From Ohio IJs to National Policy Shifts – What Providers Need to Know

Beyond the Fine Print

August 22, 2025 Edition

Immediate Jeopardy in Ohio – 1st Quarter 2025

7 Immediate Jeopardies. 6 facilities. 5 resident deaths.

The first quarter of 2025 underscores familiar—and preventable—patterns: missed supervision, delayed infection response, Coumadin mismanagement, and CPR not initiated.

Breakdown of Tags:

• F689 – Accident Hazards/Supervision: Elopement led to resident death from exposure.
• F757 – Unnecessary Drugs (Coumadin): Fatal INR mismanagement.
• F742 – Psychosocial Concerns: Resident suicide after access to scissors.
• F690 – UTI/Bladder: Untreated infection progressed to sepsis and death.
• F684 – Quality of Care: Delayed clinical intervention; resident died of pneumonia and sepsis.
• F600 – Abuse/Neglect: Resident-to-resident aggression without care plan.
• F678 – CPR: Resident died after staff failed to initiate CPR, assuming hospice equaled DNR.

Key Takeaway: These IJs—five resulting in deaths—highlight the need for vigilance in supervision, medication safety, infection recognition, and CPR response. Facilities should review both the CMS 2567 and the facility POC summary for practical lessons.

Resources:

• CMS QCOR
• ODH Survey Reports
• IJ Bulletin 1st Quarter 2025

CMS Finalizes Fall 2025 MDS 3.0 Update

CMS has released the final MDS 3.0 Item Sets v1.20.1 v3 and Matrix, effective October 1, 2025, under the FY 2026 SNF PPS Final Rule.

Notable changes:

• Section R items (Living Situation, Food, Utilities) removed.
• Transportation moved from R0340 to A1255.

SNFs and vendors should update systems and workflows now to avoid disruption.

Read more here

Understanding CMS's Shift from "Audit" to "Data Validation Process"

CMS has transitioned from traditional audits to a data validation process starting in Fall 2025. Providers must be prepared for changes in oversight and compliance expectations. Randomly selected SNFs will be required to submit documentation supporting up to 10 MDS assessments within 45 days. Noncompliance could trigger a 2% Medicare payment reduction beginning with FY 2027. Providers should monitor iQIES for notifications, update Points of Contact, and ensure documentation workflows are ready.

• CMS FAQ – Data Validation Process

CMS Pauses Nursing Home Care Compare Updates

Effective July 30, 2025, CMS has paused data updates to Nursing Home Care Compare during the transition from QIES to iQIES.

• Updates will resume in October 2025.
• Goal: Ensure data accuracy during migration.

Details here

MDS Q&A: August Clarifications

Diabetic Foot Ulcers (M1040B)

• Even after surgical debridement, a diabetic foot ulcer remains coded as M1040B.
• It does not convert to a surgical wound (M1040E).

Staff Mood Assessment (D0500)

• The staff assessment must be done within the 7-day look-back period tied to the assessment reference date.
• It should not be completed after that timeframe.

Burns (M1040F)

• Only second- or third-degree burns caused by heat or chemicals are coded here.
• Radiation burns are excluded; they may be captured under I8000 if criteria are met.

Note: ODH invites providers to submit future Question of the Month items to Cheryl.Moya@odh.ohio.gov (subject line: Question of the Month).

Question of the Month

Summary: Q1 2025 Immediate Jeopardies in Ohio show fatal lapses in supervision, infection control, and emergency response. Meanwhile, providers must prepare for October's MDS changes, adapt to CMS's data validation process, note the temporary pause on Care Compare updates, and see the MDS question of the month.