Preventable Hospital Readmissions From Nursing Homes: Questions Families Can Ask
A return to the hospital after a nursing-home or skilled-rehabilitation stay does not automatically mean the facility made a mistake.
Some residents become acutely ill despite appropriate care.
But hospital readmissions are important enough that CMS publicly tracks multiple readmission and hospitalization measures for skilled nursing facilities and nursing homes.
Families can use a readmission as a reason to ask what changed, whether warning signs were recognized, what the hospital found, and how the care plan will be different after the resident returns.
CMS tracks readmissions because they matter
CMS quality programs include measures related to:
- unplanned hospital readmissions after SNF care;
- potentially preventable readmissions after SNF discharge;
- hospitalizations among long-stay residents; and
- healthcare-associated infections requiring hospitalization.
Lower readmission rates can be favorable, but facility comparisons need context and risk adjustment.
Do not assume every hospital transfer was preventable.
Ask what triggered the transfer
Request a clear timeline:
- What symptom changed?
- When was it first noticed?
- What were the vital signs?
- Who assessed the resident?
- When was the clinician called?
- When was family notified?
- What treatment was attempted in the facility?
- Why was hospital transfer chosen?
This is more useful than asking only, “Why did Mom go back?”
Ask what the hospital diagnosed
A hospital transfer may reveal:
- infection;
- dehydration;
- heart failure exacerbation;
- pneumonia;
- medication problem;
- bleeding;
- fall injury;
- kidney problem;
- aspiration; or
- another acute condition.
Get the discharge summary when authorized.
Then ask the nursing home how the new diagnosis changes care.
Medication reconciliation is critical after return
A hospital may:
- stop medications;
- start antibiotics;
- change blood-pressure medicines;
- add anticoagulation;
- alter insulin;
- change pain treatment; or
- change oxygen orders.
Ask who reconciles the hospital discharge list against the nursing-home medication administration record.
Ask whether the care plan changed
A meaningful post-readmission review may address:
- monitoring frequency;
- weight checks;
- hydration;
- wound care;
- infection prevention;
- swallowing precautions;
- toileting;
- therapy;
- fall prevention;
- medication timing; and
- clinician follow-up.
If nothing changes after a serious repeated problem, ask why.
Repeated hospitalizations deserve a broader discussion
If the resident is going to the hospital repeatedly, ask:
- Is the nursing home still the right level of care?
- Is a different skilled facility needed?
- Is palliative care appropriate?
- Are goals of care clear?
- Is the resident’s advance directive current?
- Are the hospitalizations related to the same recurring condition?
Our guide Palliative Care vs Hospice in Senior Living can help families understand one part of that conversation.
Use quality data carefully
Care Compare can help families compare nursing-home quality measures.
A readmission measure should be one part of the picture alongside:
- inspections;
- staffing;
- turnover;
- resident needs; and
- facility-specific clinical capability.
Our guide How to Use Medicare Care Compare Without Relying on Star Ratings Alone explains that approach.
A practical example
Thomas is transferred from SNF rehabilitation to the hospital for shortness of breath.
The hospital diagnoses worsening heart failure.
When he returns, his daughter asks what will change.
The SNF updates the plan to include the clinician’s individualized weight-monitoring instructions, medication changes, and a clear threshold for reporting new swelling or breathlessness.
The readmission becomes information the next care plan can use.
Eight questions after a hospital readmission
- What triggered the transfer?
- What did the hospital diagnose?
- Were warning signs recognized early?
- What medications changed?
- What follow-up is ordered?
- What care-plan changes are being made?
- Is this part of a repeated pattern?
- Does the current facility still have the capability the resident needs?
Sources and review date
Sources checked October 12, 2026.
- CMS: SNF Value-Based Purchasing Measures
- CMS Provider Data Catalog: Nursing Home Quality Measures
