Nursing home admission checklist

A nursing home admission checklist is a step-by-step record of the documents, assessments, and consents a skilled nursing facility completes for each new resident.

It starts with pre-admission paperwork three to five days before arrival. It closes with the comprehensive care plan, which federal rules require by day 21.

Admissions coordinators, charge nurses, social workers, and the director of nursing each own part of it. The checklist below groups the work by the deadlines they share, so no form or assessment depends on someone’s memory.

Key takeaways

A nursing home admission checklist keeps intake on schedule across admissions, nursing, social work, and administration.

Pre-admission documentation covers insurance verification, medical history, advance directives, PASRR screening, and Medicare or Medicaid status.

Clinical deadlines run from the admission-day nursing assessment to a baseline care plan within 48 hours and the MDS 3.0 by day 14.

The comprehensive care plan is due within seven days of the MDS 3.0 admission assessment, so by day 21 at the latest.

Digital forms in a single resident record replace paper binders and show at a glance which admission tasks are still open.

What is a nursing home admission checklist?

A nursing home admission checklist is an administrative and clinical tool that guides skilled nursing facility staff through every required intake task. It keeps each admission consistent and documents compliance with the federal rules for long-term care facilities in 42 CFR Part 483.

• Clinical purpose: Gathers medical history, current medications, functional status, and baseline assessments needed for safe care planning.
• Administrative purpose: Collects legal documents (POA, advance directives, financial information) and confirms insurance eligibility.
• Compliance purpose: Documents resident rights notification, consent signatures, and the requirements CMS surveyors cite as F-tags.
• Operational purpose: Coordinates room readiness, equipment setup, and inventory of personal items.

Staff start it before the resident arrives and keep it open until the comprehensive care plan is signed, which is due by day 21.

Who uses the checklist?

Several roles share each admission, so the checklist shows who owns which task.

• Charge nurses: Complete clinical assessments, start the MDS 3.0, and document the admission note.
• Director of nursing (DON): Oversees the overall admission process and ensures regulatory compliance.
• Admissions coordinators: Collect pre-admission documents, verify insurance, and coordinate scheduling.
• Social workers: Review legal documents, explain resident rights, and assess psychosocial needs.
• Facility administrators: Verify Medicaid and Medicare eligibility and confirm financial arrangements.

Pre-admission documentation requirements

Completing pre-admission paperwork three to five days before the resident arrives shortens admission day and avoids last-minute delays. This phase needs coordination between the admissions team and the referring hospital, physician’s office, or family.

Medical and insurance verification

• Obtain a copy of the resident’s Medicare card and photo ID.
• Verify Medicare Part A eligibility and remaining covered days (up to 100 days after a qualifying hospital stay).
• Confirm Medicaid eligibility status through your state Medicaid agency.
• Request admission orders and a current medication list from the referring hospital.
• Obtain the discharge summary and clinical history from the hospital or primary care provider.

Legal and financial documents

Collect these documents before admission, so you have signed consent and clear legal authority for care decisions. If the resident has no DNR order on file, a DNR form template gives the physician and surrogate a standard document to complete.

• Power of attorney (POA): A healthcare or durable POA naming the surrogate decision-maker.
• Advance directive or living will: Written instructions on life-sustaining treatment preferences.
• POLST or MOLST form: Physician Orders for Life-Sustaining Treatment, which some states require at admission.
• DNR order: A do-not-resuscitate order, if applicable, signed by the physician and the resident or surrogate.
• Financial assessment form: Supports Medicaid spend-down and asset verification, with requirements that vary by state.
• Admission agreement: The facility’s admission contract, signed by the resident or surrogate. It sets out terms, costs, and resident rights.

Pre-admission screening (PASRR)

Medicaid-certified facilities must complete a Pre-Admission Screening and Resident Review (PASRR) per 42 CFR § 483.20 before admission. A positive Level I screen points to possible mental illness or intellectual disability. It triggers a Level II evaluation by the state before the resident can be admitted.

Clinical assessments from admission day to day 21

The clinical side of admission starts on day 1 and runs until the comprehensive care plan is in place. The charge nurse records the first assessment in an admission nursing note, which feeds the baseline care plan and the MDS 3.0 (Minimum Data Set). The timeline below shows how the six deadlines stack up.

Day-of-admission clinical tasks

• Complete a comprehensive nursing admission assessment, documented in SOAP format (subjective, objective, assessment, plan).
• Obtain vital signs (blood pressure, temperature, heart rate, respiratory rate).
• Perform a head-to-toe physical assessment and document skin integrity and wound status.
• Review the medication list and reconcile it with current prescriptions, flagging any discrepancies to the physician.
• Assess functional status (mobility, activities of daily living, continence).
• Conduct fall risk screening and start fall prevention protocols if indicated.
• Screen for pain, depression, and cognitive status.

Within 48 hours: The baseline care plan

Federal rules (42 CFR § 483.21(a)) require a baseline care plan within 48 hours of admission. It covers what staff need to care for the resident safely until the comprehensive plan is ready.

• Record initial goals based on the admission orders.
• Include physician orders, dietary orders, and any therapy or social services.
• Add PASRR recommendations if a Level II evaluation was completed.
• Give the resident and their representative a written summary of the plan.

Within 8 days of admission

• For Medicare Part A residents, set the 5-day assessment’s reference date between days 1 and 8.
• Complete a detailed history and physical (H&P) exam if the hospital didn’t provide one.
• Review and reconcile all current medications, and identify any contraindicated drug combinations.
• Obtain baseline lab work if ordered (CBC, CMP, UA) and clarify any abnormal findings.
• Document special precautions such as isolation status, allergies, and infection control needs.

By day 14: The MDS 3.0 admission assessment

• Complete the MDS 3.0 admission assessment, including the care area assessments, by day 14.
• Share the findings with the interdisciplinary team ahead of care planning.
• Ensure all physicians’ orders are documented and communicated to nursing staff.

By day 21: The comprehensive care plan

• Finalize the comprehensive care plan within seven days of completing the MDS 3.0 admission assessment.
• Involve the resident, their representative, and the interdisciplinary team in writing it.
• Obtain physician approval of the care plan and any standing orders.

Room readiness checklist for new residents

A well-prepared room eases the move for the new resident and removes safety hazards before they arrive. Housekeeping and nursing should finish room readiness the day before or the morning of admission.

• Clean and disinfect the room thoroughly per facility infection control protocols.
• Check the bed is clean, correctly assembled, and set at a safe height.
• Fit bed rails only after a risk assessment and informed consent, as CMS requires.
• Check that the call bell, light switches, and bathroom grab bars are accessible and working.
• Stock the room with clean linens, pillows, and blankets.
• Place personal care items (tissues, trash bin, water pitcher, cup) within reach.
• Confirm oxygen, suction, and any other medical equipment are present and functioning.
• Post the resident’s name, room number, and any isolation precautions on the door.
• Arrange furniture to allow safe mobility and wheelchair access if needed.

Resident rights and consent documentation

Federal law (42 CFR § 483.10) requires skilled nursing facilities to give each resident a written statement of their rights at admission. Staff then collect signatures confirming the resident understands those rights and the admission agreement.

Required consent and notification documents

• Resident rights notice: A written statement of resident rights under CMS regulations, often several pages long. Provide it in a language and format the resident understands.
• Admission agreement: The facility contract signed by the resident or surrogate. It covers services provided, costs, billing terms, and discharge policies.
• Advance directive notice: A written explanation of the resident’s right to create or update an advance directive. Record whether the resident already has one on file.
• HIPAA notice of privacy practices: Explains how the facility uses and protects health information.
• Consent to treatment: General authorization to provide nursing care and medical services.
• Photo consent (optional): Covers identification photos and wound photos taken for the clinical record.

Accessible communication

Provide materials in large print or alternative formats if the resident has visual or hearing impairments. Use an interpreter if the resident speaks a language other than English. Document all accommodations made.

Infection control screening at admission

Infections spread quickly in skilled nursing facilities, where residents share rooms, dining areas, and staff. CMS requires facilities to screen new residents for active infections and communicable diseases, and to isolate them where needed until cleared.

Admission-day infection screening

• Ask about respiratory symptoms (cough, shortness of breath, sore throat) in the past 14 days.
• Screen for fever or chills, and take a temperature immediately if the resident reports symptoms.
• Review the discharge summary for any active infections, a positive COVID-19 result, or other communicable diagnoses.
• Examine the skin for signs of infection (redness, warmth, wound drainage).
• If symptoms are present, start isolation precautions and notify the physician and infection control team immediately.

Documenting the results

Record all screening results, any precautions started, and the physician notification in the resident’s clinical record. Update precautions as new test results or clinical information arrive.

How Pabau keeps admission forms in one resident record

Many facilities still run admission from a paper binder, with forms scanned into the record days later. Finding an unsigned consent or an overdue assessment means flipping through that binder page by page.

Practice management software like Pabau moves the checklist into digital forms. Structured intake forms flag missing fields and collect e-signatures on the rights notice, admission agreement, and consents at the bedside.

Each completed form lands in a centralized resident record, next to the nursing assessment, medication list, and care plan. The director of nursing can then see which admission tasks are still open for every new resident.

For the admission note itself, Pabau Scribe, our AI scribe, drafts the note from the nurse’s conversation with the resident. The charge nurse reviews and signs it instead of typing it from scratch.

Automate your nursing home admission workflow

Collect admission consents digitally, keep every form in one resident record, and see which tasks are still open before day 21.

Book a demo

Conclusion

An admission checklist is only as useful as its dates. Treating admission as a single day is how the 48-hour baseline care plan and the day-21 comprehensive plan slip.

Start with the download, name one owner per resident, and put each deadline on the calendar the day the referral arrives. That costs a little planning before arrival and buys a calmer admission day and a cleaner survey record.

Book a demo to see how Pabau keeps each resident’s admission forms, assessments, and care plan in one record.

Continue your research

Need a HIPAA form for the admission packet? HIPAA authorization form gives residents a standard way to approve who can receive their health information.

Running a fuller intake evaluation? Intake assessment template structures the history, risk and functional questions behind a first assessment.

Want admission notes that hold up at survey? Nursing documentation best practices covers the principles and legal requirements behind every nursing entry.

Planning ahead for the resident’s discharge? Discharge planning checklist picks up where the admission checklist ends, from care transfer to follow-up.

Frequently asked questions