Lately, there has been a lot of noise about falls with major injury in nursing homes. And I mean a lot of noise.

Why? Falls are expensive, dangerous and potentially life-changing, all at once. They cost the healthcare system billions of dollars each year. They lead to hospital readmissions and emergency department use. They fracture not just bones, but residents’ confidence as well. And most unsettling of all, many have wondered if we’ve been undercounting and/or underreporting them.

If a resident falls in the forest — or, say, in a nursing home hallway — and no one documents it in the MDS, is it still a fall? In other words, does the incident make it into the reported numbers?

The OIG steps into the forest

The Office of Inspector General decided to find out. Its 2025 report landed with a thud: 43% of nursing home falls with major injury and hospitalization were not reported in the MDS. Forty-three percent. That is not a rounding error; it’s a reckoning.

OIG investigators matched hospital claims with nursing home records and found thousands of unreported falls. More striking, the homes with the lowest reported fall rates were often the least likely to have documented the falls that OIG confirmed. Low numbers, it turns out, didn’t necessarily mean fewer falls, just fewer entries. But to be abundantly clear, the way the OIG measured falls bears little resemblance to the coding guidelines in the MDS.

The reactions to the report were predictable and, honestly, fair. Some said, “See? We told you Care Compare was incomplete.” Others said, “You can’t judge a whole industry by what’s missing in one dataset, especially when you are using different datasets.” Both are right.

But the bigger story wasn’t about blame; it was about visibility. The OIG wasn’t accusing nurses of hiding the truth. Rather, the agency was exposing how the system itself can obscure what’s actually going on.

CMS responds

In May 2025, the Centers for Medicare & Medicaid Services convened a cross-setting Technical Expert Panel to reexamine the Falls with Major Injury quality measure. The panel’s charge was to make the QM more accurate, consistent and credible across settings.

Now, effective October 2025, CMS has redefined what it means to fall. Rather than just a descent to the floor, a fall is now “an unintentional change in position coming to rest on the ground, floor, or next lower surface, or the result of an overwhelming external force (like being pushed).” (As someone who once got knocked over by an overenthusiastic therapy dog, I appreciate the nuance.)

The new Falls QM still relies on MDS data, but CMS is clearly laying the groundwork to include claims and encounter data down the road. Translation: The invisible falls may soon have nowhere left to hide.

What does this mean for us?

First, fall rates will rise. We must brace ourselves. When the definition broadens and reporting improves, numbers go up. That doesn’t mean care has gotten worse; it means the underlying data definitions and focus on accuracy have changed.

Mainstream news coverage, of course, won’t be so considerate. Somewhere, a headline will scream: “Nursing Home Falls Surge Nationwide!” Pundits will blame the absence of a staffing mandate. And the public will shake their heads. Context, as usual, will be missing.

Finally, the legal world will notice. Plaintiffs’ attorneys will wave graphs in courtrooms, citing “rising falls” as evidence of neglect. We’ll need to explain, patiently and clearly, that data transparency is not the same as failure.

What can we do?

The simple answer is to keep doing what we do best: providing excellent care. Preventing falls is not a new science. We know that even though frail elders will sometimes fall despite our best efforts, prevention is best whenever possible. That means:

• Taking a look at our environments. Where can they be made safer? Lighting, flooring and clutter still matter.
• Encouraging movement. Residents who stretch, strengthen and stay active fall less and recover faster.
• Double-checking residents’ medications. Careful review of sedatives and antihypertensives can make a world of difference.

We already know what to do. The challenge is staying consistent when definitions, and headlines, shift beneath us.

However, we need to be better about telling our story before others beat us to it. Now is the time to communicate, communicate, communicate. Transparency is our ally, but only if we frame it first.

We must tell the new story about fall rates to:

• Families, who may panic when they see fall rates jump.
• Referral sources, who deserve to understand what the data really means.
• Residents, who need reassurance that more falls in the report does not mean less care at the bedside.
• Ombudsmen and community advocates, who can help translate these shifts into understanding instead of alarm.

Change is one of the few guarantees in this work. But when the change involves metrics, the numbers that define us, we can’t afford silence. We must get ahead of the narrative.

We learned this the hard way with the staffing data shift from the old Form 671 to Payroll-Based Journal reporting. Remember how it looked like we had suddenly fired all our RNs and replaced them with LPNs, dropping our overall staffing rates overnight? Of course this wasn’t true. But perception became reality, and we spent years explaining ourselves.

Let us not make that mistake again. This time, let us be proactive, transparent and proud of what accurate reporting really represents: not decline, but honesty. Because if a resident falls in the forest, and this time everyone does hear it, maybe that’s not a failure. Maybe it’s progress.

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.