How to Open a Nursing Home: Startup Planning Guide

Licensing, Facility Setup, and Medicare Enrollment Basics

You’ve probably had this thought at least once: “People always need care—maybe a nursing home is a stable business.”

Then reality hits. A nursing home is a large-scale, heavily regulated healthcare facility. It’s not something you start on your own with a small budget, and it’s not something you can “figure out later” after opening.

Before you go any further, read Points to Consider Before Starting Your Business. A nursing home multiplies every one of those considerations—funding, liability, staffing, and compliance.

You also need to be honest about fit. Passion matters because it helps you push through hard problems. Without it, people often look for an exit instead of solutions. If you’re unsure, revisit How Passion Affects Your Business.

Now ask yourself this question exactly as written: “Are you moving toward something or running away from something?”

If you’re starting mainly to escape a job or patch a short-term financial problem, motivation often fades once the work gets heavy. And this work is heavy.

Also do a risk and responsibility check. This type of business can mean uncertain income early on, long hours, difficult tasks, fewer vacations, full responsibility, and constant alignment with your family and support system.

Finally, talk to experienced owners—but be strict about who you talk to. Only talk to owners you will not be competing against.

You can use Business Inside Look as a guide for what to learn before you commit.

Here are smart questions to ask non-competing nursing home owners:

“What approvals and surveys took the longest before you could open your doors?”
“What part of your build-out or compliance work surprised you the most during pre-opening?”
“If you were starting again, what would you do earlier—financing, staffing, or certification prep?”

Step 1: Define Exactly What “Nursing Home” Means in Your Plan

Start by defining what kind of facility you’re planning to open. In the U.S., “nursing home” often overlaps with Medicare and Medicaid terms and state licensing categories.

Your pre-launch decisions usually include whether you’re targeting short-stay skilled nursing and rehabilitation, long-stay nursing care, or a mix. This also affects your real estate needs, staffing plan, and which approvals you pursue first.

Step 2: Confirm Demand and Competition in a Specific Area

Don’t validate demand at the state level. Pick a specific region and look for evidence that people need the services you plan to offer and that your business can earn enough to cover expenses and pay you.

A practical starting point is the federal comparison tool at Medicare Care Compare, which helps you compare Medicare-certified providers, including nursing homes.

You can also review how the federal Five-Star Quality Rating System works so you understand what families and referral sources may see when comparing facilities. The system includes an overall rating and separate ratings for health inspections, staffing, and quality measures.

Step 3: Decide Your Business Model and Ownership Structure Up Front

This is not a solo startup. A nursing home typically requires significant capital, a facility that meets strict life safety and building standards, and enough staff to operate around the clock.

That usually changes how ownership works. Some owners bring in partners, form a group with investors, or use a management company structure. Others own the real estate separately from the operating company.

If you’re unsure what fits, build your plan around who will run the day-to-day leadership role and who will fund the build-out and pre-opening costs. You can also review building a team of professional advisors early—legal, accounting, and healthcare compliance help can keep you from getting stuck.

Step 4: Check Whether Certificate of Need Applies in Your State

Some states use a certificate of need process for certain healthcare facility projects. If it applies to nursing facilities in your state, it can affect your timeline and even whether you can open at all in the location you want.

Because certificate of need rules vary by state, treat this as an early gate to check before you spend heavily on real estate, design, and staffing plans.

Step 5: Build a Real Startup Cost Picture Based on Your Size and Services

Startup costs are driven by size and scope. A smaller facility with fewer beds is different from a larger facility with specialized therapy space, dining areas, and multiple resident units.

Your job here is to list everything you need before opening, then price it. Use Estimating Startup Costs to structure your list so you don’t miss major categories.

Once you have a detailed items list, research pricing per item, compare vendors, and document assumptions in your plan.

Step 6: Choose a Property Strategy That Can Meet Facility Standards

Your site decision isn’t only about convenience. A nursing home must be designed, constructed, equipped, and maintained to protect health and safety, and federal participation rules include requirements tied to the physical environment.

Even if you’re leasing a building, you still need to confirm the property can be permitted, renovated, and approved for this use. Accessibility standards also apply to newly built or altered facilities covered by the Americans with Disabilities Act design standards.

If you need help thinking through location choices, review business location considerations, then bring your final candidates to your local planning and building offices for verification.

Step 7: Plan Licensing and Certification Paths Before You File Anything

Nursing home licensing is state-driven, and participation in Medicare and Medicaid adds federal certification requirements. This is where timelines often stretch.

A core federal reference point for Medicare and Medicaid participation is the requirements for long-term care facilities in 42 CFR Part 483, Subpart B.

For Medicare and Medicaid certification, state survey agencies perform initial surveys and periodic resurveys to determine whether providers meet participation requirements.

Step 8: Form Your Legal Entity and Tax Accounts the Right Way

Many U.S. small businesses begin as sole proprietorships because that’s the default structure when no separate entity is formed at the state level. Many later form a limited liability company for liability protection and clearer structure.

A nursing home is typically not treated like a small side business, so owners commonly use an entity such as a limited liability company or corporation from the start, especially when lenders, investors, or real estate deals are involved.

At a minimum, you’ll typically register your entity with your state, then obtain an Employer Identification Number through the Internal Revenue Service if needed for banking, payroll, and tax filings. For a walkthrough, see How to Register a Business.

Step 9: Build a Compliance Plan for Emergency Preparedness, Ethics, and Privacy

Participation requirements include emergency preparedness planning for long-term care facilities. Federal rules require an emergency preparedness program with specific elements, including an emergency plan, policies and procedures, a communication plan, and training and testing.

Federal participation rules also require a compliance and ethics program for each facility’s operating organization, with required components outlined in regulation.

Privacy is another foundational area. The Health Insurance Portability and Accountability Act rules apply to covered entities and business associates, and covered entities must comply with privacy and security requirements when the rules apply.

Workplace safety planning also matters before opening. For example, the Occupational Safety and Health Administration bloodborne pathogens standard applies to occupational exposure to blood or other potentially infectious materials.

Step 10: Plan Staffing as a Pre-Opening Requirement, Not a Post-Opening Problem

Staffing is not optional in a nursing home. You’ll need a plan that aligns with licensing and certification requirements and supports safe care from day one.

Even if you don’t personally plan to handle day-to-day facility leadership, you still need to plan key hires early enough to support build-out decisions, survey readiness, policy development, and vendor selection.

If you want a general framework for staffing decisions and timing, see How and When to Hire.

Step 11: Line Up Required Vendors and Service Agreements Before Surveys

Nursing homes commonly rely on contracted services that may be reviewed during licensing and certification readiness, depending on your scope and payer participation.

Examples can include dietary services support, pharmacy-related services, lab services, medical waste pickup, laundry systems, and clinical software systems. Your exact mix depends on your facility design and care scope.

Keep your agreements organized and ready to produce during inspections, lender due diligence, and insurance underwriting.

Step 12: Set Pricing and Payment Paths Based on Your Payer Mix

Pricing is not a single number in this industry. Many nursing homes work with multiple payers, and your rates and billing approach can vary based on the resident’s coverage and eligibility.

Even if you plan to accept private-pay residents, you still need to document your pricing strategy, the contracts you need, and how you will accept payment. A helpful baseline is Pricing Your Products and Services.

Step 13: Prepare Medicare and Medicaid Enrollment Documentation Early

If you plan to bill Medicare as an institutional provider, enrollment typically involves completing and submitting the CMS-855A enrollment application, followed by review steps that involve the Medicare administrative contractor and the state survey process.

If you plan to participate in Medicaid, state enrollment steps and provider agreements are also typically required. Build this into your pre-opening timeline because processing and survey scheduling can be a gating item.

Step 14: Choose a Name, Then Lock Down Your Online Identity

Pick a name that fits a healthcare setting and can be used consistently in licensing paperwork, payer enrollment, and marketing.

Once you have a short list, secure the domain and matching social handles if available. For naming strategy, see selecting your business name.

Step 15: Build Brand Assets That Support Trust and Verification

A nursing home is a high-trust decision for families. Your brand assets should help people verify who you are and how to reach you.

At a minimum, plan for a basic corporate identity package, a simple website, business cards, and exterior signage where allowed by local rules.

Useful references include corporate identity considerations, an overview of developing a business website, what to know about business cards, and business sign considerations.

Step 16: Plan Your Pre-Launch Marketing and Referral Approach

You still need a plan for how residents will find you. For a nursing home, marketing can include community awareness and referral relationships, depending on your payer mix and location.

If you’ll operate as a physical location serving a defined area, review how to get customers through the door and adapt it to a healthcare environment and local rules.

If a grand opening fits your timeline and local expectations, you can pull ideas from Ideas for Your Grand Opening.

Overview of a Nursing Home

A nursing home is a residential healthcare facility that provides nursing care and supportive services for people who need ongoing assistance and clinical oversight.

Facilities may serve short-stay residents recovering after a hospital stay, long-stay residents who need ongoing nursing support, or both, depending on licensing and payer participation.

How Does a Nursing Home Generate Revenue?

Nursing homes commonly generate revenue through a mix of payer sources, depending on the resident and the services provided.

That mix can include private-pay arrangements and participation in public programs such as Medicare and Medicaid when the facility is licensed, certified, and enrolled as required.

Products and Services Offered by a Nursing Home

Services vary by facility scope, licensing category, and payer participation. Your pre-launch plan should describe what you will offer so regulators, lenders, and partners can evaluate your readiness.

Common service categories include:

24/7 nursing care and clinical monitoring
Assistance with activities of daily living such as bathing, dressing, and mobility support
Medication administration and medication management processes
Rehabilitation services planning, such as physical therapy, occupational therapy, and speech therapy, when offered
Dining and nutrition services
Social services support and care planning coordination
Activities and structured programs, depending on resident needs and facility design

Types of Customers for a Nursing Home

In this business, “customers” can mean more than one group. Your marketing and contracts may involve both the person receiving care and the people or organizations helping them choose a facility.

Common customer and referral groups include:

Residents who need nursing care and supportive services
Family members and legal representatives making placement decisions
Hospitals and discharge planners referring post-acute residents
Physicians and care teams involved in discharge planning
Public payers and managed care organizations, depending on your participation and contracts

Pros and Cons of Owning and Operating a Nursing Home

This is a high-responsibility business with strict rules and high public visibility. Listing pros and cons now helps you decide whether to proceed and helps shape your business plan.

Potential advantages can include:

Ongoing demand for long-term care services in many communities
Opportunities to serve both short-stay and long-stay populations depending on licensure and certifications
A facility-based model that can support structured processes and repeatable service delivery

Potential drawbacks can include:

High startup costs tied to real estate, build-out, and equipment
Extensive licensing, certification, and survey requirements before opening
Significant liability exposure and strict documentation and privacy requirements
Staffing needs that begin before opening and continue every day once operating

Essential Equipment and Setup Items

This is a detailed, pre-opening equipment and setup list you can use to build your startup items sheet. Your final list depends on bed count, building layout, payer participation, and services offered.

Build the list first, then research pricing per item. Size and scope drive total startup cost.

Resident Rooms and Resident Care Areas

Hospital beds, based on care level
Pressure-reducing mattresses and overlays
Bedside tables and overbed tables
Resident wardrobes or closet systems
Resident room seating
Privacy curtains and track systems where required
Nurse call system with room and bathroom capability
Wheelchairs in various sizes
Walkers and rollators
Transfer aids such as gait belts and transfer boards
Mechanical lifts and slings
Stand-assist devices where appropriate
Shower chairs and commode chairs
Grab bars and bathroom safety hardware
Vital signs monitors (blood pressure, pulse oximetry, thermometers)
Glucose monitoring supplies if applicable
Resident charting stations as designed

Nursing and Clinical Equipment

Medication carts and locking storage systems
Secure medication room cabinetry and safes where required
Medication refrigeration where applicable
Treatment carts and supply carts
Wound care supply storage systems
Portable suction units where applicable
Oxygen storage and delivery setup where applicable
Sharps containers
Personal protective equipment storage and stations
Hand hygiene stations and dispensers
Clinical sinks and eyewash stations where required

Infection Prevention and Cleaning

Handwashing sinks and fixtures in required areas
Alcohol-based hand rub dispensers where permitted
Cleaning carts and locking chemical storage
Approved disinfectant storage and labeling systems
Isolation supplies storage areas where applicable
Biohazard waste containers and labeling systems
Soiled utility room fixtures and containers

Dietary and Kitchen

Commercial refrigeration and freezer units
Commercial ovens and ranges where applicable
Warming equipment such as steam tables where applicable
Commercial dishwashing equipment
Food prep tables and cutting surfaces
Food storage shelving and sealed containers
Temperature monitoring tools for food and refrigeration
Dining room tables and chairs
Adaptive dining utensils and dishware as needed

Laundry and Linen

Commercial washers and dryers if in-house
Linen carts and storage racks
Soiled linen containers and transport carts
Laundry folding tables and shelving

Housekeeping and Facility Support

Vacuum cleaners and floor care equipment
Floor scrubbers or buffers where applicable
Spill kits and safety signage
Tool storage and maintenance equipment
HVAC monitoring and maintenance tools as needed
Water temperature and safety controls where required

Safety, Fire, and Emergency Preparedness

Fire alarm systems and monitoring equipment
Emergency lighting at exits and critical areas
Emergency power generator system where required
Smoke alarms where required
Emergency communication devices
First aid kits and emergency response kits
Evacuation equipment such as chairs or sleds where applicable

Rehabilitation and Activities Spaces

Therapy mats and treatment tables if offering therapy services
Parallel bars and gait training equipment where applicable
Exercise equipment appropriate to resident populations
Adaptive equipment storage systems
Activity room furniture and storage cabinets
Audio-visual equipment for group activities

Administrative and Technology

Computers for clinical and administrative staff
Secure network equipment and secure Wi-Fi
Printers and scanners for regulated documentation
Phone system and call routing
Secure document storage systems
Access control systems for restricted areas
Timekeeping and payroll systems

Transportation (If Provided)

Wheelchair-accessible vehicle or transport agreements where applicable
Vehicle safety equipment and securement systems
Wheelchair ramps and loading equipment

Skills Needed to Operate a Nursing Home

You don’t need to personally have every skill, but you do need to make sure the skills exist in your leadership team before opening. If you don’t have a skill, you can learn it or staff for it.

Common skill areas include:

Healthcare regulatory literacy and survey readiness planning
Clinical leadership oversight through qualified staff
Risk management and documentation discipline
Budgeting, financial forecasting, and cash flow planning
Vendor contracting and service agreement review
Human resources systems and credential tracking
Privacy and security awareness where protected health information applies
Emergency preparedness planning and training coordination

Day-to-Day Activities to Operate a Nursing Home

This section is here for one reason: to help you plan pre-launch staffing and leadership coverage. If you don’t understand what normal days look like, it’s hard to build a realistic startup plan.

Common daily activity categories include:

Reviewing clinical reports and incident logs through qualified staff leaders
Coordinating staffing coverage and credential verification
Monitoring compliance items tied to surveys and participation rules
Managing vendor and service coordination (dietary, pharmacy-related, lab, waste, maintenance)
Handling family communications and care planning meetings through your team
Responding to complaints, documentation requests, and survey-related communication

A Day in the Life for a Nursing Home Owner

Some owners are on-site daily. Others focus on governance, finance, and compliance while a licensed administrator runs the building. Either way, ownership involvement tends to be steady.

A typical owner day may include reviewing financial performance, checking staffing coverage, meeting with senior leaders, signing vendor agreements, and tracking readiness items tied to surveys and inspections.

Business Models for a Nursing Home

Business models vary based on who owns the real estate, who runs the facility, and which payer programs you participate in.

Common models include:

Owner-operator model with a licensed administrator leading daily operations
Real estate owned by one entity and operations run by a separate operating company
Multi-facility ownership group with centralized administration and compliance functions
Private-pay focused model versus Medicare and Medicaid participation model, or a mix

Red Flags to Look for in a Nursing Home

This matters most if you plan to buy an existing facility, buy into an operating company, or take over a property marketed as ready to open. Red flags can also help you understand what regulators and families look for.

Examples of red flags you can research before committing include:

Poor performance shown in public comparison tools such as Care Compare star ratings
History of serious compliance issues reflected in Special Focus Facility listings or related oversight reporting
Repeated inspection problems tied to infection control and life safety issues
Unclear ownership history, unclear licensing status, or gaps in certification documentation
Real estate that cannot realistically meet required life safety, accessibility, and physical environment standards

Legal and Compliance Basics

This is a location-aware business. You’ll be dealing with federal participation rules if you want Medicare or Medicaid payment, plus state licensing rules, plus city and county building and zoning requirements.

Keep your approach simple: identify what applies, confirm it with the right office, and document what you learn. If you want a practical business registration framework, start with How to Register a Business, then layer on healthcare licensing and certification steps.

On insurance, you’ll typically plan for general liability and property coverage as part of launch readiness. For an overview, see business insurance basics.

Varies by Jurisdiction

Rules differ by state, county, and city. Use this checklist to verify requirements locally before you sign a lease, buy a building, or submit applications.

Here’s where to verify locally and what to search:

State licensing agency: Search your state site for “nursing home licensing” or “nursing facility licensure” plus your state name.
State survey agency: Search your state health department site for “state survey agency nursing home certification” plus your state name.
State Medicaid agency: Search “Medicaid provider enrollment nursing facility” plus your state name.
City or county planning and zoning: Search your city or county site for “zoning lookup,” “use permit,” and “nursing home” or “healthcare facility.”
Building department: Search “certificate of occupancy requirements” plus your city or county name.
Fire marshal: Search “life safety inspection healthcare facility” plus your jurisdiction.

Smart questions to ask when you contact offices:

“What approvals must be completed before I can apply for a nursing facility license in this jurisdiction?”
“Does this use require a special use permit, and what triggers a public hearing?”
“Which inspections must be passed before a Certificate of Occupancy is issued for this use?”

Pre-Opening Checklist

This is your final readiness sweep. The goal is simple: no missing approvals, no missing equipment, and no missing setup steps that delay opening.

Before you announce an opening date, confirm:

Entity registration is complete and your tax accounts are active
Licensing and certification steps are scheduled or completed as required
Life safety and building approvals are complete for your facility type
Emergency preparedness documentation and training plans are prepared
Compliance and ethics documentation is prepared where required
Privacy and security policies are in place where protected health information applies
Key leadership roles are filled and credential tracking is organized
Vendor agreements needed for launch are signed and documented
Your website and contact paths are live and accurate
You have a plan for how residents and families will find you at launch

101 Tips for Operating a Profitable Nursing Home

In this section, you’ll find practical tips that cover many parts of running a nursing home.

Use the tips that match where you are right now, and save the rest for later.

It helps to pick one tip, put it into practice, and then move on to the next.

If you’re building your routines from scratch, start with the early categories and work forward.

What to Do Before Starting

1. Before you buy or lease anything, confirm your state’s nursing facility licensing category for the care level you plan to provide.

2. If you plan to bill Medicare or Medicaid, build your timeline around certification surveys and enrollment steps; opening dates often depend on them.

3. Read the federal long-term care participation requirements end to end and turn each section into a checklist you can audit.

4. Create a document library before opening so policies, procedures, contracts, and inspection records are easy to produce on request.

5. Choose a bed count and service mix you can staff safely on day one; profit disappears fast when you open understaffed.

6. Design your building flow to reduce falls and wandering risk—traffic patterns and sight lines affect safety and staffing needs.

7. Plan a quality program early using a structured approach; it is easier to build good habits before residents move in.

8. Build a compliance calendar before opening that includes required reviews, trainings, drills, and documentation updates.

What Successful Nursing Home Owners Do

9. Treat surveys like a routine business process: do internal audits on a schedule, not only when you hear inspectors are coming.

10. Track a small set of “must-not-fail” measures weekly, such as falls, pressure injuries, weight loss, and medication incidents.

11. Hold short daily huddles with department leads to surface risks early and assign same-day fixes.

12. Keep resident rights central in policies and staff training; complaints often start when residents feel ignored or rushed.

13. Use root-cause thinking after any serious incident; fix the system, not only the person.

14. Write clear job expectations for every role and keep them current; confusion creates errors and turnover.

15. Build relationships with hospitals, discharge planners, and community providers long before you need referrals.

16. Standardize how you communicate with families—updates, meetings, and escalation paths reduce conflict.

17. Keep vendor performance measurable; written service levels help you control quality and cost.

18. Review your payer mix monthly and understand how it affects cash flow timing and staffing decisions.

Running the Business (Operations, Staffing, SOPs)

19. Create a “day-one readiness” binder for every shift that includes emergency contacts, key policies, and escalation rules.

20. Use consistent documentation routines for care notes; incomplete notes become compliance risk and billing risk.

21. Set up a secure process for medication storage and access control; limit keys and track access.

22. Schedule regular medication reconciliation reviews with clinical leadership to reduce errors during transitions of care.

23. Build a staffing model that accounts for planned absences; relying on last-minute coverage is expensive and unsafe.

24. Cross-train supervisors to cover critical functions during sick calls and vacations.

25. Establish a clear chain of command for nights and weekends so staff know who can make decisions.

26. Use structured shift handoffs with a checklist; many avoidable errors happen during handoff gaps.

27. Keep a written falls-prevention protocol that includes assessment, environment checks, and post-fall review steps.

28. Implement a pressure injury prevention routine with risk screening, repositioning plans, skin checks, and supply availability.

29. Create a standardized process for meal assistance and hydration checks for residents who need support.

30. Audit call-light response patterns; slow response is a customer service issue and a safety issue.

31. Maintain clear cleaning and disinfection schedules by area, with sign-offs that can be verified.

32. Store chemicals securely and label them consistently; mix-ups cause injuries and inspection findings.

33. Maintain a routine for equipment checks, such as lifts, wheelchairs, alarms, and oxygen storage when used.

34. Set up a preventive maintenance calendar for building systems; failures create immediate life-safety risks.

35. Use a documented process for handling complaints: receive, log, investigate, respond, and close the loop.

36. Keep admission and discharge processes tightly managed with checklists; transitions are high-risk moments.

37. Train staff on de-escalation and respectful communication; conflict often starts with tone, not policy.

38. Create a staffing and competency file system that is easy to audit, including licenses, training, and background checks where required.

39. Establish a written exposure control plan if staff have occupational exposure to blood or other potentially infectious materials.

40. Make hand hygiene easy: place supplies where work happens, not where it is convenient for storage.

41. Run regular emergency drills that match your risks, such as power loss, fire, and severe weather, and document lessons learned.

42. Use a structured quality improvement cycle for recurring problems; pick one issue, test a change, measure, and adjust.

43. Protect resident information with role-based access; only staff who need information should be able to view it.

What to Know About the Industry (Rules, Seasons, Supply, Risks)

44. Learn how the public quality rating system is calculated and what data feeds it; it can affect reputation and referrals.

45. Monitor your facility’s public profile routinely so you can correct factual errors quickly.

46. Expect rules to differ by state on staffing, reporting, and facility requirements; keep a state-specific compliance checklist.

47. Treat infection prevention as a year-round program, not a seasonal task; outbreaks can destroy occupancy and morale.

48. Build a clear visitor policy and update it when public health conditions change; confusion creates conflict at the front desk.

49. Understand that complaint investigations can be triggered by residents, families, staff, or outsiders; teach staff how to respond professionally.

50. Plan for survey backlogs and changing inspection cadence; maintain readiness rather than timing your preparation.

51. Know which events must be reported to state agencies in your jurisdiction and track them consistently.

52. Treat resident rights requirements as non-negotiable business rules; violations can lead to serious penalties.

53. Keep your emergency preparedness program current with annual reviews and updates; inspectors may ask for evidence.

54. Build a cash buffer for delayed payments and unexpected staffing costs; healthcare payment timing can be uneven.

55. If you operate as part of a group, standardize compliance basics across sites but allow local rules to override when required.

Marketing (Local, Digital, Offers, Community)

56. Build your marketing around trust signals: clear services, transparent visiting information, and easy-to-find contact routes.

57. Keep your phone response and follow-up fast; families often call several facilities in one day.

58. Create a simple “what to expect” guide for tours that explains care services, room options, and next steps.

59. Train tour staff to answer questions factually and to document follow-up tasks the same day.

60. Maintain relationships with hospital discharge planners by being responsive and dependable, not pushy.

61. Track which referral sources send residents who stay longer; focus outreach on sources that match your care strengths.

62. Use community presentations to educate, such as fall prevention or caregiver support topics, and invite questions.

63. Keep your website updated with accurate admissions criteria, visiting information, and contact details; outdated information loses leads.

64. Ask satisfied families for feedback you can use internally to improve your tour and communication process.

65. If you advertise, set clear expectations for response time and staffing capacity so you do not overpromise.

Dealing with Customers (Trust, Education, Retention)

66. Treat families as partners by giving them a predictable update rhythm, especially during the first two weeks after admission.

67. Explain care plans in plain language and confirm understanding; confusion often turns into complaints later.

68. Document family preferences and communication boundaries so staff do not reinvent the wheel every shift.

69. Provide a clear path for concerns: who to contact first, what happens next, and when they will hear back.

70. Use a consistent welcome routine for new residents to reduce anxiety and improve early satisfaction.

71. Offer realistic expectations about therapy, recovery, and daily routines; “surprises” damage trust.

72. Make it easy for families to participate in care planning meetings, including remote options when appropriate.

73. Track early-warning signs of dissatisfaction, such as repeated call-light complaints or meal refusals, and intervene quickly.

74. When a resident’s condition changes, communicate early and document the conversation; silence creates suspicion.

75. If you cannot meet a specific need, say so clearly and help coordinate alternatives; honesty protects your reputation.

Customer Service (Policies, Guarantees, Feedback)

76. Write service standards for front desk, phone, and tour experiences; these touchpoints shape first impressions.

77. Use a formal grievance log and review it in leadership meetings; patterns reveal process problems.

78. Give staff scripts for common hard conversations, like room changes, visitation limits, or safety restrictions.

79. Build a “no surprises” billing communication routine that explains charges and payer coverage limits upfront.

80. Set response-time goals for family messages and track performance; delays feel like neglect even when care is good.

81. Use resident and family satisfaction surveys on a schedule and share themes with staff, not only leadership.

82. Treat complaints as data for improvement; follow up with the person who raised the issue after changes are made.

83. Keep service recovery consistent: apologize when appropriate, explain what you will do, and confirm when the fix is complete.

Staying Informed (Trends, Sources, Cadence)

84. Assign one person to monitor federal nursing home updates and distribute a monthly summary to leadership.

85. Review official guidance updates when quality measures, staffing reporting, or survey guidance changes.

86. Track inspection findings from your own surveys and compare them to common deficiency areas in your state.

87. Keep a short list of “must-read” sources and schedule time to review them, such as monthly or quarterly.

88. Attend reputable training on quality improvement and survey readiness, then turn the lessons into updated procedures.

89. Keep a change log for policies and forms so staff know what changed and when.

Adapting to Change (Seasonality, Shocks, Competition, Tech)

90. Build contingency staffing plans for flu season and other predictable surges; waiting until people call out costs more.

91. Stress-test your emergency plan for long power outages, supply disruptions, and staffing shortages, then update your plan.

92. Evaluate new technology by whether it improves documentation accuracy, communication speed, or safety—not by novelty.

93. After any major change, run a short audit to confirm staff are following the new process and understand why.

94. When competitors change pricing or services, respond by clarifying your strengths and improving experience, not by racing to the bottom.

95. Keep vendor alternatives ready for critical services so one failure does not stop operations.

What Not to Do

96. Do not wait for a survey to fix known problems; inspectors typically find what your staff already know.

97. Do not let documentation become an afterthought; if it is not documented, it is hard to defend.

98. Do not ignore small maintenance issues; minor hazards often lead to falls and larger repairs.

99. Do not treat training as a one-time event; turnover and changing guidance require refreshers.

100. Do not allow casual sharing of resident information; privacy breaches damage trust and can trigger enforcement.

101. Do not chase occupancy at the expense of fit; admitting residents whose needs you cannot meet creates risk for everyone.

FAQs

Question: What licenses do I need to open a nursing home?

Answer: You usually need a state nursing facility license, and the exact license type depends on the care level you plan to provide. Requirements vary by state, so confirm with your state health or licensing agency before you sign a lease or buy property.

Question: Do I have to be certified for Medicare or Medicaid to operate?

Answer: No, but if you want to bill Medicare or Medicaid, you must meet federal participation rules and pass certification surveys. Many facilities build their startup plan around these steps because they can affect timing and cash flow.

Question: What is the difference between state licensing and federal certification?

Answer: State licensing gives you permission to operate under state rules. Federal certification is about meeting Medicare and Medicaid requirements set by the Centers for Medicare & Medicaid Services (CMS).

Question: Who performs the initial surveys and inspections before opening?

Answer: State survey agencies conduct surveys to check whether a facility meets federal participation requirements. Your state also may have separate inspections tied to state licensure.

Question: Do I need a certificate of need to open a nursing home?

Answer: In some states, a certificate of need program can apply to nursing facilities or bed expansion, and in other states it does not. Check your state health planning office or state health department to confirm what applies to your project.

Question: When should I start looking for a building?

Answer: Start early, because the building must meet health and safety rules and also pass local zoning and building approvals. Do not assume a “good deal” property can be converted without major work.

Question: What local approvals can block me from opening?

Answer: Zoning approval, building permits, fire and life safety checks, and a Certificate of Occupancy are common gating items. These steps are local, so confirm with your city or county building and planning offices.

Question: What is required for emergency preparedness before I open?

Answer: CMS rules require an emergency preparedness program with an emergency plan, policies and procedures, a communication plan, and training and testing. It must be reviewed and updated at least annually if you are a Medicare or Medicaid participating facility.

Question: Do I need a quality program before I accept residents?

Answer: Federal rules require a Quality Assurance and Performance Improvement program for nursing facilities that participate in Medicare or Medicaid. Build it before opening so staff routines and tracking systems are in place on day one.

Question: What privacy rules apply to a nursing home owner?

Answer: Nursing homes can be covered entities under the Health Insurance Portability and Accountability Act (HIPAA) if they transmit health information electronically in standard transactions. If HIPAA applies, you need policies and controls to protect protected health information.

Question: What safety rules should I plan for before hiring staff?

Answer: If your staff could have occupational exposure to blood or other potentially infectious materials, the Occupational Safety and Health Administration bloodborne pathogens standard applies. Plan training, supplies, and written procedures before your first shift.

Question: Do I need an Employer Identification Number?

Answer: You will often need an Employer Identification Number for taxes, payroll, and banking. The Internal Revenue Service issues it, and you can apply directly through the IRS website.

Question: Do nursing homes need a National Provider Identifier?

Answer: If you plan to bill as an organization, you may need a National Provider Identifier, which is requested through the National Plan and Provider Enumeration System. Confirm your enrollment needs based on your payer mix and billing setup.

Question: How do I enroll to bill Medicare as a facility?

Answer: Institutional providers use the CMS-855A application, either through CMS’s online enrollment system or by paper form. Enrollment and certification are connected steps, so plan them together in your startup timeline.

Question: What insurance should I have in place before opening?

Answer: Most owners plan for general liability and property coverage before opening, and lenders often require coverage as a condition of financing. Requirements can vary by state, payer contracts, and your lease terms, so confirm with your insurer and legal advisor.

Question: What equipment should I plan for first?

Answer: Start with resident safety and core care equipment, like beds, call systems, mobility aids, and lifts, plus medication storage and basic clinical supplies. Next, plan building life safety systems, kitchen and laundry capacity, and secure technology for records.

Question: How should I plan staffing before opening day?

Answer: Build staffing around 24/7 coverage and the roles required by your state license and payer participation goals. Hire key leaders early enough to shape policies, train staff, and prepare for surveys.

Question: What should I track weekly as the owner?

Answer: Track a small set of safety and quality signals, like falls, pressure injuries, weight change, medication incidents, and complaint volume. Pair those with staffing stability and cash position so you can act fast.

Question: How do I manage cash flow when payments are delayed?

Answer: Build a cash reserve and a billing follow-up routine, because payment timing can lag behind payroll and vendor bills. Review your payer mix often so you understand how it changes revenue timing and risk.

Question: What are the most common mistakes new nursing home owners make?

Answer: Opening before systems are ready is a top mistake, especially documentation, training, and maintenance routines. Another is treating survey readiness as a one-time event instead of an ongoing process.

Question: How can I stay on top of rule changes without getting overwhelmed?

Answer: Use a small set of official sources and schedule a monthly review so updates do not pile up. CMS posts nursing home compliance resources and quality materials you can track over time.

Sources:

ADA.gov: 2010 ADA Design Standards
CMS: Nursing Homes Certification, Nursing Homes Regulations, Five-Star Rating System, Five-Star Technical Guide, CMS-855A Enrollment Form
eCFR: Subpart B Requirements, Emergency Preparedness, Compliance Ethics Program, Physical Environment
HHS.gov: HIPAA Covered Entities
Internal Revenue Service: Get Employer ID Number
Medicaid.gov: PASRR Overview
Medicare.gov: Care Compare Tool
Occupational Safety and Health Administration: Bloodborne Pathogens