30-60-90 day plan for directors of nursing
On this page
- What makes a director of nursing's first 90 days different?
- Which CMS requirements does a new DON check first?
- What does the 30-60-90 day plan look like?
- What goes in the clinical and staffing baseline?
- How should the administrator use the plan in the final interview?
- What should each check-in cover?
- A filled example
- What does the administrator owe the new DON?
- Common mistakes
- How do you adapt the plan?
- Questions people ask
A 30-60-90 day plan for a director of nursing in a nursing home should spend the first month finding out where the facility stands with the regulations: the last surveys and plans of correction, staffing and the daily staffing posting, abuse reporting, PBJ staffing data and nurse aide competency records. The second month takes over the clinical operating rhythm (daily clinical meeting, the quality assessment and assurance committee, a mock survey), and the third delivers one measured quality improvement and a staffing plan. All rules below are from the CMS requirements for long-term care facilities as they read in October 2026.
This plan is for the administrator, owner or regional clinical director hiring a director of nursing (DON) for a skilled nursing or nursing facility. Hospital nursing leaders are covered in the last section, and unit leaders in the 30-60-90 day plan for nurse managers.
What makes a director of nursing's first 90 days different?
A nursing home can be surveyed at any time without notice, so a new DON does not get a grace period. Standard surveys must be unannounced (42 CFR 488.307) and must happen no later than 15 months after the previous one, with a statewide average of 12 months or less (42 CFR 488.308). Complaint surveys can happen in between. The DON also carries named duties in the regulations: the DON sits on the quality assessment and assurance committee and takes part in the facility assessment, and the facility's staffing data is published.
At the same time the DON has to earn the trust of nurses and aides who often work short-staffed and have seen several DONs. The plan keeps both in view: regulatory checks in the first two weeks, and presence on every shift throughout.
Which CMS requirements does a new DON check first?
The table lists federal requirements a DON is directly involved in, current as of October 2026 and not legal advice. State licensing rules often add staffing ratios, training hours and reporting steps; check them with your state survey agency.
| Area | What the rule requires | Source |
|---|---|---|
| Nurse staffing | Sufficient staff with the right competencies based on the facility assessment; a charge nurse on each tour of duty; an RN at least 8 consecutive hours a day, 7 days a week; a full-time RN as DON, who may be charge nurse only if average daily occupancy is 60 or fewer (waivers aside) | 42 CFR 483.35(a)-(b) |
| Staffing posting | Daily posting at the start of each shift of RN, LPN or LVN and CNA numbers and hours, with the census, in a prominent place; kept for at least 18 months or longer under state law | 42 CFR 483.35(g) |
| Payroll-Based Journal | Direct care staffing data, including agency and contract staff, submitted electronically at least quarterly; CMS lists deadlines 45 days after each quarter | 42 CFR 483.70(p); CMS PBJ page |
| Nurse aides | Registry verification before an aide works, checks of every state registry likely to hold information, a performance review at least every 12 months, and in-service training of at least 12 hours a year | 42 CFR 483.35(d); 483.95(g) |
| Abuse and neglect reporting | Alleged violations reported to the administrator and the state survey agency no later than 2 hours if abuse or serious bodily injury is involved, otherwise within 24 hours; investigation results within 5 working days | 42 CFR 483.12(c) |
| Resident assessment (MDS) | Comprehensive assessments within 14 days of admission and of a significant change, and at least every 12 months; quarterly reviews; an RN signs and certifies completion | 42 CFR 483.20 |
| QAPI and QAA committee | The DON is a required member of the QAA committee, which meets at least quarterly with the medical director, the infection preventionist and leadership | 42 CFR 483.75(g) |
| Facility assessment | Reviewed at least annually and on major change, with the DON actively involved; it drives staffing and competencies | 42 CFR 483.71 |
The 2024 federal minimum staffing standards (hours per resident day and a 24-hour RN) do not appear in the current text of 42 CFR 483.35, which was last amended on December 3, 2025. Staffing still shows up publicly: CMS's Five-Star Quality Rating System rates each nursing home on health inspections, staffing and quality measures on Care Compare.
What does the 30-60-90 day plan look like?
30-60-90 day plan — [Name], Director of Nursing, [facility]
Reports to: [administrator] Start date: [date]
Licensed beds: [N] Average census: [N] Short-stay / long-stay mix: [ ]
Nursing staff: [N] RNs, [N] LPNs, [N] CNAs; agency use: [hours / week]
Last standard survey: [date] Open plans of correction: [N]
DAYS 1-30 — Know where the facility stands
Goals:
- Read the last standard survey and complaint surveys; confirm each
plan of correction is in place and monitored
- Check staffing against 483.35 and state rules for every shift of
the last [4] weeks; check the daily posting and its retention
- Reconcile the last PBJ submission with payroll and agency invoices
- Review the abuse prohibition policy, the reporting log and one
recent investigation from start to finish
- Audit nurse aide files: registry checks, annual reviews, in-service
hours
- Meet the administrator, medical director, infection preventionist,
MDS coordinator, staff development coordinator and unit managers
- Round on day, evening and night shifts and on a weekend; attend
the resident council and meet family members who raise concerns
Deliverables by day 30:
- Survey readiness baseline with owners and dates for each gap
- Clinical and staffing baseline (see below)
Check-in: day 30, with administrator
DAYS 31-60 — Take over the clinical rhythm
Goals:
- Run the daily clinical meeting: admissions, changes in condition,
falls, wounds, infections, hospital transfers, staffing
- Lead nursing's part of the QAA meeting with data, not anecdotes
- Run a mock survey with an outside or regional nurse
- Choose one performance improvement project from the baseline
- Build a staffing plan that reduces agency hours and covers weekends
Deliverables by day 60:
- Mock survey findings with owners and dates
- PIP charter: measure, baseline, interventions, review date
Check-in: day 60
DAYS 61-90 — Own the results
Goals:
- Report the PIP's first results at QAA
- Update the facility assessment with the administrator if staffing
or acuity has changed
- Set the annual education plan with the staff development coordinator
- Present a 6-month nursing plan: staffing, quality, survey, retention
Deliverables by day 90:
- No unmonitored plan of correction; PIP measured
- 6-month plan agreed with the administrator
Check-in: day 90 — full reviewWhat goes in the clinical and staffing baseline?
These are example measures. Use the facility's own reports and CMS's published quality measures for the facility, and show each with its trend.
| Area | Example measures | Usual source |
|---|---|---|
| Survey | Deficiencies by tag and scope and severity, repeat citations, open plans of correction | Statement of deficiencies, state survey agency |
| Staffing | Nursing hours per resident day by role, agency hours, weekend coverage, turnover | Payroll, PBJ, scheduling system |
| Clinical quality | Falls with major injury, pressure injuries, antipsychotic use, infections, weight loss, hospital transfers | MDS-based quality measures, incident logs, infection surveillance |
| Resident experience | Grievances and their themes, resident council minutes | Grievance log, social services |
| Workforce | Nurse aide in-service completion, overdue annual reviews, open positions | Staff development records, HR |
How should the administrator use the plan in the final interview?
Ask finalists to bring a short plan for your facility, using a brief with the bed count, the last survey's main findings and the staffing picture. Score it with the rubric in how to evaluate a 30-60-90 day plan in an interview, then test judgment with scenarios:
- "At 7 p.m. a CNA tells the charge nurse a resident said another aide was rough with her last night. Walk me through the next two hours." Listen for the resident's safety, protecting residents while the investigation runs (often by taking the aide off resident contact), and reporting within 2 hours, because the allegation involves abuse.
- "Surveyors walk in tomorrow morning. What do you check tonight?"
- "Agency hours are high and your weekend CNAs keep calling off. What would you look at first?"
- "How do you know a plan of correction is still working six months later?"
What should each check-in cover?
| Checkpoint | Questions to ask | On track | Worth a direct conversation |
|---|---|---|---|
| Day 30 | "Where would we be cited if surveyors came tomorrow?" | Specific gaps with owners; PBJ reconciled; every shift visited; abuse process walked through | Only day-shift presence; "we are ready" with no evidence |
| Day 60 | "What did the mock survey find, and what is fixed?" | Mock survey done; daily clinical meeting running; PIP chosen with a baseline | The DON is covering shifts most days; the QAA meeting runs on anecdotes |
| Day 90 | "What changed for residents?" | PIP shows process measures moving; staffing plan reducing agency; plans of correction monitored | No measures; turnover rising without a plan |
A filled example
Director of nursing: Denise Howard (invented), new DON at a 110-bed skilled nursing facility with a high share of short-stay rehabilitation residents and a recent complaint survey.
Day 30: Found that one plan of correction for fall care plans was being audited only on day shift. The PBJ reconciliation showed agency CNA hours missing from one month's submission because the invoices arrived late. Nurse aide in-service hours were short for a group of night-shift aides, who could not attend daytime sessions.
Day 60: Extended fall audits to evenings and nights. Added an agency-invoice check to the PBJ process with the payroll lead. The mock survey found care plans not updated after falls on one unit. She chose falls with major injury as her PIP, with post-fall huddles as the process measure.
Day 90: Post-fall huddles were documented after most falls on all units; it was too early to judge the outcome measure, and she said so at QAA. Night-shift in-service sessions brought aide hours up to date. Her 6-month plan included a weekend CNA incentive to cut agency hours.
What does the administrator owe the new DON?
- The survey history and every open plan of correction, complaint and state communication.
- Access to the clinical record system, scheduling, payroll reports for PBJ, the incident and grievance logs.
- A clear limit on floor coverage, so the DON is not the default nurse for every call-off.
- A budget conversation on agency use and wages before day 60.
Common mistakes
| Mistake | Result | Fix |
|---|---|---|
| Assuming plans of correction are still in place | Repeat citations on the next survey | Check each one in the first two weeks |
| Treating PBJ as a payroll task | Published staffing that does not match reality | DON reviews the submission against the schedule |
| DON as permanent floor nurse | No time for QAA, audits or staff development | Track coverage hours at each check-in |
| Quality projects without measures | Activity reported, outcomes unknown | One PIP with a baseline and process measure |
How do you adapt the plan?
- Hospital director of nursing or nursing services: the hospital conditions of participation make the director responsible for the operation of the nursing service, including the types and numbers of nursing staff (42 CFR 482.23(a)). Replace survey and PBJ items with unit staffing plans, quality indicators and accreditation readiness.
- Assisted living: federal nursing home rules do not apply; use the state's assisted living regulations for the compliance check.
- Working with an educator: the 30-60-90 day plan for nurse educators covers the competency inventory and in-service planning the DON relies on.
For hiring the aides and nurses the staffing plan depends on, the CNA screening questions and registered nurse screening questions cover certification, registry status and shift availability.
Questions people ask
What should a new director of nursing do in the first 30 days?
Read the last standard and complaint surveys and confirm every plan of correction is in place, check staffing against the federal and state rules and the daily staffing posting, confirm the abuse reporting process and log, review the last PBJ submission, audit nurse aide registry checks, in-service hours and annual reviews, and round on every shift. The aim is to know where the facility would be cited if surveyors arrived tomorrow.
Do the 2024 nursing home minimum staffing rules still apply?
As of October 2026, the text of 42 CFR 483.35 in the eCFR, last amended on December 3, 2025, does not contain the 2024 total nurse staffing hours per resident day or 24-hour registered nurse requirements. It requires an RN for at least 8 consecutive hours a day, 7 days a week, a full-time RN director of nursing, and sufficient staff to meet residents' needs based on the facility assessment. State staffing rules may be stricter. This is not legal advice.
How is a director of nursing plan different from a nurse manager plan?
A nurse manager runs one unit. A director of nursing in a nursing home is accountable for nursing across the whole facility and for its regulatory compliance: survey readiness, staffing and staffing data, the quality assessment and assurance committee, abuse prevention and reporting, and the competence of every nurse and nurse aide. The plan is built around those obligations as well as the unit-level work.
Can the director of nursing also work as the charge nurse?
Under 42 CFR 483.35(b)(3), as of October 2026, the director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. In larger facilities the DON should not be counted as the charge nurse on the schedule.