In September 2025, the OIG released a report finding that nursing homes failed to report nearly half of resident falls with major injury.
In September 2025, the U.S. Office of Inspector General (OIG) released a report finding that nursing homes failed to report nearly half of resident falls with major injury and hospitalization in their required Minimum Data Set (MDS) assessments. This underreporting distorts federal quality measures, misleads consumers on Care Compare, and undermines efforts to improve resident safety. The fall evaluation is part of OIG’s larger body of work examining nursing home safety and oversight.
Key Findings from the Report
The OIG analysis revealed alarming gaps in fall reporting:
Extent of the problem: 43% of serious falls were never reported in MDS data, representing 18,369 out of 42,236 cases reviewed.
Facility factors: For-profit, chain-affiliated, and large nursing homes were more likely to underreport.
Resident impact: Younger residents, males, short-stay residents, and those with Medicare-only coverage were disproportionately affected.
Regional variation: Nonrural facilities and certain states (including California, Nevada, and Washington, D.C.) had the highest nonreporting rates—60% or more.
Distorted ratings: Ironically, facilities with the lowest reported fall rates on Care Compare were often those with the highest rates of nonreporting. Even some 5-star facilities failed to accurately report falls.
What This Means for Long-Term Care Facilities
For facilities, the OIG findings send a clear message: compliance is no longer just about reporting, but about validating that reporting is accurate and consistent across data sources. CMS is now implementing MDS validation audits and integrating Medicare claims data into quality measure calculations.
This means surveyors won’t just accept self-reported MDS data. They may cross-check fall logs, hospital transfer records, and resident charts against claims. Patterns of underreporting could trigger more serious deficiency citations or even referrals to the OIG for falsification.
Ultimately, strong Care Compare ratings will not shield a facility if reporting practices don’t hold up under scrutiny.
Action Steps for Facilities
To respond effectively and stay compliant, facilities should:
- Tighten fall reporting systems. Make sure all falls with major injury are entered into MDS accurately, even if information comes in after discharge.
- Conduct or outsource internal audits. Compare fall logs, incident reports, and hospital transfer data against MDS submissions regularly.
- Educate interdisciplinary staff. Ensure nurses, CNAs, rehab teams, and physicians understand reporting rules and documentation requirements.
- Prioritize fall prevention. Strengthen prevention programs, especially for high-risk groups (short-stay, Medicare-only residents).
- Track survey trends. Watch for heightened oversight in states with higher nonreporting rates.
- Prepare for audits. Keep documentation organized and ready for CMS validation reviews.
This OIG report is a warning shot: underreporting falls not only misleads families and regulators but also exposes facilities to compliance risks and reputational harm. To stay ahead, long-term care facilities must double down on accurate documentation, proactive fall prevention, and transparent reporting. Doing so strengthens regulatory compliance, enhances resident safety, and builds public trust.
Polaris Group’s experienced MDS consultants provide expert audits of your MDS processes, helping ensure accuracy, maintain compliance, and prepare your team for CMS validation reviews. Reach out today to strengthen your facility’s compliance and quality reporting.
Source: U.S. Department of Health & Human Services, Office of Inspector General. Nursing Homes Failed to Report 43 Percent of Falls With Major Injury and Hospitalization in Their Required MDS Assessments. September 2025 | OEI-05-24-00180
