To put someone in a nursing home, you need a physician’s written order that the person requires daily skilled nursing or rehabilitation care that can only be delivered in an inpatient facility, legal authority to act for them if they cannot consent on their own, a completed state preadmission screening, and a plan to pay through Medicare, Medicaid, private funds, or long-term care insurance. The steps below walk through each piece in the order most families face them.
Step 1: Confirm a Nursing Home Is Medically Appropriate
A nursing home, formally a skilled nursing facility, is for people who need hands-on care from nurses or therapists every day. Federal rules require that the person need skilled nursing or skilled rehabilitation services on a daily basis, and that those services realistically can only be provided in an inpatient setting rather than at home or in an outpatient clinic.1eCFR. 42 CFR 409.31 – Level of Care Requirement Common triggers are recovery from a stroke or hip fracture, advanced dementia that requires around-the-clock supervision, or complex wound care a family cannot safely manage.
A physician must personally approve the recommendation in writing before admission.2eCFR. 42 CFR 483.40 – Physician Services The physician has to determine that the person’s clinical needs cannot be met safely through outpatient care, home health, or assisted living. If the plan is a short-term Medicare-covered rehab stay, additional hospital-stay requirements apply, covered under payment below.
Step 2: Confirm Consent or Get Legal Authority
A competent adult cannot be placed in a nursing home against their will just because family believes it is safer. If the person understands the risks of living independently and refuses, family generally cannot override that decision, and the facility itself will require either the resident’s own consent or someone with legal authority to consent for them.
When a person genuinely cannot make safe decisions because of cognitive impairment or serious mental illness, a family member can petition the court for guardianship, called conservatorship in some states. Courts typically require a medical evaluation showing the person lacks decision-making capacity and hold a hearing before a judge determines placement is in the person’s best interest. Because guardianship strips away autonomy, courts treat it as a last resort and usually require proof that less restrictive alternatives, such as in-home aides, medication management, or assisted living, have been considered or tried.
If the person signed a durable power of attorney for health care while they still had capacity, the named agent can consent to admission. Without either a health care power of attorney or guardianship papers, you generally cannot sign the admission contract or consent to treatment on someone else’s behalf.
Step 3: Gather Documents and Complete PASRR Screening
Admission requires two categories of paperwork: medical records and legal authority documents. Missing either can delay things significantly.
Medical Records
The facility must have physician orders covering the person’s immediate care needs at the time of admission.3eCFR. 42 CFR 483.20 – Resident Assessment In practice, plan to bring:
- Recent medical history, including diagnoses, hospital discharge summaries, and rehab notes
- A current medication list with dosages and schedules
- A negative tuberculosis screening result, which state health departments typically require before or shortly after admission
- Insurance information: Medicare and Medicaid numbers, supplemental insurance cards, and any long-term care policy details
Legal and Advance Directive Documents
Bring the health care power of attorney or guardianship order that establishes decision-making authority. Federal law also requires the facility to ask about advance directives such as a living will or do-not-resuscitate order, and to document and follow those preferences. If the person has a POLST or MOLST form (Physician Orders for Life-Sustaining Treatment), bring it, because those translate end-of-life preferences into medical orders that staff must follow across care settings.
PASRR Screening
Before any nursing home admission, the state must conduct a Preadmission Screening and Resident Review, or PASRR, for anyone who has a mental illness or intellectual disability.4eCFR. 42 CFR 483.100 – Basis The screening determines whether a nursing home is the right setting or whether specialized community-based services would be more appropriate. A Level I questionnaire is completed for every applicant to check, even if no such diagnosis is known. The state Medicaid agency or the hospital discharge planner usually initiates the process.
Step 4: Choose a Facility
Not every nursing home provides the same quality of care, accepts the same payment types, or has beds open when you need one. Researching before a crisis gives far better options than scrambling after a hospital discharge.
Use the CMS Five-Star Ratings, But Read the Details
The Centers for Medicare & Medicaid Services rates every Medicare- and Medicaid-certified nursing home from one to five stars. The overall rating combines three separate scores: health inspection results, staffing levels, and quality-of-care measures.5Centers for Medicare & Medicaid Services. Five-Star Quality Rating System You can look up and compare facilities using the Care Compare tool on Medicare.gov.6Medicare. Find Healthcare Providers: Compare Care Near You
Look at each component score rather than just the overall stars. A facility might carry a five-star quality score but a two-star staffing score, which can mean good outcomes on paper alongside long waits for help day to day. State inspection reports available through Care Compare detail specific deficiencies and safety violations, how severe each was, and whether it was corrected.
Staffing and Specialty Care
Staffing levels are one of the strongest predictors of care quality. CMS collects payroll-based staffing data directly from nursing homes, so the hours reported on Care Compare come from actual payroll records rather than self-reported estimates.7U.S. Department of Health and Human Services Office of Inspector General. CMS Use of Staffing Data To Inform State Oversight of Nursing Homes Check total nursing hours per resident per day and whether a registered nurse is on site around the clock.
If the person has dementia, ask whether the facility runs a dedicated memory care unit. Federal regulations do not mandate separate staffing ratios for memory care, though CMS has noted that residents with Alzheimer’s and related dementias tend to have better outcomes in facilities with higher licensed-nurse staffing.8Federal Register. Medicare and Medicaid Programs; Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting Visit in person. Watch whether staff interact calmly and frequently with residents and whether the unit is secure against wandering.
Payment Fit and Availability
Before you settle on a facility, confirm it is certified to accept your expected payment source. Not every nursing home takes Medicaid, and some that do limit the number of Medicaid beds. Ask the admissions director about current bed availability, waitlist timing, and whether the facility can handle the specific needs involved, such as ventilator care, dialysis, or behavioral health support. If the resident is likely to start as private pay and transition to Medicaid once assets run down, confirm that the facility will let them stay in the same bed after that switch.
Step 5: Sign the Admission Agreement Carefully
On admission day, you will be asked to sign an admission agreement. It is a legally binding contract covering services, costs, billing, and facility policies on everything from visitation to medical emergencies. Read it before signing. Federal law requires nursing homes to provide equal services whether the resident pays through Medicare, Medicaid, or private funds, so any provision suggesting a higher level of care for private-pay residents is a red flag.9eCFR. 42 CFR 483.10 – Resident Rights
Watch for a binding arbitration clause. That is a provision under which you agree to resolve disputes, including negligence or abuse claims, through a private arbitrator rather than a court. Federal regulations prohibit a nursing home from making you sign this as a condition of admission or continued care, and the facility must explicitly tell you that you can refuse the arbitration agreement and still be admitted.10eCFR. 42 CFR 483.70 – Administration Pressure to sign as a prerequisite violates federal rules.
After signing, clinical staff perform an initial nursing assessment to establish a baseline, orient the resident to their room, and begin care under the physician’s admission orders. A fuller comprehensive assessment follows within 14 days and becomes the basis for the individualized care plan.3eCFR. 42 CFR 483.20 – Resident Assessment
How to Pay for Nursing Home Care
Nursing home care is expensive. National median cost runs roughly $9,300 per month for a semi-private room and about $10,600 per month for a private room, with wide variation by region. Most families cover the bill through some combination of Medicare, Medicaid, private funds, and long-term care insurance.
Medicare Covers Only Short-Term Rehab
Medicare Part A covers skilled nursing facility stays only for short-term rehabilitation, not long-term custodial care. To qualify, the person must have been admitted as an inpatient to a hospital for at least three consecutive calendar days, not counting the day of discharge.11eCFR. 42 CFR 409.30 – Basic Requirements Time spent under “observation status” does not count toward the three days, even if the person stayed overnight, and this distinction catches many families off guard.12Medicare. Inpatient or Outpatient Hospital Status Affects Your Costs Confirm with the hospital in writing whether your family member has been formally admitted as an inpatient.
If the three-day requirement is met, Medicare covers up to 100 days per benefit period in a skilled nursing facility:13eCFR. 42 CFR 409.61 – General Limitations on Amount of Benefits
- Days 1 through 20: Medicare pays the full cost with no copayment
- Days 21 through 100: the resident pays a daily coinsurance of $217 in 2026, with Medicare covering the rest14Medicare. Costs
- Day 101 onward: Medicare coverage ends and the resident pays everything
Coverage can also end before day 100 if the person is no longer receiving skilled care or is no longer improving under therapy. Medicare does not cover long-term custodial care for chronic conditions like advanced dementia where the primary need is supervision.
Medicaid Covers Long-Term Stays With Financial Limits
Medicaid, sometimes called Institutional Medicaid or Nursing Home Medicaid, is the primary payer for long-term nursing home stays. It can cover indefinite stays, but it has strict financial eligibility rules.
For 2026, most states cap countable monthly income at $2,982, which equals 300 percent of the federal Supplemental Security Income benefit of $994 per month.15Social Security Administration. SSI Federal Payment Amounts for 2026 The countable asset limit in most states is $2,000 for the applicant. Certain assets are typically excluded, most notably the applicant’s primary home up to a state equity limit, one vehicle, personal belongings, and a small amount of life insurance.
If the applicant has a spouse who is not entering the nursing home (the “community spouse”), federal spousal impoverishment protections allow that spouse to keep a share of the couple’s combined assets. For 2026, the protected amount ranges from a minimum of $32,532 to a maximum of $162,660 depending on the state and the couple’s total countable resources. The community spouse can also keep a monthly income allowance for living expenses.
The Five-Year Look-Back on Transfers
Federal law imposes a 60-month look-back on asset transfers before a Medicaid application.16Office of the Law Revision Counsel. 42 USC 1396p – Liens, Adjustments and Recoveries When someone applies for Medicaid nursing home coverage, the state reviews the previous five years of financial records for any assets given away, sold below fair market value, or transferred to family. If it finds such transfers, it calculates a penalty period during which Medicaid will not pay. The penalty length is the total value transferred divided by the state’s average daily cost of nursing home care.
Giving away assets, even to children or grandchildren, within five years of needing Medicaid can leave the applicant personally responsible for months or years of bills. Some transfers are exempt, including transfers to a spouse, transfers of the home to certain family members such as a child who lived in the home and provided care, and transfers by people who can prove the transfer was made exclusively for a reason other than qualifying for Medicaid. Anyone anticipating a future need for nursing home care should talk to an elder law attorney well before the five-year window.
Private Pay and Long-Term Care Insurance
Residents who do not qualify for Medicare or Medicaid pay out of pocket, often from savings, retirement accounts, or proceeds from selling a home. Long-term care insurance policies reimburse nursing home expenses up to a daily or monthly maximum, subject to a waiting period, commonly 30 to 90 days, and a benefit duration. If a policy is in place, contact the insurer before admission to understand the claims process and confirm the facility is eligible under the policy’s terms.
What Protects the Resident After Admission
Once admitted, the resident is covered by broad federal rights that apply regardless of cognitive status, payment source, or medical condition. These include dignity and self-determination, participation in care planning, visitation, privacy, control over personal finances, and equal treatment across payment types.9eCFR. 42 CFR 483.10 – Resident Rights
A nursing home also cannot simply ask a resident to leave. Federal regulations allow involuntary transfer or discharge only for six specific reasons: the facility cannot meet the resident’s needs, the resident’s health has improved enough that nursing home care is no longer necessary, the resident’s behavior endangers others’ safety, the resident’s condition endangers others’ health, the resident has failed to pay after reasonable notice, or the facility ceases to operate.17eCFR. 42 CFR 483.15 – Admission, Transfer, and Discharge Rights Except in emergencies, the facility must give at least 30 days’ written notice with the reason, effective date, and appeal information, and send a copy to the state Long-Term Care Ombudsman.
If problems come up, every state has a federally mandated Long-Term Care Ombudsman program that investigates and resolves complaints made by or on behalf of residents.18eCFR. 45 CFR 1324.13 – Functions and Responsibilities of the State Long-Term Care Ombudsman Contact information should be posted in the facility, and you can reach your local ombudsman through the federal Eldercare Locator at 1-800-677-1116.