the notice to submit contact information for all accountable parties.

“[The revisions] may change which facilities reach the candidate list and the SFF designation based on their prevalence of falls, rather than staffing, as in the prior version of the memo,” said Cantinieri. “State Agencies use health inspection scores, and the prevalence of falls is a criterion to consider in that determination.”

Graduation from SFF program

A nursing home will graduate from the SFF program after two consecutive standard health surveys with 12 or fewer deficiencies at level “E” or below, the memo notes. Facilities cannot graduate if any survey shows deficiencies at “F” or higher, LSC/EP deficiencies at “G” or higher, 13 or more total deficiencies, or pending complaint surveys triaged as Immediate Jeopardy or Non-IJ High. Graduation requires the facility to have returned to substantial compliance across all surveys.

Also unchanged from past guidance is the monitoring period. CMS will monitor SFF graduates for three years, and facilities showing continued serious deficiencies may face enhanced enforcement, including possible termination from Medicare or Medicaid.

Since each state has a designated number of SFF candidates and SFF facilities, Cantinieri said the revisions shouldn’t affect the number of facilities on the SFF list unless, of course, CMS decides to change the numbers in the individual states.

Operators hope for more improvements

For Steve LaForte, CEO and principle at Cascadia Healthcare, the move away from staffing is positive.

“[It] hopefully relates to more realistic assessments of the demographics of staffing, and also that quality care can be provided without arbitrary staffing rations,” he said, adding, “The move to falls could result in more difficult and subjective survey applications, makign it more difficult for facilities to work through the process, but it really depends on how it is applied.”

As changes get made to the SFF program, LaForte is continuing to look for some collaboration from CMS on keeping facilities open, while improving quality of care.

“One way to do this is create incentives in the program for quality operators to take over SFF facilities, but, as we have experienced in the past, CMS employs survey tactics that disincentivize those turnarounds, and I worry the ultimate result will be a loss of beds and a commensurate loss of access to care for older and vulnerable adults.”