Hospital Readmissions and Nursing Homes

Why nursing home residents return to the hospital, how CMS measures it, and what families can do to support a safer transition and recovery.

Category: safety-and-health · Updated 2026

When a nursing home resident goes back to the hospital soon after a stay, it can signal problems with care transitions, infection, medication management, or early recognition of a change in condition. CMS reports a short-stay rehospitalization measure and uses readmission data in payment programs, because avoidable readmissions are costly and disruptive to residents.

This guide explains what the measure means, what drives readmissions, and how families can support a safer recovery and transition.

What the measure tracks

CMS reports a short-stay rehospitalization quality measure that tracks residents who return to an acute-care hospital within a defined window after admission to a skilled nursing facility. The measure helps consumers see how often a facility's rehabilitation and post-acute care results in a hospital return. CMS explains its quality measures in the Five-Star Technical Users' Guide and shows facility results on Care Compare.

Common reasons for readmission

Infections that were not caught early, such as pneumonia or sepsis
Worsening heart failure or breathing problems
Falls with injury
Medication problems or side effects
Dehydration or poor nutrition
Uncontrolled pain or a rapidly changing condition
Incomplete communication between hospital and facility

Many of these are preventable with early monitoring and good handoffs. Facilities that track subtle changes, such as mental status or appetite, can intervene before a crisis.

The transition is the riskiest moment

Transition	What should happen
Hospital to facility	Medication reconciliation, transfer summary, and a care plan review within a day
Facility to hospital	Facility sends records, medication list, and current care plan
Return to facility	Updated orders, a new assessment, and monitoring for the reason for the hospital visit

Federal care-planning and pharmacy rules support these steps. Ask who is responsible for reconciliation at each handoff.

Questions families should ask

What is your rehospitalization rate, and how does it compare locally?
How do you monitor residents for early signs of infection or decline?
Who communicates with the hospital before and after a transfer?
How are medications reconciled when a resident returns?
What triggers a call to the family about a change in condition?
How do you involve physical and occupational therapy in recovery goals?

What families can do

Visit regularly and report changes you notice, such as confusion, poor appetite, or more trouble breathing. Bring an updated medication list and know the goals of care. If a readmission happens, ask what led to it and what will change to prevent another. A pattern of readmissions is one of the signals worth investigating with the administrator or ombudsman. See Hospital to Nursing Home Discharge for the practical steps.

Sources: CMS Five-Star Technical Users' Guide; CMS Care Compare; CMS Skilled Nursing Facility Value-Based Purchasing. Health content is informational only and not medical advice.

Related guides

Frequently asked questions

Does a high rehospitalization rate mean poor care?

It can reflect problems with monitoring, staffing, or coordination, but it is also affected by how sick residents are. Use it with the other CMS domains, and ask the facility to explain its rate and improvement plan.

Can residents refuse to go back to the hospital?

Residents or their representatives can discuss goals of care and, in some cases, choose to stay with comfort-focused care. This is a medical and ethical decision to make with the care team. Advance directives can guide the choice.

What is a transition of care plan?

It is a plan for moving a resident between settings safely, including medication reconciliation, clear communication, and follow-up. Federal rules require care planning and coordination.

How can I reduce the risk of readmission?

Keep vaccinations current, follow the care plan, report changes early, and make sure medications are reconciled after every transition. Ask the facility how it monitors high-risk residents.

Data sources

CMS Provider Data Catalog · CMS Care Compare. This guide is informational and is not medical advice. Processing date: 2026-10-05.

Important disclosures

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