CMS has finalized the next version of the Long-Term Care Facility Resident Assessment Instrument (RAI) User’s Manual, version 1.20.11.
CMS has finalized the next version of the Long-Term Care Facility Resident Assessment Instrument (RAI) User’s Manual, version 1.20.11, effective October 1, 2026. As with most RAI Manual updates, many of the changes involve minor clarifications and reference corrections. However, several revisions change how MDS coordinators, nurses and therapists should code specific items.
Below are the key CMS RAI Manual changes skilled nursing facilities should understand before October 1.
Federal MDS Coding Rules Come First
CMS updated both Chapter 2 and the Chapter 3 introduction with nearly identical language reinforcing a simple but important point: State or other payer requirements cannot replace, modify or add to CMS item definitions, coding instructions or response options for non-Section S items.
This requirement applies even when a state adds its own items to the Quarterly or PPS assessment sets. If a state auditor or payer contract attempts to override federal MDS coding logic, facilities can point directly to this updated language.
CMS also updated Section P, Restraints and Alarms, to cite the specific F-tags from Appendix PP of the State Operations Manual. The section now references F603 for locked or secured units and F604 for position-change alarms, making it easier for SNFs to trace CMS restraint-coding guidance back to its regulatory source during survey preparation.
New RAI Manual Guidance for Public Health Emergencies
CMS added substantial new guidance to Chapter 2, Section 2.3 regarding resident transfers during a declared public health emergency. When CMS invokes Section 1135 waiver authority, facilities should contact their CMS Location, State Agency and Medicare Administrative Contractor for guidance. CMS also added a direct link to its 1135 waiver resource page.
This represents new procedural guidance that did not exist in the previous version of the RAI Manual.
MDS Demographic Data Collection Gets a Refresh
Section A includes one of the more operationally significant changes. CMS removed the “resident interview” icon from Ethnicity (A1005), Race (A1010), Language (A1110) and Transportation (A1255).
CMS also introduced a new reassessment rule for ethnicity and race. If staff asked a resident about ethnicity or race less than one year ago, the facility may carry forward the previous response instead of asking again. Once one year or more has passed, staff must ask the resident again.
The change may appear small on paper, but it directly affects the workflow for interdisciplinary team members completing subsequent MDS assessments.
CMS Clarifies BIMS and Mood Interview Tie-Breakers
CMS added the same clarification to Sections C and D. If staff conduct multiple interviews during the look-back period, such as the BIMS in Section C or PHQ-2 to 9 in Section D, they should code the MDS using the interview conducted closest to the Assessment Reference Date (ARD).
The clarification establishes a clear rule for a coding question that frequently arises during MDS completion.
CMS Revises MDS Wound Care Coding Guidance
Section M includes some of the most substantive revisions in the October 2026 RAI Manual update. In three separate places, M0210, M1040 and M1200, CMS reiterates that applying an advanced wound care dressing or skin substitute to a pressure ulcer does not qualify as a surgical procedure and should not be coded as surgical wound care.
CMS also reversed its previous guidance for recurring pressure ulcers. Under the prior version, facilities coded a pressure ulcer that was present on admission, closed and later reopened at the same stage as “present on admission.”
Under the updated guidance, if the pressure ulcer genuinely heals and later reopens, staff should code it as a new occurrence rather than “present on admission,” regardless of the stage at which it returns.
Respiratory Therapy Coding Gets More Precise
CMS also made significant revisions to Section O, which covers special treatments and therapies. The updated RAI Manual explicitly states that only the time a respiratory therapist or respiratory nurse actively spends with the resident counts toward the 15-minutes-per-day threshold for respiratory therapy.
Self-administered nebulizer treatments and unsupervised incentive spirometry do not count toward the total. CMS also added worked examples explaining when a resident meets the threshold and when the resident does not, including a case in which staff should not check O0390D, Respiratory Therapy, because the resident never reached 15 minutes on any single day during the observation period.
CMS Updates MDS Guidance for Shortness of Breath and Falls
Section J includes two clarifications clinical staff should understand. Under J1100, Shortness of Breath, CMS now explicitly states that facilities should not require a resident to perform an activity, such as lying flat, solely to test for symptoms when the resident reports avoiding that activity because of shortness of breath.
Under J1800, Falls, CMS now defines the review period following a reentry as the period from the reentry date (A1600) through the ARD. This replaces the previous “day after last ARD” logic.
CMS Updates Language in PDPM Nursing Classification
Chapter 6 includes a terminology change across the Special Care High, Special Care Low and Clinically Complex classification tables. CMS replaced “resident qualifies as depressed” with “resident qualifies for depression signs and symptoms.”
This person-first language update does not change the underlying PDPM scoring logic. CMS also added a clarifying note under the Restorative Nursing Count explaining that toileting programs (H0200C and H0500) do not require day or minute documentation in the same way as other restorative services.
What the October 2026 RAI Manual Update Means for SNFs
None of these changes are dramatic on their own, but together they affect some of the highest-stakes areas of MDS coding and reimbursement, including wound care, therapy documentation and PDPM classification. With the updated CMS RAI Manual guidance taking effect October 1, 2026, SNFs should ensure MDS coordinators, wound care teams, therapy staff and other key members of the interdisciplinary team understand the changes and how they affect day-to-day practice.
This is exactly the type of transition Polaris Group helps skilled nursing providers navigate. Rather than leaving facilities to interpret CMS change tables on their own, we translate regulatory updates into practical, role-specific education and operational strategies that teams can put into practice. That support extends beyond a single RAI Manual release. Through ongoing compliance support, MDS and clinical reviews, mock surveys and interdisciplinary education, Polaris Group helps facilities strengthen accuracy, reduce risk and stay prepared as CMS guidance continues to evolve.
