Falls with major injury (N013): what counts, and for how long

Falls with major injury is a small measure with a long memory. One J1900C coded on one assessment can count against a building for about a year, and it counts whether or not the resident has fallen since.

It is CMS measure N013.02, built only from the MDS, and one of the long-stay measures in the Five-Star quality rating. There is no risk adjustment.

Who is counted

The denominator is every long-stay resident (101 or more cumulative days in the current episode) with at least one assessment in the look-back scan, described below. A resident is in the numerator if any assessment in that scan has J1900C coded 1 or 2: one major-injury fall, or two or more. A resident is excluded only if J1900C is dashed on every assessment in the scan.

How far back the measure looks

This is where people get confused, because two CMS documents describe it differently. The Five-Star guide says the measure covers the target period or look-back period, “one full calendar year.” The QM User’s Manual gives the rule itself:

The same page explains why the two descriptions agree:

So, precisely:

• The scan is made of assessments, not falls. It takes the target assessment and every earlier qualifying assessment whose date is no more than 275 days before it.
• Qualifying means an OBRA assessment (admission, quarterly, annual, significant change or correction), a PPS 5-Day, or an OBRA discharge.
• Each of those assessments reports falls since the one before it. That is how 275 days of assessments reach back about a year in falls.
• The scan stays inside the current episode. A hospital stay the resident returns from within 30 days is a reentry, not a new episode, so it doesn’t reset anything.

Nothing but time clears it. A significant change assessment is just one more assessment in the scan. The one other way out is a modification that corrects a J1900C that was wrong.

What counts as a major injury now

CMS revised the fall and injury definitions in RAI Manual v1.20.1, effective October 1, 2025, and they carry into v1.20.11, effective October 1, 2026. If your team learned a short list of four injuries (fractures, dislocations, closed head injury with altered consciousness, subdural hematoma), that list is out of date. The current wording:

Three more rules from the same pages decide most close calls:

• Injury except major (J1900B) includes skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains, or any fall-related injury that makes the resident complain of pain.
• The injury has to be attributed to the fall. It counts if it happened as a result of the fall or was recognized within a short time after it, hours to a few days, and attributed to it.
• Pathologic fractures are not major injuries. If a physician confirms the fracture came from the resident’s bone disease, not the fall, J1800 is still Yes but J1900C is 0. If the physician attributes it to the fall, it is traumatic and J1900C is coded.

An injury found after the ARD

Fractures don’t always show on the first film. The RAI Manual tells you to look past the ARD for follow-up results such as an emergency room X-ray, MRI or CT, and to fix the assessment if the injury level changes:

That works in both directions. A hairline fracture found three days later means modifying a J1900B up to J1900C. A major injury coded in error, where the chart shows no injury, is corrected down the same way.

What changed in October 2026

RAI Manual v1.20.11 rewrote the J1800 steps for assessment (page J-35). Step 1 now covers the first assessment after an admission (A0310E = 1 and A1700 = 1): review from the admission date to the ARD. Step 2 now covers the first assessment after a reentry (A0310E = 1 and A1700 = 2): review from the reentry date (A1600) to the ARD. It replaced the old step 2, which set the review period for later assessments as the day after the prior ARD through the current ARD.

The J1900 steps did not change; they still set the review period from the day after the last ARD. Step 3 of J1800 still says to include falls in any setting since the last assessment, including an acute hospital. If you aren’t sure where a fall that happened around a hospital transfer belongs, ask your State RAI Coordinator before you code it.

Common coding mistakes

• Coding up. A laceration, bruise, skin tear or sprain is J1900B, even if the resident went to the emergency room for it.
• Coding without the attribution. A fracture found weeks later with nothing tying it to a fall is not automatically a fall with major injury. The physician’s note is what ties them together.
• Missing the late finding. The quarterly was submitted with J1900B, and the repeat X-ray shows a fracture. The assessment has to be modified.
• Skipping falls that didn’t happen in the building. Falls on an outing, or during therapy with safety measures in place, are still falls.

What supports the code: the incident report, the nursing note, the imaging result, and the physician’s note saying whether the injury came from the fall. Keep them together, because one J1900C affects your rate for about a year.

How Five-Star scores it

Falls with major injury is a 100-point measure. Buildings are split into fifths on the national distribution, and the rate is the four-quarter average weighted by each quarter’s denominator.

Because one fall stays in the scan for about four quarterly assessments, a single resident can show up in all four quarters of the same Five-Star window.

SuperQM lays the fall note next to the J1900 code the day the fall is charted, and shows the date each coded fall leaves the scan.