Stepping into the role of a Nursing Home Administrator (NHA) is both an exciting and challenging opportunity. Whether you are a newly appointed administrator, an interim leader, or an experienced professional entering a new organization, the first 90 days are critical for establishing credibility, understanding operations, building relationships, and creating a foundation for long-term success.
A successful administrator must balance regulatory compliance, quality outcomes, financial performance, staffing challenges, and resident-centered care while developing trust with residents, families, and employees.
The goal of the first 90 days is not to change everything immediately, it is to listen, assess, prioritize, and implement sustainable improvements.
Days 1-30: Assess, Listen, and Build Relationships
1. Build Leadership Relationships
Effective leadership begins with relationships. A new administrator should take time to understand the facility culture, current challenges, and team dynamics.
Schedule meetings with:
- Director of Nursing (DON)
- Assistant Director of Nursing (ADON)
- Department leaders
- Medical Director and providers
- Residents and Resident Council
- Family representatives
- Frontline caregivers
- Corporate leadership or ownership
Key questions to ask:
- What is working well?
- What are the biggest barriers to success?
- What concerns do staff have?
- What improvements would make the greatest impact?
Employees who feel heard are more likely to support organizational goals and participate in meaningful change.
2. Review Regulatory Compliance and Survey Readiness
A new administrator should immediately evaluate the facility’s regulatory standing and identify areas requiring attention.
Review:
- Most recent CMS and state survey results
- Plans of Correction (POCs)
- Quality Measures
- Five-Star Quality Rating
- Facility Assessment
- QAPI program
- Infection Prevention and Control Program
- Abuse prevention program
- Incident investigations
- Grievances and complaint investigations
- Emergency preparedness plan
- Policies and procedures
Skilled nursing facilities must maintain compliance with federal requirements under 42 CFR Part 483, Subpart B, which outlines requirements for participation in Medicare and Medicaid programs. State survey agencies evaluate compliance through survey processes designed to determine whether facilities meet federal requirements (Centers for Medicare & Medicaid Services [CMS], Nursing Home Requirements and Survey Information).
A survey-ready facility is not created days before surveyors arrive, it is built through consistent daily systems, monitoring, and accountability.
Days 31-60: Create Action Plans and Improve Operations
3. Evaluate Financial and Operational Priorities
The administrator must understand the operational and financial health of the organization.
Key areas include:
- Census Development: Current census compared to budget, referral relationships, hospital partnerships, admission processes, and discharge planning effectiveness.
- Labor Management: Staffing patterns, agency utilization, overtime trends, recruitment and retention efforts, and productivity management.
- Expense Management: Supply utilization, contract services, pharmacy costs, therapy utilization, and preventable expenses.
Strong operational management supports the facility’s ability to provide quality care and maintain long-term sustainability.
4. Strengthen Staffing and Team Accountability
Staffing challenges require intentional leadership strategies.
Successful administrators focus on:
- Clear expectations
- Consistent communication
- Employee recognition
- Leadership rounding
- Coaching and accountability
- Professional development opportunities
A strong workplace culture improves employee engagement and supports better resident outcomes.
Days 61-90: Implement, Measure, and Sustain Improvements
5. Establish a Strong Organizational Culture
Culture is created through leadership actions every day.
Effective administrators promote:
- Respectful communication
- Accountability
- Teamwork
- Transparency
- Resident-centered decision-making
- Continuous improvement
Leaders must model the behaviors they expect from their teams.
6. Strengthen the Quality Assurance and Performance Improvement (QAPI) Program
QAPI should be integrated into daily operations, not treated as a monthly meeting requirement.
CMS describes QAPI as a systematic, comprehensive, and data-driven approach designed to improve quality, safety, and resident outcomes. Effective QAPI programs involve all levels of the organization in identifying opportunities, implementing solutions, and monitoring results (CMS QAPI Resources).
Administrators should ensure:
- Meaningful performance improvement projects are identified
- Data is reviewed consistently
- Root cause analysis is completed
- Action plans are implemented
- Results are monitored
Final Thoughts
The first 90 days as a Nursing Home Administrator establish the foundation for leadership success. The strongest administrators lead through relationships, accountability, communication, and a commitment to excellence.
Whether leading a new facility, supporting a turnaround, or serving as an interim administrator, success comes from creating systems that support compliance, empower employees, and improve the lives of residents.
At Kay Consulting Group, LLC, we support long-term care organizations through:
- Interim Nursing Home Administrator Services
- Regulatory Compliance Support
- Survey Readiness
- QAPI Development
- Operational Assessments
- Leadership Coaching
Our mission is to help healthcare organizations achieve operational excellence while maintaining a strong commitment to resident-centered care.
Learn more about Kay Consulting Group at kayconsultingroup.com.
References
- Centers for Medicare & Medicaid Services (CMS). Nursing Homes: Certification, Compliance, and Survey Information.
- Centers for Medicare & Medicaid Services (CMS). Nursing Home Requirements for Participation and Survey Guidance.
- Centers for Medicare & Medicaid Services (CMS). Quality Assurance and Performance Improvement (QAPI) Resources.