Nursing Home Team Structure: Every Leadership Role Explained
Some of these roles exist because federal regulation names them directly. Others exist because a facility can't run without them. Knowing which is which matters when you're staffing — and when you're figuring out which seat is quietly empty.
Quick answer
Federal regulation names only a handful of nursing home leadership roles directly: the Administrator, the Director of Nursing, the Medical Director, the Infection Preventionist, and — only above 120 beds — a full-time Social Services Director. The rest of the structure (ADON, MDS Coordinator, Dietary/Food Service Director, Activities Director, Business Office Manager) is facility-designed to meet other regulatory functions. One seat, a dedicated QA/QAPI Coordinator, isn't federally required at all — CMS mandates the QAA committee and its function, not a specific job title to run it, which is why smaller and multi-facility operators often leave it unfilled.
Why the org chart looks different from most industries
In most businesses, the leadership structure is entirely a management decision. In a nursing home, part of it is a management decision and part of it is a federal one. A handful of roles exist because 42 CFR Part 483 names them directly and requires the facility to fill them with someone who meets specific qualifications. The rest of the structure exists because those same regulations require certain functions — nutrition oversight, activities programming, accurate resident assessments — and leave it to the facility to decide who owns them day to day.
Roles federal regulation names directly
Administrator
42 CFR §483.70(d)Overall operational, financial, and regulatory accountability for the facility. CMS requires every certified nursing home to employ a licensed Administrator by name.
Director of Nursing (DON)
42 CFR §483.35A Registered Nurse designated full-time to direct the entire nursing program. The federal bar is the RN license itself — no mandated years of experience or degree.
Medical Director
42 CFR §483.70(g)A physician the facility designates to implement resident care policies and coordinate medical care facility-wide, and who also sits on the QAA committee.
Infection Preventionist
42 CFR §483.80(h)Must have primary training in nursing, medical technology, microbiology, epidemiology, or a related field, plus specialized infection-prevention training, and work at least part-time at the facility. At least one IP must sit on the QAA committee.
Social Services Director
42 CFR §483.70(o)A full-time qualified social worker is federally required only in facilities with more than 120 beds. Smaller facilities must still provide medically related social services, but not necessarily through a dedicated full-time position.
For the Administrator and DON specifically, see our full breakdowns of how to hire a Nursing Home Administrator and how to hire a Director of Nursing, including the licensing path and a ready-to-post job description for each.
Roles the facility designs to meet other requirements
These positions aren't named in federal regulation the way the roles above are, but each one exists because a regulatory function still needs an owner.
Assistant Director of Nursing (ADON)
Supports the DON on staffing, scheduling, and clinical oversight, and often steps in during the DON's absence. Federal regulation doesn't create or require this position — it's a facility staffing decision, common in mid-size and larger buildings that need a second in command on the nursing side.
MDS Coordinator
Owns the resident assessment (RAI/MDS) process. Federal regulation (42 CFR §483.20) requires a Registered Nurse to conduct or coordinate each assessment and certify its accuracy — that RN function is what the industry calls the MDS Coordinator, though CMS regulation doesn't itself define or require that job title.
Dietary / Food Service Director
Federal regulation (42 CFR §483.60(a)) requires a qualified dietitian on a full-time, part-time, or consultant basis. Where a facility doesn't employ one full-time, it must designate a Director of Food and Nutrition Services with at least two years of experience in the role at a nursing facility and completed food-safety training, working under regular dietitian consultation.
Activities Director
Federal regulation (42 CFR §483.24(c)) requires the activities program to be directed by a qualified professional — a licensed/registered therapeutic recreation specialist or activities professional, or someone meeting one of several defined experience or training alternatives.
Business Office Manager
Owns billing, accounts receivable, census reporting, payroll coordination, and admissions financial paperwork. There's no federal regulation naming this role — it exists because a facility can't run without it, not because CMS requires it.
The seat that often goes unfilled: QA/QAPI Coordinator
CMS requires every facility to maintain a Quality Assessment and Assurance (QAA) committee under 42 CFR 483.75, with specific required members — the Director of Nursing, the Medical Director or a designee, the Infection Preventionist, and at least three additional staff including one in a leadership role. See our full guide to QAPI committee membership and the five required elements for how that works. What the regulation doesn't require is a dedicated person whose job is running that committee day to day — pulling the data, tracking Performance Improvement Projects, scheduling meetings, chasing root-cause analyses.
Larger, better-resourced facilities often create that seat anyway, because someone has to do the work whether or not the org chart names them. Smaller facilities and multi-facility operators spread thin across several buildings frequently don't — the DON or Administrator absorbs it on top of an already full plate, and the QAPI program drifts toward the "binder pulled out before survey week" pattern that surveyors are trained to flag.
A leaner team doing more, not software replacing a person
PoC360 doesn't replace a role CMS requires a human for — it takes the load off the QA function that often doesn't have a dedicated person. The Daily Compliance Task Scheduler runs 76 pre-loaded daily tasks mapped to F-tags with one-tap sign-off and a full audit log, and Compliance Intelligence surfaces your highest-risk repeat F-tags and flags policy gaps from your own citation history — so a facility without a dedicated QAPI Coordinator still gets the monitoring that role would otherwise chase manually.
Start Free Trial →Frequently Asked Questions
How many leadership positions does CMS require a nursing home to have by name?+
A handful. Federal regulation names the Administrator (42 CFR §483.70(d)), the Director of Nursing (42 CFR §483.35), the Medical Director (42 CFR §483.70(g)), and the Infection Preventionist (42 CFR §483.80(h)) directly, and requires a full-time qualified social worker only in facilities with more than 120 beds (42 CFR §483.70(o)). Most of the rest of a facility's org chart — ADON, MDS Coordinator, Business Office Manager, and others — is a facility staffing decision built to meet other requirements, not a named federal position.
Is a QAPI Coordinator a federally required position?+
No. CMS requires a functioning Quality Assessment and Assurance (QAA) committee under 42 CFR 483.75, with specific required membership — the Director of Nursing, the Medical Director or a designee, the Infection Preventionist, and at least three more staff including one in a leadership role. See our full guide to QAPI committee requirements. What CMS doesn't require is a dedicated staff member whose job is running that committee's day-to-day data and project tracking — many facilities create that seat anyway; many don't.
Does an Assistant Director of Nursing (ADON) have to be a Registered Nurse?+
CMS regulation doesn't create the ADON position at all, so it sets no licensure requirement for it either. Where a facility chooses to staff the role, it typically requires RN licensure to mirror the DON's own requirement — but that's a facility- or state-level decision, not a direct federal mandate.
Do all nursing homes need a full-time Social Services Director?+
Only facilities with more than 120 beds are federally required to employ a full-time qualified social worker, under 42 CFR §483.70(o). Smaller facilities still have to provide medically related social services to residents, but federal regulation doesn't require a dedicated full-time position to do it.
Sources: 42 CFR §483.70, §483.35, §483.80(h), §483.60(a), §483.24(c), §483.20, and §483.75. Last reviewed 2026-09-27. We review this article as CMS regulations and enforcement guidance change.
More CMS compliance guides