When Nursing Home Residents Return to the Hospital

Why nursing home residents are sent back to the hospital, how CMS measures readmissions, and what families can do to support a safer recovery.

Updated 2026

This guide is informational and is not medical advice.

Category: safety-and-health · Updated 2026

A trip back to the hospital shortly after entering a nursing home can reveal gaps in care transitions, an infection, trouble with medications, or a change in condition that went unrecognized. CMS reports a short-stay rehospitalization measure and factors rehospitalization data into payment programs, because avoidable returns are costly and hard on residents.

This guide covers what that measure reflects, what tends to drive readmissions, and how families can support a safer recovery and handoff.

What the measure captures

CMS tracks a short-stay rehospitalization quality measure that counts residents who are admitted to an acute-care hospital within a set window after arriving at a skilled nursing facility. The measure lets consumers gauge how often a facility's rehabilitation and post-acute care ends in a hospital return. CMS documents its quality measures in the Five-Star Technical Users' Guide and publishes facility results on Care Compare.

Why readmissions happen

Infections that were missed early, such as pneumonia or sepsis
Worsening heart failure or breathing difficulty
Falls that cause injury
Medication errors or adverse reactions
Dehydration or inadequate nutrition
Pain that is not controlled, or a condition that changes quickly
Weak communication between hospital and facility

Many of these can be prevented with close monitoring and clean handoffs. Facilities that notice subtle shifts, such as a change in mental status or appetite, can step in before a crisis.

The handoff is the riskiest point

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 fresh assessment, and monitoring for the reason for the hospital visit

Federal care-planning and pharmacy rules underpin these steps. Ask who owns reconciliation at each handoff.

Questions families should ask

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

What families can do

Visit regularly and speak up about changes you see, such as confusion, poor appetite, or more trouble breathing. Bring an updated medication list and understand the goals of care. If a readmission occurs, ask what caused it and what will change to prevent another. A pattern of readmissions is one of the signals worth raising 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 point to poor care?

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

Can residents decline to go back to the hospital?

Residents or their representatives can discuss goals of care and, in some cases, opt 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 lower 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. Data as of 2026-10-06.

Required disclosures

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