A director of nursing (DON) is the senior clinical leader of a care organization outside the hospital: the registered nurse a nursing home designates full-time, or the clinical manager who oversees all patient care services and personnel in a Medicare-certified home health agency.
This guide explains what the DON seat looks like in nursing homes, home health, hospice and assisted living, what it is responsible for, and how experienced nurses move into it.
What is a director of nursing?
A director of nursing holds the top clinical seat in a senior care organization.
The title covers the nurse who owns how care is staffed, delivered, supervised and documented.
Postings abbreviate it DON, and employers use neighboring titles such as clinical manager for the same clinical authority.
In nursing homes the title is written into federal rule.
Unless a facility is waived, CMS requires an RN on duty at least 8 consecutive hours a day, 7 days a week, and a registered nurse designated as the full-time director of nursing (42 CFR 483.35(b)).
The DON is not the administrator.
Nursing homes must also designate a physician as medical director, a role separate from both the administrator and the director of nursing (42 CFR 483.70).
The administrator, appointed by the governing body, is responsible for management of the facility (42 CFR 483.70).
Home health uses a different name for the same clinical authority.
Medicare-certified agencies must have a clinical manager who oversees all patient care services and personnel, including making patient and personnel assignments, coordinating patient care and referrals, ensuring ongoing assessment, and ensuring plans of care are developed and updated (42 CFR 484.105(c)).
Federal home health rules do not limit that seat to nurses.
A licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker or registered nurse can hold it (42 CFR 484.115(c)).
This guide covers the seat as senior care uses it, not hospital nursing leadership.
Employers post the work under several of these titles, so a title-only search can miss seats.
You can browse director of nursing jobs gathered in one place on CaregiverHires.
Director of nursing by setting
The rulebook behind the seat changes with the setting.
Here is where DON-family roles sit in each corner of senior care.
Nursing homes and skilled nursing facilities.
The full-time RN designation in 42 CFR 483.35(b) is the federal requirement behind the title.
Around the DON sits a coverage floor: an RN on duty at least 8 consecutive hours a day, 7 days a week, unless the facility is waived.
CMS even limits when the DON can double as a charge nurse, allowing it only when the facility's average daily occupancy is 60 or fewer residents.
The seat is management-first.
Home health.
The clinical manager oversees all patient care services and personnel (42 CFR 484.105(c)).
The agency's administrator runs day-to-day operations and must ensure a clinical manager is available during all operating hours (42 CFR 484.105(b)).
When the administrator is unavailable, a qualified pre-designated person authorized in writing — who may be the clinical manager — assumes the administrator's responsibilities (42 CFR 484.105(b)(2)).
Hospice.
Every Medicare hospice interdisciplinary group must include a registered nurse, and the hospice designates an RN in the group to coordinate care (42 CFR 418.56(a)).
Hospice nursing services must be provided by or under the supervision of a registered nurse (42 CFR 418.64(b)(1)).
Because nursing, physician services and drugs must be routinely available 24 hours a day, 7 days a week, hospices staff on-call and triage nurses (42 CFR 418.100(c)(2)).
Assisted living and memory care.
Assisted living runs on a different rulebook.
The full-time DON requirement above is a federal nursing home rule (42 CFR 483.35(b)).
An HHS (ASPE) compendium describes residential care settings, including assisted living, as governed almost exclusively by state laws and regulations rather than federal rules, and they vary from state to state.
So the state requirements that apply to a community, along with its own org chart, shape any director-level clinical seat there.
What a director of nursing is responsible for
One federal duty list is written out in full, and it belongs to the home health clinical manager.
The Conditions of Participation direct the clinical manager to oversee all patient care services and personnel, broken into concrete functions (42 CFR 484.105(c)).
- Making patient and personnel assignments
- Coordinating patient care
- Coordinating referrals
- Ensuring ongoing assessment
- Ensuring plans of care are developed and updated
Around that list, the Conditions of Participation build a deadline-dense calendar the clinical seat owns.
In home health, a registered nurse must conduct the initial assessment visit within 48 hours of referral, of the patient's return home, or on the ordered start-of-care date (42 CFR 484.55(a)).
The comprehensive assessment must be completed no later than 5 calendar days after start of care and, except for therapy-only cases, by a registered nurse (42 CFR 484.55(b)).
That assessment is updated in the last 5 days of every 60 days from start of care, within 48 hours of return home from a hospital stay of 24 hours or more (other than for diagnostic tests), and at discharge (42 CFR 484.55(d)).
Hospice runs on a similar clock.
The interdisciplinary group must review, revise and document each patient's plan of care as often as the condition requires, but at least every 15 calendar days (42 CFR 418.56(d)).
Federal hospice rules also set an initial assessment within 48 hours after election and a comprehensive assessment within 5 calendar days after election.
Coordination is its own duty.
Home health agencies must communicate with all physicians or allowed practitioners in the plan of care, integrate their orders and all services, and involve the patient, representative and caregivers in coordination (42 CFR 484.60(d)).
People leadership is the other half.
BLS notes some registered nurses oversee licensed practical nurses, nursing assistants and home health aides, and federal home health rules have LPNs furnishing services under the supervision of a qualified registered nurse (42 CFR 484.115(e)).
Staffing decisions run through the seat as well.
A home health agency must maintain and review annually a patient acceptance-to-service policy applied to every referral, weighing the patient's anticipated needs, the agency's caseload and case mix, staffing levels and staff skills (42 CFR 484.105(i)).
Quality programs run through the seat's people too: home health skilled professionals are responsible for participating in QAPI and in-service training (42 CFR 484.75(b)).
Path to DON
For nurses, the route into the seat starts with a nursing license.
Registered nurses usually take one of three education paths BLS counts — a bachelor's degree in nursing, an associate's degree in nursing, or a diploma from an approved program — and must be licensed.
BLS also notes some RNs oversee LPNs, nursing assistants and home health aides, which can be a nurse's first exposure to leading care.
The credential the seat requires depends on the setting.
In nursing homes, the full-time DON must be a registered nurse, unless the facility is waived (42 CFR 483.35(b)).
In Medicare home health, the clinical manager seat is open to an RN and to several other licensed disciplines (42 CFR 484.115(c)), and a state or an individual employer can still require an RN for the job.
BLS describes the broad management category that covers these seats — medical and health services managers — as typically needing a bachelor's degree plus less than 5 years of related experience.
For 2025 to 2035, BLS projects 24% growth for that category, much faster than average.
Experience in the building matters alongside the degree.
BLS notes that nursing home administrators may have years of experience as a registered nurse, one description of the RN-to-leadership ladder these seats sit on.
The assistant director of nursing title appears nowhere in the federal nursing home staffing rule; it is a role employers create.
The DON rule itself names the other familiar rung: at an average daily occupancy of 60 or fewer residents, CMS lets the DON also serve as charge nurse, a pairing the rule allows only at that size.
Requirements change by setting and state
The hardest parts of the job
The seat's hardest parts come straight from its structure.
Start with around-the-clock accountability: BLS notes that in around-the-clock settings such as nursing homes, health services managers may need to work evenings or weekends and be on call for emergencies.
Federal coverage floors make that structural rather than occasional.
A nursing home must have an RN on duty at least 8 consecutive hours a day, 7 days a week unless waived, and hospice nursing services must be routinely available 24 hours a day, 7 days a week.
The calendar is deadline-dense.
Assessment clocks run in hours and days: 48 hours to the initial visit (measured from referral or return home in home health, from hospice election in hospice), and 5 calendar days to the comprehensive assessment (after start of care or election).
In home health, that assessment is updated in the last 5 days of every 60 days, and a hospice plan-of-care review is due at least every 15 calendar days.
Clinical accountability concentrates in one seat.
The clinical manager standard says it plainly: this role oversees all patient care services and personnel (42 CFR 484.105(c)).
The balancing act is constant, too.
The patient acceptance-to-service policy a home health agency must apply to every referral weighs anticipated needs against caseload, case mix, staffing levels and staff skills — a judgment call that sits on the clinical side of the house.
None of that adds up to quiet work: the coverage floors, the assessment clocks and the oversight standard make this a management job with clinical accountability attached.
Next step: from director of nursing to administrator
The administrator's office is the natural next seat, and the two roles are built to work together.
In nursing homes, the administrator is appointed by the governing body, is responsible for management of the facility, and reports to that body (42 CFR 483.70).
Licensure is the dividing line on the business side: BLS says all states require licensure for nursing home administrators, with requirements that vary by state, and that nursing home administrators manage all aspects of a facility, including admissions, building maintenance and resident care.
Home health sets the bar in its own rule.
An administrator hired on or after January 13, 2018 must be a licensed physician, a registered nurse, or hold an undergraduate degree (42 CFR 484.115(a)(2)).
The rule also requires experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program.
Hospice leaves the qualifications to its governing body.
A hospice administrator must be a hospice employee appointed by and reporting to the governing body, with the education and experience that body requires (42 CFR 418.100(b)).
The two seats already overlap in daily structure.
The home health administrator runs day-to-day operations and must ensure a clinical manager is available during all operating hours (42 CFR 484.105(b)); in the administrator's absence, a qualified pre-designated person — who may be the clinical manager — assumes the administrator's responsibilities (42 CFR 484.105(b)(2)).
Pay in both seats lands in the same BLS category: medical and health services managers (11-9111), the occupation that covers nursing home, assisted living, home care and hospice administrators and directors of nursing in a management role.
Its May 2025 national median was $59.55 per hour, or $123,860 per year.
For context, BLS puts registered nurses (29-1141) at a $97,550 national median the same year.
That figure is a different occupation — all RNs, not DONs — so read the two as neighboring categories, not as a DON-versus-staff-nurse pay gap.
The director of nursing salary page carries this figure with its closest-available-occupation labelling.
On the employer side of this seat?
Hire for this role (employers) through the CaregiverHires hiring hub, which covers the employer and owner side of senior and home care hiring.
This page is career information, not licensing, legal, medical or tax advice. Licensing and coverage rules change: confirm requirements with your state board of nursing, the state board that licenses administrators, and CMS before you act on them.