Nursing Homes in Ohio (2026): OAC 3701-17, Care Compare, NF Medicaid, and the Federal Staffing Rule's Demise

A nursing home in Ohio is a specific kind of regulated facility, and the distinctions matter to families who arrive at this decision under pressure. Ohio licenses nursing homes (the legal terms are "nursing home" and "nursing facility," used interchangeably, with the federal Medicare term "skilled nursing facility" or SNF used for short-term rehab) under Ohio Revised Code Chapter 3721 and Ohio Administrative Code Chapter 3701-17. These are the buildings that deliver 24/7 skilled nursing care, accept residents whose acuity has progressed beyond what an assisted-living building can legally provide, and are dual-regulated by the Ohio Department of Health and the federal Centers for Medicare and Medicaid Services (CMS) under 42 CFR Part 483.

This is not the same regulatory universe as an Ohio Residential Care Facility (RCF, the legal term for what families call "assisted living"). RCFs are governed by OAC 3701-16 and are limited by the 120-day skilled-nursing rule. Nursing homes are governed by OAC 3701-17, deliver unlimited skilled nursing, and operate to a state staffing floor that has no parallel in assisted living. The dual federal-and-state regulation also means nursing homes are the only long-term care setting in Ohio with a federal public quality-rating system (CMS Care Compare's Five-Star) and federal residents'-rights protections that go well beyond what RCFs receive. This guide walks through the licensure framework, the 2026 cost picture, how Medicare and Medicaid actually pay for nursing home care, what the federal staffing rule's 2025 collapse means in practice, the alternatives to nursing-home placement, contract red flags families should know before signing the admission packet, and how to use Care Compare and Ohio's Quality Navigator to compare facilities seriously.

By Brevy Care Team

• Ohio's licensed nursing homes are regulated under ORC 3721 and OAC 3701-17, certified by ODH and CMS under 42 CFR Part 483.
• Ohio sets a minimum staffing floor under OAC 3701-17-08. The federal 8-hour-per-day, 7-day-per-week RN requirement at 42 CFR 483.35(b)(1) is still in effect.
• The 2024 federal staffing rule expanding minimum nurse staffing has been rescinded as of 2026: vacated by a federal court, and formally rescinded by CMS via Interim Final Rule.
• Medicare does not pay for long-term nursing-home care. Medicare Part A covers up to 100 days per benefit period of skilled rehab after a qualifying 3-day inpatient hospital stay, with $0 days 1 to 20 and $217 per day coinsurance days 21 to 100 in 2026.
• NF Medicaid in 2026: income cap $2,982 per month (300 percent SSI), resource cap $2,000 single / $3,000 couple, Personal Needs Allowance of $75 per month (raised from $50 effective 10/1/2025).
• Pre-dispute binding arbitration is prohibited in Medicare/Medicaid-certified nursing facilities under federal law. Third-party guarantor signatures are also prohibited under federal law. Both are common admission-packet traps.

Ohio's Licensing Framework: ODH and CMS, Both at Once

Nursing-home regulation in Ohio is genuinely dual-sovereign. The federal framework comes from the Nursing Home Reform Act of 1987 (OBRA-87), codified at 42 USC 1395i-3 (Medicare SNF participation) and 42 USC 1396r (Medicaid NF participation), with implementing regulations at 42 CFR Part 483. The state framework is ORC Chapter 3721 (the umbrella nursing home statute, which also covers RCFs by definition) and OAC Chapter 3701-17 (the operative rule chapter for nursing homes specifically). The two regulatory streams are stitched together by ODH's Bureau of Survey and Certification (BSC), which operates under a federal-state cooperative agreement to conduct CMS-mandated surveys and enforce both federal F-tag deficiencies and Ohio-specific requirements.

What this means practically: an Ohio nursing home holds an ODH license under ORC 3721 and OAC 3701-17, AND a CMS certification under 42 CFR Part 483 to participate in Medicare (as a SNF) and Medicaid (as an NF). The overwhelming majority of Ohio's nursing homes are dual-certified for both Medicare and Medicaid. A few are SNF-only (Medicare short-term rehab, no Medicaid long-stay), and a vanishingly small number are licensed without federal certification at all (private-pay only, no Medicare or Medicaid billing).

ODH's BSC conducts at least one unannounced standard inspection every 9 to 15 months at every Ohio nursing home, using CMS State Operations Manual Appendix PP as the surveyor guidance for federal F-tag deficiencies and adding Ohio-specific findings on top. Deficiencies are scored on the federal scope-and-severity grid from A through L, with "G or above" indicating actual harm and "J/K/L" indicating immediate jeopardy. The enforcement remedies range from warning letters and plan-of-correction approvals up through civil money penalties, denial of payment for new admissions, state-imposed monitoring or temporary management, and license revocation. Federal CMP revenue collected from Ohio facilities is held in escrow and redeployed for resident quality-improvement projects under ORC Chapter 5165.

The ODH complaint hotline is 1-800-342-0553, with live staffing Monday through Friday from 8 a.m. to 5 p.m. and 24/7 voicemail. Complaints can be filed by anyone, including anonymously, and ORC 3721.031 protects complainant identity in the investigation. If the complaint alleges immediate jeopardy, ODH may dispatch a surveyor unannounced. The complaint form HEA 1685 is available at odh.ohio.gov and complaints can also be emailed to HCComplaints@odh.ohio.gov.

Ohio's Staffing Floor for Nursing Homes

The Ohio state staffing floor for nursing homes lives at OAC 3701-17-08, which sets a minimum hours-of-direct-care floor averaged across nurse aides, LPNs, and RNs. "Direct care" includes time spent in administrative and supervisory duties that count toward the average, which gives facilities meaningful flexibility in how they document compliance.

The rule layers additional requirements on top of the direct-care floor:

• The Director of Nursing must be a registered nurse, working at least 5 days per week and 8 hours per day, predominantly between 6 a.m. and 6 p.m. Two RNs may share the role as co-DONs.
• The facility must have an RN on call whenever one is not on duty in the home, which together with the federal 8-hour-per-day rule means an Ohio nursing home effectively has RN coverage 24 hours a day, with onsite presence at least 8 of those hours.
• Facilities with 100 or more beds need a full-time administrator. Smaller facilities (under 100 beds) need an administrator onsite at least 16 hours per week.
• Facilities with 120 or more beds must employ a full-time licensed social worker, mirroring the federal requirement at 42 CFR 483.70(p).
• The federal requirement at 42 CFR 483.35(b)(1), which predates and survived the 2024 staffing-rule expansion, requires 8 consecutive hours of RN coverage per day, 7 days per week.

These rules are materially higher than Ohio's assisted-living floor under OAC 3701-16-15, which requires only "one staff member on duty" at all times in an RCF. The staffing architecture is the central reason families pay more for nursing-home care than for RCF care: the building is staffed continuously by licensed nursing staff and is held to a quantified average that has no parallel in the RCF rule book.

The Federal Staffing Rule's Demise

The 2024 federal staffing rule was supposed to drive Ohio facilities to higher staffing levels than the state floor required, and for most of 2024 and into early 2025 the industry was preparing for compliance. That rule is now dead. The story matters because it shapes what's enforceable in 2026 and beyond.

CMS published a minimum staffing rule for long-term care facilities in 2024. The rule set three new requirements: a higher total nurse staffing minimum; 24/7 onsite RN coverage replacing the older 8-hours-per-day rule; and an enhanced facility-assessment process. Rural facilities had extended compliance timelines, and a hardship-exemption process was built in.

A coalition led by the American Health Care Association sued in federal court. A federal judge vacated the numerical staffing components and the 24/7 RN requirement, holding that CMS had exceeded its statutory authority. HHS appealed, then withdrew the appeal, and the case was dismissed. A parallel case in a second federal district produced a similar outcome. Independently, Congress enacted a statutory moratorium prohibiting CMS from implementing the 2024 staffing rule for a 10-year period. CMS then published an Interim Final Rule rescinding the staffing standards.

What remains in effect as of 2026:

• The pre-2024 8-hours-of-RN-per-day, 7-days-per-week rule at 42 CFR 483.35(b)(1), which predated the 2024 rule and survived the rescission, still applies.
• The facility-assessment process requirements at 42 CFR 483.71 survived as well. Facilities must continue to document an assessment of resident acuity, staff competencies, and staffing decisions.
• Ohio's state staffing rule under OAC 3701-17-08 is now the operative numerical staffing floor for Ohio nursing homes.
• CMS Care Compare's staffing star rating remains the primary public-facing accountability mechanism. Even without a federal HPRD floor, the 5-star staffing rating still penalizes facilities that report low staffing through the Payroll-Based Journal under 42 CFR 483.70(r).

The practical consequence is that the federal expansion that would have pulled Ohio facilities upward never materialized, and staffing accountability now depends on state floors plus the public visibility of Care Compare ratings.

CMS Five-Star Quality Rating

CMS's Care Compare at medicare.gov/care-compare is the federal flagship public-quality tool, and it is the single most important resource any family should learn to use before choosing a facility. Each nursing home in Ohio has a Care Compare profile with an Overall 5-star rating and three domain ratings: Health Inspections, Staffing, and Quality Measures.

The Overall rating starts with the Health Inspection rating, then adjusts up or down based on staffing and quality measures. A facility with a 4-star or 5-star staffing rating and that exceeds its health-inspection rating gets an extra star added to the Overall. A facility with 1-star staffing gets a star subtracted. Five-star quality-measure performance can add a star; 1-star QM performance subtracts. Special rules apply to Special Focus Facilities, low-occupancy facilities, and facilities flagged with the abuse icon. The rating cut points are recalibrated monthly to keep the state-level distribution stable, which means a 5-star nursing home in Ohio is in the top quintile of Ohio nursing homes, not necessarily in the top quintile nationally.

The Health Inspection domain uses the most recent 3 years of standard and complaint survey data, weighted toward the most recent year (50 percent), the prior year (33 percent), and the third year (17 percent). The Staffing domain pulls Payroll-Based Journal data on six measures: total nurse HPRD, RN HPRD, weekend total staffing, weekend RN staffing, total nurse turnover, RN turnover, and administrator turnover. CMS audits a sample of facilities' PBJ submissions annually and downgrades facilities that fail audit. The Quality Measures domain uses 10 to 15 clinical measures spanning short-stay outcomes (rehab success, hospital readmissions, community discharge) and long-stay outcomes (pressure ulcers worsened, urinary tract infections, antipsychotic medication use, falls with major injury, ADL decline).

Special Focus Facilities are the worst-performing facilities nationally. CMS publishes the active SFF list and the SFF Candidate list monthly. Ohio typically has 2 to 6 facilities on the active SFF list at any time and several more on the candidate list. SFFs receive standard surveys every 6 months (compared to the 9 to 15 months for non-SFFs) and either graduate, terminate, or are decertified within 18 to 24 months.

Alongside Care Compare, Ohio runs its own state transparency tool: the Ohio Long-Term Care Quality Navigator at aging.ohio.gov. The Navigator includes the same Five-Star ratings, recent deficiency data, staffing data, and contact information, as well as an interactive Care Quiz that helps families distinguish among nursing-home, assisted-living, and home-care options, with an interface tailored to Ohio search patterns. The older Ohio Long-Term Care Consumer Guide at ltc.ohio.gov publishes consumer satisfaction survey results (resident and family surveys conducted by an ODA contractor) and remains useful for the satisfaction-survey data that Care Compare does not provide.

2026 Cost Picture

Ohio nursing-home costs vary significantly by metro area and room type, with larger urban markets like Cincinnati, Toledo, and Cleveland typically more expensive than smaller markets. These are private-pay "rack rates"; actual amounts billed can be lower (private negotiations) or higher (rehab settings with PT/OT layered in). For Medicaid-paying residents, the facility receives a state-set per-diem rate under ORC Chapter 5165's case-mix methodology, and the resident contributes patient liability (see the NF Medicaid section). For Medicare short-stay rehab, the facility is paid under Medicare's prospective payment system at rates that do not directly map to private-pay rates.

A separately useful number is the Ohio Medicaid Average Private Pay Rate, currently set at $7,787 per month. This is the figure ODM uses as the divisor for transfer-penalty calculations under OAC 5160:1-6-06; it was last set on September 1, 2024 and is due for periodic update. Families doing Medicaid planning math should use the APPR as the operative number for penalty calculations rather than higher private-pay market rates.

For Medicare beneficiaries planning around a SNF stay, the 2026 Medicare Part A cost-sharing numbers (announced by CMS on November 14, 2025) matter:

• Days 1 to 20 of a Medicare-covered SNF stay: $0 (fully covered after a qualifying 3-day inpatient hospital admission).
• Days 21 to 100: $217 per day coinsurance.
• Days 101 and beyond: $0 coverage; Medicare Part A SNF benefit exhausted.
• Inpatient hospital deductible (which must be paid for the qualifying hospital stay before the SNF benefit can attach): $1,736 in 2026.

A common consumer trap: the qualifying hospital stay must be inpatient. Observation status, which has become more common as Medicare audits scrutinize hospital admissions, does not satisfy the 3-day rule, and patients discharged from observation to a SNF often discover their stay is not Medicare-covered. Patients and families should ask the hospital case manager explicitly whether the resident is in inpatient status or observation status, and should request inpatient classification if the case manager indicates a SNF placement is being planned.

Medicare's SNF coverage requires the resident to need and be receiving daily skilled-level care (skilled nursing, PT, OT, or speech therapy at frequencies that require licensed professional delivery) and to be improving. Many residents are discharged from Medicare SNF coverage well before day 100 because they "plateau" or are deemed maintenance-only, at which point the bill flips to private pay or to Medicaid if the resident qualifies. $217 per day over the typical days-21-to-100 coinsurance window is $17,360 out of pocket from a single Medicare-covered stay if the resident lacks a Medigap policy or Medicaid wraparound. This is one of the largest single-event Medicare bills most families ever face.

NF Medicaid: How It Actually Works

Ohio's Nursing Facility Medicaid is the long-term financing program most families end up needing. Medicare does not pay for long-term care. Long-term care insurance, where the family owns a policy, helps but rarely covers the full bill. Private pay drains savings. NF Medicaid is the safety net the federal-state Medicaid program puts under nursing-home residents who have spent down their resources to within the program's limits.

Three independent eligibility tests apply in 2026:

1. Income test: countable income at or below $2,982 per month, which is 300 percent of the federal SSI benefit rate (2026 SSI FBR = $994). Applicants whose income exceeds this cap must establish a Qualified Income Trust (commonly called a Miller Trust) under OAC 5160:1-6-03.1 to funnel income through the trust each month.
2. Resource test: countable resources at or below $2,000 for a single applicant or $3,000 for a couple where both apply, with the home, one car, personal effects, and certain burial funds excluded.
3. Level-of-care test: the applicant must meet nursing-facility level of care, determined through Pre-Admission Screening (PAS) for new applicants and Continued Stay Review for existing residents. The clinical tool is the Adult Comprehensive Assessment Tool (ACAT) for HCBS waivers; PAS for NF applicants.

Once eligibility is established, the resident's monthly Patient Liability is calculated under OAC 5160:1-6-07. The formula:

Gross monthly income minus income exclusions minus the Personal Needs Allowance of $75 per month (the institutional PNA, raised from $50 effective October 1, 2025) minus an Earned Income Allowance of $65 per month if applicable minus a Community Spouse Monthly Income Allowance up to the MMNA maximum of $4,066.50 if the resident has a community spouse minus dependent family member allowances minus health insurance premiums (Medicare Part B, Medigap, Medicare Part D, dental) minus court-ordered or physician-prescribed non-covered medical expenses minus any Miller Trust administration fees up to roughly $20 per month. The remainder is the Patient Liability, which the resident pays to the facility each month. The facility bills Medicaid for the daily per diem minus the patient liability.

The PNA increase from $50 to $75 was politically interesting and worth understanding. The Ohio General Assembly's HB 96 (the FY 2026-2027 main operating budget bill, signed by Governor DeWine on June 30, 2025) included statutory language raising the institutional PNA from $50 to $75. Governor DeWine line-item vetoed that specific budget language, because the veto message indicated the legislature's language risked applying retroactively, but he directed ODM to implement the increase administratively through OAC rulemaking. ODM finalized the rule amendment to OAC 5160:1-6-07 with an effective date of October 1, 2025. The underlying statute at ORC 5163.33 still reads "not less than fifty dollars" individual and "not less than one hundred dollars" couple; the $75 operational figure is set by ODM rule above the statutory floor. Note that the Assisted Living Waiver PNA was not raised in the same rulemaking. ALW residents continue to retain only $50 per month, an equity gap that Ohio aging-advocacy groups have flagged but no proposed rule has yet addressed.

The community-spouse protections matter enormously for married couples where one spouse enters a nursing home and the other remains in the community. The Community Spouse Resource Allowance in 2026 ranges from $32,532 (federal floor) to $162,660 (federal ceiling): the community spouse keeps the greater of $32,532 or one-half of the couple's countable resources at the snapshot date (the first date of continuous institutionalization of 30 or more days), capped at $162,660. The Minimum Monthly Maintenance Needs Allowance preserves between $2,643.75 and $4,066.50 per month of the institutionalized spouse's income for the community spouse, depending on the community spouse's housing costs. The MMNA resets each July 1.

The 60-month look-back applies to NF Medicaid applications. Uncompensated transfers in the 60 months before application are summed and divided by Ohio's APPR ($7,787 per month) to produce a penalty period during which Medicaid will not pay. The penalty period begins the later of the date of transfer or the date the applicant would otherwise have been eligible for Medicaid. Exceptions exist for transfers to a spouse, a minor child, a blind or disabled adult child of any age, a sibling with equity interest in the home who lived there 1 year before institutionalization, and the caregiver-child exception for adult children who lived in the parent's home for the 2 years immediately preceding institutionalization and provided care that delayed institutionalization. Special needs trusts for disabled persons under age 65 (d4A trusts) and pooled SNTs (d4C trusts) are similarly excluded from the transfer penalty.

The home equity exclusion in 2026 is the federal floor of $752,000. OBBBA Section 71112 will freeze the cap at $1,000,000 effective January 1, 2028, with no inflation adjustment thereafter, which means the practical exemption will erode over time.

PASRR and Specialty Populations

Before any Medicaid-certified nursing facility admission, every applicant must clear Pre-Admission Screening and Resident Review (PASRR) under 42 CFR 483.100 to 483.138. PASRR was added to federal law by OBRA-87 to prevent inappropriate institutionalization of individuals with serious mental illness (SMI) or intellectual disability (ID) when their needs could be met in less-restrictive settings.

The screening has two levels. Level I is universal: performed by hospital discharge planners, MD offices, or nursing-home admissions staff using a brief screening form. A positive Level I screening (indicating possible SMI or ID/DD) triggers a Level II evaluation by a qualified mental-health professional or DD professional, who conducts a face-to-face clinical assessment to determine whether the individual actually has SMI or ID, whether nursing-facility level of care is appropriate, and whether the individual needs specialized services for SMI or ID that nursing facilities cannot provide. A negative Level II evaluation can result in placement denial or placement with conditions.

In Ohio, PASRR is operationalized through a multi-agency structure. Level II SMI evaluations are conducted by a contracted evaluator, with the state mental health authority issuing the Level II determination. The ID/DD path runs through County Boards of Developmental Disabilities under DODD jurisdiction. PASRR tracking is maintained in HENS (Healthcare Enrollment and Notification System) at hens2.age.ohio.gov. Non-compliance gets referred to ODM and can result in claims recoupment if a facility bypassed PASRR and billed Medicaid.

Beyond PASRR, certain specialty populations have their own framing within the nursing-home universe:

• Memory care in nursing homes is governed by OAC 3701-17-07.1, the "specialty unit" rule. When a nursing home "holds itself out as providing" specialty care (dementia care, hospice care, mental-health care, behavioral care) by advertising, representing to ODH or the public, or admitting 10 or more residents with common specialized needs, additional staff training requirements attach. This is structurally different from the assisted-living memory-care endorsement under OAC 3701-16-21, which is a separate certification ODH issues. For high-acuity dementia residents with complex behaviors, comorbid skilled needs (G-tube feeding, complex medications, IV therapy), or wandering risk, a nursing-home memory unit is often more appropriate than an RCF memory-care unit, even at the higher price point.
• Ventilator-dependent units are a specialty service line; Ohio Medicaid pays a daily ventilator add-on for vent-dependent and vent-weaning residents at specialty rates set by ODM. Capacity is concentrated in Cleveland, Columbus, and Cincinnati.
• Bariatric units are facilities equipped for residents weighing more than 300 pounds, with oversized beds, lifts, and trained staff. Bariatric care is not a separate Ohio certification.
• Short-term rehab vs. long-stay custodial: most Ohio nursing homes serve both populations from the same building. Short-term rehab (typical length of stay 25 to 30 days, intensive PT/OT/SLP under Medicare's Patient-Driven Payment Model) and long-stay custodial care (months to years; Medicaid-funded for the majority of long-stay residents) are billed under different reimbursement systems but delivered from often the same physical setting.

HCBS Alternatives: Keeping People Out of Nursing Homes

The deliberate national policy direction since the 1999 Supreme Court Olmstead decision has been to expand home- and community-based services and reduce institutionalization. Ohio offers a broad HCBS waiver portfolio that families should know about before agreeing to a nursing-home placement, particularly if the resident's clinical needs could be met in a less-restrictive setting.

• PASSPORT is Ohio's flagship HCBS waiver for adults age 60 and older, authorized under CMS's 1915(c) waiver framework. PASSPORT is administered by ODA through the Area Agencies on Aging under interagency agreement with ODM, with regulatory authority at OAC Chapter 5160-31. Eligibility requires nursing-facility level of care, income at or below $2,982 per month (the same as NF Medicaid), and resources at or below $2,000 single or $3,000 couple. Services include personal care, homemaker, adult day, home-delivered meals, Personal Emergency Response Systems, transportation, skilled nursing, respite, home modifications, specialized equipment, and participant-directed care options. Application is through any Area Agency on Aging; statewide warm-transfer line is 1-866-243-5678.
• Ohio Home Care Waiver (OAC Chapter 5160-46) serves adults age 21 to 59 with disabilities. Same income and resource limits, NF level of care required. Administered by ODM directly rather than through ODA/AAA. Transition to PASSPORT available at age 60.
• Assisted Living Waiver (OAC Chapter 5160-33) pays for assisted-living services in an ODA-certified Residential Care Facility, roughly 6,000 slots, $50 PNA, $944 monthly room-and-board contribution from the SSI federal benefit rate. The companion piece to this guide covers ALW mechanics in depth.
• MyCare Ohio Waiver is the capitated managed-care program for full-benefit dual-eligibles age 21 and over. Statewide rollout phasing through August 2026 under the Next Gen MyCare procurement; four MCOs hold contracts (Anthem, CareSource, Molina, Buckeye/Wellcare).
• PACE (Programs of All-Inclusive Care for the Elderly) is a fully capitated, all-inclusive program for adults age 55 and older who meet nursing-facility level of care, live in a PACE service area, and can live safely in the community at the time of enrollment. Ohio currently has one PACE operator, McGregor PACE, with five locations (Warrensville Heights, Forest Hill in Cleveland Heights, Brooklyn, Akron at Ohio Living Rockynol, and Elyria). Service counties are Cuyahoga, Summit, and Lorain plus some connected counties. Statutory authorization exists for expansion into additional metros (Franklin, Hamilton, Montgomery, Lucas, Trumbull, Ashtabula, Mahoning), but no firm operational dates beyond McGregor's existing footprint. PACE Association of Ohio is at paceoh.org or 614-481-5444. PACE is mutually exclusive with Next Gen MyCare enrollment.
• Money Follows the Person (branded HOME Choice in Ohio) is the federal-state transition program that pays for the costs of moving a Medicaid recipient out of a qualifying institutional setting (nursing facility, ICF/IID, or IMD) back to community living. Eligibility requires Medicaid enrollment, 60 consecutive days of institutional residence, age 18 or older, and a community living plan with sufficient supports. Federal MFP funding has been extended under continuing-resolution authority; permanent reauthorization is pending. Application is through ODM at homechoice.medicaid.ohio.gov.

The strategic implication for families: if a parent is being discharged from a hospital into a nursing facility for rehab, ask the discharge planner explicitly whether HCBS pathways have been considered. Ask whether PASSPORT (for 60+), Ohio Home Care (for under 60), or even PACE (where service area allows) would be clinically appropriate. The default discharge path often defaults to institutional placement because it is administratively simpler, but the resident's clinical needs and the community-spouse situation may make HCBS the better fit.

What to Look For When Touring

Touring a nursing home is more consequential than touring any other care setting. The acuity is higher, the cost is higher, and the resident is typically less able to advocate for themselves than in an RCF setting. The questions that matter most often do not appear on the marketing materials.

Pull the Care Compare profile before the tour. The Overall 5-star rating, the staffing rating, and the most recent 3 years of inspection deficiencies are public information at medicare.gov/care-compare. Look for repeated G-or-above deficiencies (actual harm), repeated J/K/L deficiencies (immediate jeopardy), patterns of CMP enforcement, and whether the facility appears on the active SFF list or candidate list. A facility on the SFF list is in the worst-performing tier nationally; that doesn't automatically disqualify it (a new owner may be turning the building around) but it warrants direct questions about leadership change and quality improvement.

Look at staffing turnover. Care Compare publishes total nurse turnover, RN turnover, and administrator turnover. Turnover above the state median is a red flag that something structural is wrong (low wages, poor management, unsafe acuity ratios). Cross-check the published PBJ staffing data against the impression you get on the tour: ask how many CNAs and nurses are on duty per resident per shift, weekend and overnight separately. Ask whether the facility uses agency staff to fill gaps. A facility that runs heavy agency staffing on weekends and overnight is a facility where care will be inconsistent.

Visit at meals and visit in the evening. Marketing tours happen during business hours when the building is at its best. Ask if you can come back unannounced for dinner or for an evening activity. Watch how staff interact with residents who are not on a tour route. Look at how call lights are answered. Look at the dining room: are residents engaged and assisted, or are trays sitting in front of disengaged residents who can't feed themselves? Ask other family members in the building how their experience has been; they are the most honest reviewers you'll find.

For memory care or dementia-specialty units, ask how the unit handles wandering, elopement protocols, sundowning, and behavioral expression. Ask whether the unit is purpose-designed (secured outdoor courtyard, dementia-appropriate wayfinding, low-stimulation environments) or whether it's a converted general-care unit. Ask whether memory-care staff have dementia-specific training beyond the general continuing-education hours, and how long the memory-care unit director has been in the role.

For short-term rehab placements, ask about the rehab team: how many PT/OT/SLP hours per week the resident will receive, whether the facility staffs its own therapists or contracts out (in-house therapy teams tend to produce better continuity), and what the facility's average length of stay for Medicare rehab residents is. Ask about discharge planning: when in the stay does the team begin planning the home transition, who coordinates the home-health handoff, and how does the facility handle residents who need to extend beyond their initial Medicare-covered period.

Ask for a copy of the admission agreement before you commit. Read it slowly. The contract red flags below are the issues most families regret not pushing on before they signed.

Contract Red Flags

Nursing-home admission agreements include federal protections that go beyond what's available in assisted living, but the protections only work if families know what they are and ask questions about clauses that conflict with them.

Pre-dispute binding arbitration clauses are prohibited in Medicare/Medicaid-certified nursing facilities under federal regulations finalized in 2019. A facility cannot require a resident to sign a binding pre-dispute arbitration agreement as a condition of admission or as a condition of continuing to receive care. Voluntary post-dispute arbitration is permitted, with procedural guardrails including plain-language explanation that the resident is not required to sign, a 30-day rescission period, a prohibition on waiving the resident's right to a state survey agency or LTC Ombudsman investigation, and neutral-arbitrator and convenient-venue requirements. Despite the prohibition, admission packets occasionally still include pre-dispute arbitration language; the family's job is to identify it and decline to sign that clause. The contract should otherwise be enforceable without it.

Third-party guarantor clauses are prohibited under federal law: "The facility must not request or require a third party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility." This is one of the most frequently violated federal protections. A facility MAY require a "resident representative" (a power-of-attorney holder, guardian, or other authorized signatory) to sign a contract committing to apply the resident's own income and resources to facility payment, but the representative cannot be made personally liable for the bill. The distinction is critical: the representative is committing the resident's funds, not the representative's own funds. CMS issued new surveyor guidance in March 2025 specifically directing surveyors to review admission agreements for third-party-liability clauses. Watch for language like "I personally guarantee payment" or "I will be financially responsible for any amounts not covered by insurance," and strike those clauses.

Anti-solicitation rule under 42 CFR 483.15(a)(4): facilities cannot demand a "donation" or "gift" or "contribution" as a precondition of admission, expedited admission, or continued stay, beyond what's required under the Medicaid State Plan. This prohibition cuts against the occasional practice of facilities asking for an upfront "deposit" or "endowment" to secure a bed; if such language appears in the admission agreement, push back.

Discharge protections under 42 CFR 483.15(c) allow involuntary transfer or discharge for only six reasons: the facility cannot meet the resident's needs, the resident's condition has improved enough that nursing-home care is no longer needed, the resident endangers the health and safety of others, the resident's safety is endangered (and the facility can't address it), the resident has failed to pay after reasonable notice and opportunity, or the facility ceases to operate. Thirty-day advance written notice is required (with exceptions for emergencies), and the resident has the right to appeal to an ODM state hearing. Watch the admission agreement for discharge clauses that go beyond these six grounds, particularly clauses that allow discharge for "behavioral issues" or "non-compliance with care plan" without further definition; those are often pretexts for retaliatory discharge against residents who advocate for themselves.

Bed-hold policies govern what happens when a resident leaves the facility temporarily (hospitalization, leave for family event). Federal law (42 CFR 483.15(d)) requires the facility to notify the resident of its bed-hold policy in writing at admission and again at the time of any transfer to a hospital. Ohio Medicaid pays a partial per-diem rate for bed-hold days, with the rate varying by the facility's prior-year occupancy under ORC Chapter 5165. Watch for admission-packet language that requires the family to pay private-rate bed-hold fees during Medicaid-covered absences.

Source-of-payment discrimination is prohibited under federal law and ORC 5165.51 at the Ohio state level. A dually-certified facility cannot deny admission or continued stay based on the resident being on Medicaid as the payment source. Common violations include "private-pay only" admission policies in dually-certified buildings or "duration of private pay required" clauses requiring a minimum number of months of private-pay before Medicaid conversion is accepted. Both are unlawful in dually-certified facilities.

Residents' Rights and Complaints

Ohio Revised Code 3721.13 enumerates statutory residents' rights for nursing-home and RCF residents. The federal residents' rights at 42 CFR 483.10 layer additional federal protections on top for nursing-home residents specifically. ORC 3721.13(C) states that "any attempted waiver of the rights listed in division (A) of this section is void," and the same anti-waiver principle applies to the federal rights.

Among the rights every Ohio nursing-home resident holds: the right to a safe and clean living environment; freedom from abuse, neglect, and exploitation; the right to dignified existence; participation in care planning; choice of physician and pharmacist; confidential treatment of medical records; refusal of treatment; freedom from physical or chemical restraints except as authorized; access to recreational and religious activities; private unrestricted communication with family and counsel; retention of personal clothing and possessions; full disclosure of rates and charges at admission; monthly itemized billing; freedom from financial exploitation; advance notice of room or roommate changes; limited grounds for involuntary transfer; orderly discharge preparation; right to voice grievances without retaliation; and choice of licensed hospice provider. The right to organize a resident or family council under 42 CFR 483.10(f) is a powerful federal protection that families should know about; a resident or family council is a formal structure that gives the resident community ongoing standing to engage with facility leadership.

When something goes wrong, Ohio offers four main complaint pathways, each with a different function.

ODH's Bureau of Survey and Certification handles complaints about the facility itself, including safety, abuse, neglect, staffing, medication errors, and survey deficiencies. The complaint hotline is 1-800-342-0553. Anyone may file, including anonymously, and identity is protected.

The Ohio Long-Term Care Ombudsman, administered by ODA under ORC 173.16 et seq. and the federal Older Americans Act Title VII, is an independent advocate for nursing-home residents. The Ombudsman does not investigate or police facilities; the Ombudsman advocates for the resident to facility management. The Ombudsman can sit in on family meetings with facility leadership, help families understand and exercise residents' rights, mediate disputes, and refer matters to ODH or APS when warranted. The statewide hotline is 1-800-282-1206, and 12 regional ombudsman programs operate across Ohio (Pro Seniors in southwest Ohio, COAAA in central Ohio, Western Reserve in northeast Ohio, Direction Home in Akron-Canton and eastern Ohio, plus others). The service is free.

Adult Protective Services handles abuse, neglect, self-neglect, and financial exploitation of adults age 60 and older. Investigations are conducted by the County Department of Job and Family Services in each of Ohio's 88 counties under ODJFS supervision. The statewide reporting line is 1-855-OHIO-APS (1-855-644-6277), toll-free and 24/7. Per ORC 5101.61, physicians, nurses, social workers, clergy, peace officers, and others have a statutory duty to report suspected abuse, neglect, or exploitation.

The ODH Abuse, Neglect, Misappropriation Program at 614-752-8805 handles criminal-level caregiver misconduct and maintains the Ohio Nurse Aide Registry, which flags caregivers found to have abused or neglected residents and prevents their re-employment in long-term care.

For Medicaid-fraud concerns specifically, the Ohio Attorney General's Medicaid Fraud Control Unit (614-466-0722) investigates provider over-billing and fraud. Disability Rights Ohio, the federal Protection and Advocacy agency, investigates abuse and neglect for residents with disabilities at 800-282-9181. Pro Seniors Inc. (800-488-6070) provides free legal advice statewide to Ohioans age 60 and older. Legal Aid networks across Ohio handle elder-law cases at no cost to qualifying low-income clients.

Frequently Asked Questions

Does Medicare pay for nursing-home care?

Only short-term skilled care, not long-term custodial care. Medicare Part A covers up to 100 days per benefit period of skilled nursing or rehab in a Medicare-certified SNF after a qualifying 3-day inpatient hospital stay. Days 1 to 20 are fully covered; days 21 to 100 have a $217 per day coinsurance in 2026; days 101 and beyond are not covered by Medicare. Coverage requires the resident to need daily skilled-level care and be improving; many residents are discharged from Medicare coverage well before day 100 because their condition plateaus. Custodial care (help with bathing, dressing, eating) without a skilled component is never covered by Medicare regardless of how long it lasts.

What's the difference between a nursing home and an RCF in Ohio?

Different OAC chapters (3701-17 vs. 3701-16), different staffing rules (nursing homes require a quantified minimum of direct care hours per resident per day; RCFs require only one staff member on duty), different Medicaid pathway (NF Medicaid vs. Assisted Living Waiver), different federal protections (federal residents' rights at 42 CFR 483.10 plus arbitration prohibition vs. no federal substantive protections for RCFs). Nursing homes serve higher-acuity residents who need 24/7 skilled nursing; RCFs are limited by the 120-day skilled-nursing rule and serve lower-acuity residents. The two settings are not interchangeable and the cost difference reflects the staffing difference.

What is the 2026 institutional PNA in Ohio?

$75 per month, raised from $50 effective October 1, 2025. The increase came through ODM administrative rulemaking after Governor DeWine line-item vetoed the budget statutory increase to avoid retroactivity issues and directed ODM to implement it via rule. The underlying statute at ORC 5163.33 still reads "not less than fifty dollars"; the $75 operational figure is set by ODM rule under OAC 5160:1-6-07. Note: the Assisted Living Waiver PNA remains at $50 and was not raised in the same rulemaking.

Is the 3.48 HPRD federal staffing rule in effect?

No. The federal expansion rule was vacated by a federal court, Congress imposed a moratorium, and CMS formally rescinded the rule via Interim Final Rule. Ohio's state staffing floor under OAC 3701-17-08 is the operative numerical staffing rule. The pre-2024 federal 8-hours-of-RN-per-day, 7-days-per-week rule at 42 CFR 483.35(b)(1) is still in effect.

Can my dad's nursing home make me personally responsible for the bill?

No. Federal law prohibits Medicare/Medicaid-certified nursing facilities from requiring a third party to guarantee payment as a condition of admission or continued stay. The facility may require a "resident representative" (POA holder, guardian) to sign a contract committing to apply the resident's own income and resources to facility payment, but the representative cannot be made personally liable. If the admission agreement contains language requiring you to "personally guarantee" payment or to be "financially responsible," strike that language and ask the facility to provide an admission agreement that complies with federal law.

What is PASRR and why does it matter?

PASRR (Pre-Admission Screening and Resident Review) is the federal screening process at 42 CFR 483.100 to 483.138 required before any Medicaid-certified nursing-facility admission. Level I screening (universal) checks for serious mental illness or intellectual disability; positive Level I screenings trigger Level II evaluation by a qualified mental-health or DD professional. Ohio's Level II SMI evaluations are conducted by a contracted evaluator, with the state mental health authority issuing determinations. PASRR exists to prevent inappropriate institutionalization and to ensure individuals with SMI or ID receive specialized services they need. Non-compliance can result in Medicaid claims being recouped from the facility.

Can a nursing home discharge my mother for being too much trouble?

Federal law at 42 CFR 483.15(c) allows involuntary transfer or discharge for only six reasons: the facility cannot meet the resident's needs, the resident's condition has improved enough that nursing-home care is no longer needed, the resident endangers the health and safety of others, the resident's safety is endangered, the resident has failed to pay after reasonable notice, or the facility ceases to operate. Discharge for "complaining" or "being difficult" is unlawful retaliation. Thirty-day advance written notice is required (with limited emergency exceptions) and the resident has the right to appeal to an ODM state hearing. If you believe your mother is facing wrongful discharge, contact the Long-Term Care Ombudsman at 1-800-282-1206 immediately and consider engaging Pro Seniors Inc. or a legal-aid attorney.

What does the Long-Term Care Ombudsman actually do?

The Ombudsman is the resident's independent advocate to facility management. The Ombudsman does not investigate or police facilities (that's ODH's role) and does not have enforcement authority. The Ombudsman helps families resolve concerns about care, billing, discharge, roommate conflicts, food, activities, family visitation; can sit in on family meetings with facility leadership; explains residents' rights; refers families to ODH or APS when the complaint warrants investigation; and provides confidential support. The service is free and authorized under the federal Older Americans Act Title VII and ORC 173.16 et seq. The statewide line is 1-800-282-1206.

Next Steps for Ohio Families

The single most useful first step for any family weighing a nursing-home placement in Ohio is to spend an hour on medicare.gov/care-compare looking at the candidate facilities. Pull the Overall 5-star, the staffing rating, the turnover numbers, and the last 3 years of inspection deficiencies. Cross-check with Ohio's Long-Term Care Quality Navigator at aging.ohio.gov for state-specific context. Tour each facility at least twice, including once unannounced at dinner or in the evening. Pull the admission agreement and look for arbitration clauses and third-party guarantor language that federal law prohibits. Ask about staffing per resident shift by shift, weekend and overnight separately, and ask about turnover. Talk to families with residents currently in the facility.

For middle-income families looking at private pay running down to NF Medicaid, the financial planning conversation should start before the savings are exhausted. The 60-month look-back can penalize transfers made in the years before application, and the community-spouse protections work best when planning begins early. An Ohio elder-law attorney is usually worth the consultation fee. The Pro Seniors statewide hotline (800-488-6070) and the NAELA Ohio chapter referral network are both reasonable starting points.

If a nursing-home placement is not yet clinically required, ask the discharge planner about HCBS alternatives: PASSPORT for 60-plus, Ohio Home Care for under 60, PACE where service area allows, and the Assisted Living Waiver if an RCF setting could meet the resident's needs. The default discharge path often defaults to institutional placement because it is administratively simpler, but it is often not the clinically necessary path.

Key Ohio nursing-home hotlines and resources, all free:

• Ohio Long-Term Care Ombudsman: 1-800-282-1206 (resident advocacy)
• ODH Healthcare Facility Complaints: 1-800-342-0553 (Monday to Friday, 8 a.m. to 5 p.m. ET)
• Adult Protective Services: 1-855-OHIO-APS / 1-855-644-6277 (24/7)
• ODH Abuse, Neglect, Misappropriation Program: 614-752-8805
• Ohio Medicaid Consumer Hotline: 1-800-324-8680
• Area Agency on Aging (statewide line for PASSPORT, ALW intake): 1-866-243-5678
• Pro Seniors Inc. (statewide elder-law legal advice for 60-plus): 800-488-6070
• Disability Rights Ohio: 800-282-9181

Compare facilities at medicare.gov/care-compare (federal) and aging.ohio.gov/care-and-living/long-term-care-quality-navigator (Ohio state).

Find personalized help choosing a nursing home in Ohio at brevy.com.