Nursing Homes: Skilled Nursing and Long-Term Residential Care

Two Distinct Types of Nursing Home Care

Short-Term Skilled Nursing and Rehabilitation

After a hospitalization for surgery, a stroke, a hip fracture or a serious illness, many people need intensive rehabilitation before they can safely return home. A skilled nursing facility provides physical therapy, occupational therapy, speech therapy, wound care, IV therapy and 24-hour nursing supervision. The goal is recovery and discharge to a lower level of care.

Medicare may cover short-term skilled nursing facility care after a qualifying 3-day hospital stay, subject to strict conditions and significant cost-sharing after day 20. See our Medicare and long-term care guide for details.

Long-Term Custodial Care

Long-term nursing home care is for people with complex, ongoing medical needs who cannot be safely cared for at home or in assisted living. This includes people with advanced dementia, multiple chronic conditions requiring daily nursing management, or significant physical limitations requiring total care.

Medicare does not cover long-term custodial care. Medicaid is the primary payer for long-term nursing home care for people who meet financial and medical eligibility requirements. Private funds and long-term care insurance are other common payment sources.

Staffing in Nursing Homes

Staffing is one of the most important indicators of nursing home quality. Federal law requires nursing homes that participate in Medicare and Medicaid to have a registered nurse (RN) on duty at least 8 hours per day, 7 days a week, and a licensed nurse (RN or LPN) on duty 24 hours a day. Many advocates and researchers believe these minimums are insufficient.

When evaluating a nursing home, ask about:

• Registered nurse hours per resident per day (higher is better)
• Certified nursing assistant (CNA) hours per resident per day
• Staff turnover rate — high turnover is associated with lower quality care
• Staffing levels on evenings, weekends and holidays
• How the facility handles staffing shortages

Inspections and Quality Ratings

Nursing homes certified by Medicare and Medicaid are inspected annually by state survey agencies. Inspections assess health and safety standards, care quality and resident rights. Inspection reports are public records.

• Review the most recent inspection report on Medicare Care Compare
• Look for patterns of deficiencies — repeated citations for the same issue are a warning sign
• Check for abuse-related citations, which are especially serious
• Review any civil monetary penalties or enforcement actions
• Ask the facility to explain any significant deficiencies you find

How Nursing Home Care Is Paid For

• Medicare: covers short-term skilled nursing after a qualifying hospital stay — does not cover long-term custodial care
• Medicaid: the primary payer for long-term nursing home care for those who meet financial and medical eligibility — rules vary by state
• Private funds: many people pay out of pocket until they qualify for Medicaid
• Long-term care insurance: policies vary widely in covered settings, benefit amounts and elimination periods
• Veterans benefits: the VA may help eligible veterans pay for nursing home care

For a full comparison of payment options, see our guide to paying for long-term care.

Nursing Home Resident Rights

Federal law gives nursing home residents a broad set of rights, including the right to:

• Be treated with dignity and respect
• Participate in their own care planning
• Refuse treatment
• Privacy in their room and in communications
• File complaints without fear of retaliation
• Have family and friends visit
• Be free from abuse, neglect and exploitation
• Contact the Long-Term Care Ombudsman

The Long-Term Care Ombudsman program advocates for nursing home residents. Contact your state ombudsman through the Eldercare Locator at eldercare.acl.gov or 1-800-677-1116.