Every nursing home and skilled nursing facility that bills Medicare or Medicaid must designate a registered nurse as Director of Nursing on a full-time basis. That is the core CMS requirement for a Director of Nursing, set out at 42 CFR ยง 483.35, and it makes the DON the facility’s senior clinical leader and the person accountable for how nursing care is delivered, staffed, and evaluated.1eCFR. 42 CFR 483.35 – Nursing Services Around that core sit a handful of specific rules on qualifications, presence, dual roles, waivers, and oversight duties that surveyors actively check.
Who Qualifies to Serve as DON
The person must hold a current registered nurse license. That is all the federal regulation says about credentials on its face. There is no CMS-mandated minimum for years of experience, advanced degrees, or specialty certification in geriatrics or long-term care. What the regulations do require is that every professional staff member be licensed under the laws of the state where the facility operates, so the DON’s RN license has to satisfy whatever conditions that state imposes for active status.2eCFR. 42 CFR Part 483 Subpart B – Requirements for Long Term Care Facilities
The practical bar is higher than the plain text suggests. Every facility must conduct an annual assessment of its resident population and match staffing competencies to those residents’ needs, and the DON is required to be actively involved in that assessment. The assessment itself must address whether leadership possesses the skill sets the facility’s acuity levels and diagnoses demand.3eCFR. 42 CFR 483.71 – Facility Assessment A facility with a complex dementia population needs a DON who can demonstrate competency in that area, even though no federal checkbox lists it. Surveyors evaluate whether leadership competencies match the resident population, so a technically licensed but underqualified DON is a real compliance exposure.
OIG Exclusion Check Before Hiring
Before appointing anyone to the DON position, the facility must verify the candidate does not appear on the HHS Office of Inspector General’s List of Excluded Individuals and Entities. Hiring an excluded individual triggers civil monetary penalties, and no federal payment will be made for items or services that person furnishes, orders, or directs.4U.S. Department of Health and Human Services, Office of Inspector General. Background Information – Exclusions The check should be repeated routinely for current employees, not run once and forgotten.
Full-Time Designation and Coverage
The DON must be designated on a full-time basis. In practice that means this person works solely in the director capacity and is not pulled into other administrative roles that would divide their attention. The nursing department needs a dedicated leader on site who can respond to clinical issues, manage staffing, and make decisions in real time.1eCFR. 42 CFR 483.35 – Nursing Services
When the DON is temporarily away for vacation, illness, or any other reason, the facility must have a qualified nurse designated to cover the duties. CMS expects nursing department oversight to continue without interruption, and surveyors routinely ask what the facility does when no RN is available and how often days pass without an RN on site. A vague answer signals a gap.
When the DON Can Also Serve as Charge Nurse
The DON may double as a charge nurse only when the facility’s average daily occupancy is 60 or fewer residents.1eCFR. 42 CFR 483.35 – Nursing Services Above that threshold the position is purely leadership and oversight, with no direct bedside assignments. This is one of the more common deficiencies surveyors cite when they pull staffing data. CMS has published survey examples where a DON routinely worked as charge nurse while the facility averaged 65 to 70 residents, and the finding stood even though no resident had been harmed. The potential for harm from splitting the DON’s attention was enough.
Even at or below 60 residents the dual role carries risk. A DON tied up in a medication pass or wound care cannot simultaneously handle a staffing crisis, a family complaint, or a surveyor’s questions. Small facilities that rely on this allowance should build backup plans for the days when administrative duties demand full attention.
Waivers for Rural and Small Facilities
Two waiver provisions can relax certain nursing staffing requirements, including aspects of the DON designation. These are the only legal paths to operating below the standard.
A state may waive the requirement for 24-hour licensed nurse coverage in a nursing facility if the facility demonstrates a genuine inability to recruit staff despite offering competitive wages. The state must find that the waiver will not endanger residents, and a physician or RN must be available to respond immediately by phone during any uncovered period. These waivers are reviewed annually.5eCFR. 42 CFR 483.35 – Nursing Services
Separately, the Secretary of HHS may waive the requirement that a skilled nursing facility provide RN services for more than 40 hours per week, including the full-time DON requirement, if the SNF is in a rural area with insufficient skilled nursing supply, has at least one full-time RN regularly on duty 40 hours per week, and either has no residents needing RN-level care during the gap periods or has arranged for an RN or physician to visit as needed.5eCFR. 42 CFR 483.35 – Nursing Services
Both waivers require notification to the state’s Long-Term Care Ombudsman and to the protection and advocacy system. The nursing facility waiver also requires notice to residents. Facilities operating under waiver face closer scrutiny on every other staffing metric.
What the DON Is Responsible For
The DON carries overall responsibility for the facility’s nursing department. The governing standard is that the facility must provide enough nursing staff with the right competencies to keep each resident safe and help each resident reach or maintain their highest practicable physical, mental, and psychosocial well-being.1eCFR. 42 CFR 483.35 – Nursing Services Surveyors evaluate DON performance against that standard.
In practice the role covers several concrete duties:
- Oversight of care planning, including assessing each resident’s needs and translating those assessments into individualized plans nursing staff follow.
- Development of the written policies and procedures that govern day-to-day nursing operations, from medication administration to fall prevention.
- Receiving pharmacist reports of medication irregularities identified during regimen review, alongside the attending physician and medical director.
- Active involvement in the annual facility assessment covering resident acuity, staff competencies, contract and temporary staff, and resources across day, evening, and night shifts. Findings from that assessment must drive staffing decisions, not sit in a binder.3eCFR. 42 CFR 483.71 – Facility Assessment
- Ownership of the system that evaluates and documents staff competency. The DON does not have to personally assess every nurse aide, but must be able to explain how orientation, ongoing competency checks, and verification of agency or contract staff work in the facility.
- Mandatory membership on the Quality Assessment and Assurance Committee, which meets at least quarterly to coordinate quality assessment and performance improvement and to develop corrective action plans when problems surface.6eCFR. 42 CFR 483.75 – Quality Assurance and Performance Improvement
Infection control sits slightly to the side. Every facility must designate at least one infection preventionist with specialized training to run the infection prevention and control program, and that person also serves on the QAA committee.7eCFR. 42 CFR 483.80 – Infection Control The regulation does not put the DON in charge of the program, but the DON oversees the nursing staff who carry out hand hygiene, isolation protocols, antibiotic administration, and outbreak response. Cooperation between the two roles is what makes the program work on the floor.
Notifying the State When the DON Changes
When a facility changes its Director of Nursing, it must give written notice to the state agency responsible for licensing the facility. The DON position is tracked at the regulatory level, not just internally, and continuity in the role is treated as a compliance matter.
What Happens When These Requirements Aren’t Met
Failing to meet DON-related requirements triggers CMS’s graduated enforcement system, and the penalties escalate with the seriousness of the deficiency and whether residents are harmed. Beyond civil money penalties, CMS can deny payment for new admissions, appoint temporary management, require directed in-service training, or impose state monitoring. If a facility remains out of compliance for three months after the survey that identified the problem, CMS must deny payment for all new admissions. Three consecutive standard surveys with substandard quality of care citations trigger mandatory payment denial and state monitoring.8eCFR. Enforcement of Compliance for Long-Term Care Facilities with Deficiencies
The most severe scenario is a finding of immediate jeopardy to resident health or safety. In that situation the state must either terminate the provider agreement or appoint a temporary manager within 23 calendar days of the survey.8eCFR. Enforcement of Compliance for Long-Term Care Facilities with Deficiencies Immediate jeopardy findings frequently trace back to leadership and oversight failures: insufficient staffing, untrained staff, uninvestigated abuse allegations, or missed changes in a resident’s condition. A DON who is absent, unqualified, or stretched between administrative and clinical duties is the kind of systemic weakness that produces those findings.