Building closer relationships with facility staff and health care partners of nursings homes, such as hospital providers and pharmacies, is going to be key for the sector as providers navigate new and old compliance challenges in 2026.

Updates to the MDS and antipsychotic medication rules are creating new compliance challenges for nursing homes, even as some requirements ease. Providers are reassessing how prescriptions are coded and tracked, particularly for medications given on an as-needed basis, as filled prescriptions can now affect quality measures. These changes are pushing operators to strengthen relationships with pharmacy and hospital partners and to better document nonpharmacological interventions ahead of increased survey scrutiny.

And even though providers won’t have to worry as much about financial penalties tied to staffing now that the Biden-era federal staffing mandate has been repealed, facilities still need to focus on building stronger connections among staff. That’s because some compliance requirements on that front still in place.

One of those ongoing requirements – facility assessments – though demanding of precious staff time, also gives organizations a clearer, big-picture look at their staffing, sector leaders said.

According to Heather Haberhern, senior executive vice president of operations and onboarding at Health Dimensions Group, it’s important that providers maintain compliance with the facility assessment and accurately report their staffing levels and patterns, or they could face citations.

Besides, she said, facility assessments remain crucial to estimating the correct level of staffing.

“It’s beneficial to our communities that we’re able to determine what the appropriate staff levels are to meet the needs of our residents and communities at the end of the day,” she told Skilled Nursing News. “We should still be following what we said was necessary and appropriate for staffing levels in a given community.”

Joe Veno, president of consulting firm EF Senior Care, agreed that he felt a sense of relief at the mandate’s repeal because it would have been financially destabilizing for providers, but without some creative initiatives, facilities will have a tough time maintaining staffing levels.

To better meet compliance challenges in the coming year, leaders at EF Senior care, which has a consulting arm, have been encouraging their partner facilities to pay good wages based on skill and expertise, and train up staff and set a positive tone through leadership, Veno said.

“There’s a saying, ‘you get what you pay for’,” said Veno, adding, “Beyond looking for staff (to fit exact needs), we can train up and make them into what we hope and achieve their full potential.”

The company has created compensation ladder programs to give new employees opportunities to advance, Veno said.

“We’re always looking for new blood in our communities, and we have some cherished folks that, with a little support, a little time and little investment in them, they could be the stars of the future,” he said. “One of the initiatives is to enhance what we already have.”

MDS changes on psych meds

Haberhern said the initial messaging around updates to the minimum data set (MDS) was that therapy minutes had been removed. However, updates to antipsychotic medication rules could make quality tracking more complicated.

Haberhern said HDG is auditing their current MDS diagnoses for antipsychotic medication claims, looking for where a prescription was filled and not just medications administered.

“We’re going to want to foster a stronger relationship with our pharmacy partners,” she said.

Part of the anticipated change is around PRN medication administration, or medication given on an as-needed basis, she said. Previously, providers coded for any meds administered in a seven-day period. The changes mean that if the prescription was filled, it’s recorded in a way that impacts quality measures.

Surveyors are going to be looking for proof of nonpharmacological interventions. Veno said stronger relationships with hospital providers will be key.

“It’s critical the interdisciplinary team identifies the potential psych needs at admission and really fosters an environment to accommodate those needs,” he said. “A lot of people are coming in with needs. It’s just a pervasive aspect of the patients we care for now.”

He said surveyors are looking beyond the care plans to staff. They’re going to want to know if your staff have training in trauma informed care, he said.

“If the surveyors see staff understand the patient, they’re not reactionary, they’re calming the situation and treating the patient with dignity and respect, I think you’re much better off in a survey than with a staff that’s untrained,” he said.

SFF-related compliance on falls

And in 2026, CMS issued new compliance by issuing a revised memo strengthening the Special Focus Facility (SFF) program by directing state survey agencies to prioritize resident fall rates when selecting facilities for SFF designation. When facilities have similar compliance histories, those with higher fall prevalence may now be chosen. The change is driven by Office of Inspector General (OIG) findings that suggested facilities may be underreporting serious falls, including a September 2025 report showing nursing homes failed to report 43% of falls involving major injury and hospitalization among Medicare residents.

The latest revisions build on SFF reforms finalized in 2022 and 2023 and aim to accelerate improvement, reduce repeat noncompliance, and increase accountability for facilities that put residents at risk. Notably, CMS replaced prior emphasis on staffing levels data with falls prevalence as a key selection factor. Zimmet Managing Director Alicia Cantinieri noted surprise that CMS focused on overall fall prevalence rather than more detailed data on falls resulting in injury.

“[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,” Alicia Cantinieri, managing director of clinical reimbursement and regulatory compliance at Zimmet, told SNN. “State Agencies use health inspection scores, and the prevalence of falls is a criterion to consider in that determination.”