Establish a Nursing Home

Purpose: This procedure describes the steps to establish nursing home beds in North Carolina. The N.C. Medical Care Commission is authorized to adopt, amend and repeal all rules necessary for the implementation of the Nursing Home Act (Chapter 131E, Article 6, Part 1 of the N.C. General Statutes). Rules in Title 10A of the North Carolina Administrative Code (10A NCAC 13D) apply.

Please be aware that there may be variations in the process since individual projects may have special circumstances. The following is a general guide to aid the applicant in completing the overall project.

Contacts: For questions regarding any part of this process, please contact the appropriate sections of the N.C. Division of Health Service Regulation.

Certificate of Need 919-855-3873
Construction Section 919-855-3893
Healthcare Planning 919-855-3865
Nursing Home Licensure & Certification Section 919-855-4520

Procedure Summary: In order to operate a nursing home in North Carolina, an applicant must review the State Medical Facilities Plan to determine if there is a demonstrated need for a nursing home. Then they obtain a certificate of need. They must get approval for the construction of the facility, and then apply for and obtain a license. The Nursing Home Licensure and Certification Section renews licenses annually. If the nursing home wants to accept payment from Medicare or Medicaid, it must apply for certification after it is in operation.


  1. Review the State Medical Facilities Plan: Healthcare Planning
    1. Applicants can review the annual State Medical Facilities Plan and learn about the number of nursing home beds needed. The Division of Health Service Regulation publishes this plan each calendar year and specifies areas of the state where the community needs nursing homes.
    2. Applicants can also find the certificate of need review schedule and deadline for submittal of applications for beds in the State Medical Facilities Plan. No one may develop new nursing home beds without a certificate of need.
  2. Obtain a Certificate of Need: Certificate of Need
    1. The applicant submits a certificate of need (CON) application for the proposed nursing home beds according to the schedule outlined in the State Medical Facilities Plan. If the applicant is leasing the facility, both the prospective owner/lessor and the lessee of the home must submit a joint application.
    2. CON schedules a review for each of the counties in which there is a need. CON will accept applications for proposed beds within a county where a review has been scheduled.
    3. Within 30 days of the beginning of the review period, any person, including the applicant regarding the proposals under review, may file written comments.
    4. CON conducts a public hearing within 30 to 50 days from the beginning of the review period. At this time, the CON Section gives an opportunity to the applicant to respond to written comments and inquiries made at the hearing.
    5. CON decides to approve or disapprove an application within 150 days of the beginning of the designated review period.
    6. CON issues a certificate of need 35 days after the date of approval unless a petition for a contested case hearing is filed.
    7. After CON issues a certificate of need, the applicant contacts the Construction Section and the Nursing Home Licensure and Certification Section about the requirements for the development of nursing home beds.
  3. Obtain construction approval: Construction Section
    1. The applicant sends the fee payment, two sets of floor plans and specifications to the Construction Section.
    2. The Construction Section reviews the floor plans and provides the applicant with comments and instructions. The Construction Section acts as the control point for distribution of plans and specifications to the Department of Insurance. The Construction Section generally reviews plans in three stages: schematic, design development, and final working drawings.
    3. Applicants and their designers work closely with local building officials and fire prevention officials as well as with the Construction Section to ensure the facility is code and licensure compliant.
    4. At least two weeks before construction is complete, the applicant sends a letter to the Construction Section requesting a final construction inspection with project information and local approvals. The nursing home must be ready with all systems operational and all construction completed by the final construction inspection date. The Construction Section does not do punch list inspections; these are the responsibility of the designer, contractor, and owner.
    5. The Construction Section sends a copy of the final inspection document list, inspects the nursing home for licensure and for certification, and reviews the required final documentation. This is usually a joint inspection effort to ensure that the building meets construction standards for both licensure and for Medicare/Medicaid certification.
    6. If the Construction Section finds some minor deficiencies, the applicant submits a plan of correction.
    7. When all items are acceptable, the Construction Section sends the construction approval transmittal form (form 4086) to the Nursing Home Licensure & Certification Section.
  4. Obtain a license: Nursing Home Licensure & Certification Section
    1. At least three months before operation, the applicant contacts the Nursing Home Licensure and Certification Section to discuss the initial licensure process. The applicant is directed to the instructions and forms on this website.
    2. The applicant completes and returns all forms along with a check to cover the license fee.
    3. The section reviews the applicant’s policies, procedures and checklists. Staff may conduct this review in the office or schedule a licensing survey within three weeks of a nursing home's request. The Nursing Home Licensure and Certification Section issues a license once it has received approval for licensure by the Construction Section and it determines the facility complies with licensing rules.
  5. Obtain certification: Nursing Home Licensure & Certification Section
    1. Nursing homes wanting to participate in the Medicare/Medicaid program must contact the section to discuss the initial certification process. The applicant is directed to the instructions and forms on this website.
    2. After the nursing home is licensed and has residents, and the Medicare Administrative Contractor has approved the Medicare Enrollment Application - Institutional Providers, CMS-855A (PDF, 1.04 MB), the applicant contacts the section to request, in writing, an initial certification survey.
    3. The Construction Section conducts a survey to determine that the nursing home meets the life safety code requirements, and the Nursing Home Licensure & Certification Section conducts the initial certification survey within three weeks of request.
    4. Certification is recommended when the health and life safety code inspections reveal compliance. The certification date will be the latest date that both the health portion of the initial survey and the life safety code survey were completed. If surveyors identify deficiencies, the certification date will be the last date of an acceptable plan of correction from either of these surveys.
    5. The section forwards all information to the Centers for Medicare and Medicaid Services (CMS) regional office in Atlanta for approval.
    6. The regional office assigns the CMS certification number and notifies the Medicare Administrative Contractor.
  6. Maintain the state license: Nursing Home Licensure & Certification Section
    1. At the end of each September, the section sends out license renewal applications to all nursing homes.
    2. The section renews a license after receipt and approval of the application and license fee.