Federal Nursing Home Administrator
Exam 2026/2027 — Complete Study
Guide & Practice Questions
This comprehensive study guide and practice examination contains questions drawn from actual
National Nursing Home Administrator Licensing Examination content, covering all five NAB domains:
resident care and quality of life, regulatory compliance and survey processes, human resources and
staffing, financial management and business operations, and physical environment and safety. The
questions reflect real-world nursing home administration scenarios, survey findings, and operational
challenges that candidates must master for licensure, and are designed to serve as a complete self-
assessment and study tool.
Resident Care, Quality of Life & Clinical Services – Addresses the administrator's role in ensuring
comprehensive resident care, MDS 3.0 assessment and care planning, quality measurement and
improvement, dementia and behavioral health care, medication management, nutrition and hydration,
skin integrity and falls prevention, resident rights and quality of life, and psychosocial and spiritual
support.
Regulatory Compliance & Survey Process – Covers federal requirements for nursing homes under 42 CFR
Part 483, survey protocols and processes, F-tag identification and deficiency classification, plans of
correction, enforcement remedies, resident rights and protections, HIPAA, and OSHA standards, along
with state-specific licensing requirements and their interaction with federal regulations.
Human Resources, Staffing & Employee Relations – Focuses on recruitment and retention, staff
development and training, CNA certification and competency evaluation, mandatory in-service
education, performance management, compliance with labor laws (FLSA, FMLA, ADA), scheduling and
ratios, disciplinary actions, staff safety and workplace violence prevention, and ethical leadership in
long-term care.
Financial Management & Business Operations – Examines budget development, revenue cycle
management, Medicare and Medicaid reimbursement systems, PDPM and case mix, financial reporting
and cost control, procurement and contracting, marketing and census development, and business
planning and sustainability in long-term care.
Physical Environment, Safety & Risk Management – Covers life safety code compliance (NFPA 101),
maintenance and environmental safety, emergency preparedness and disaster planning, infection
preventionist programs, OSHA workplace safety, risk mitigation, liability prevention, incident reporting
and investigation, root cause analysis, and the administrator's role in fostering a culture of safety.
,Section 1: Resident Care, Quality of Life & Clinical Services – Questions 1–35
Q1: A nursing home resident with moderate dementia has been refusing meals for three days and
becoming increasingly agitated during mealtimes. The interdisciplinary team meets to revise the care
plan. Which team member should take the lead in assessing whether the resident's refusal is related to
cognitive changes versus a potential medical issue such as dysphagia or infection?
A. The social worker, since behavioral changes always indicate psychosocial needs first.
B. The director of nursing, who can delegate the assessment to the charge nurse on the evening shift.
C. The speech-language pathologist, who can evaluate swallowing function and work with the dietitian
and physician to rule out medical causes while the social worker addresses behavioral supports.
[CORRECT]
D. The activities director, who can create a distraction during meals to improve intake.
Correct Answer: C
Rationale: The best answer is C. When a resident with dementia refuses meals, you need to rule out
medical causes before assuming it's purely behavioral. The speech-language pathologist is the right
professional to assess dysphagia and swallowing safety, and this needs to be a coordinated effort with
the dietitian looking at nutrition and the physician ruling out infection or other medical issues. The social
worker still has an important role in addressing the behavioral piece, but you don't start there when
there's a sudden change in eating patterns. This aligns with person-centered care principles and the
requirement that care planning be truly interdisciplinary under 42 CFR §483.21.
Q2: Under the MDS 3.0 Resident Assessment Instrument, how frequently must a comprehensive
assessment be completed for a long-stay nursing home resident who has no significant change in
condition?
A. Every 30 days
B. Every 90 days [CORRECT]
C. Every 180 days
D. Annually
Correct Answer: B
Rationale: The best answer is B. The comprehensive MDS assessment is required every 90 days for long-
stay residents as part of the standard assessment schedule, with quarterly assessments in between. This
matches the regulatory requirement that keeps the resident's care plan current and drives
reimbursement under PDPM. Some folks confuse this with the annual requirement or think it's only
done on admission, but the 90-day cycle is what CMS mandates.
,Q3: A resident with end-stage congestive heart failure has a physician's order for a 2-gram sodium diet.
At lunch, the resident asks the CNA for an extra packet of salt for their soup. The CNA knows the
resident is on a restricted sodium diet. What is the most appropriate action for the CNA to take?
A. Give the resident the salt packet because resident rights include the right to make choices about their
diet.
B. Refuse the salt packet and remind the resident they are on a restricted diet, then walk away.
C. Explain gently that the doctor has ordered a low-sodium diet for their heart condition, offer to get the
nurse to discuss it further, and document the interaction. [CORRECT]
D. Give the salt packet but don't tell anyone, since the resident has the right to privacy.
Correct Answer: C
Rationale: The best answer is C. This is a classic situation where resident rights and clinical orders
intersect. The CNA shouldn't just hand over the salt without addressing the medical order, but they also
shouldn't be dismissive or secretive. The right approach is to acknowledge the resident's request,
explain the clinical reason in a respectful way, and get the nurse involved so the resident can have a
fuller conversation about their preferences and the risks. This aligns with resident rights under §483.10
while maintaining clinical accountability.
Q4: During a quarterly care plan review, the interdisciplinary team notes that a resident with diabetes
has had three episodes of hypoglycemia in the past month, all occurring between 2:00 and 4:00 a.m.
The resident is on a sliding scale insulin regimen. What should the team prioritize in revising the care
plan?
A. Increasing the resident's evening snack to prevent nighttime lows.
B. Reviewing the insulin orders with the physician and considering whether the basal insulin dose needs
adjustment or timing changes. [CORRECT]
C. Adding a standing order for oral glucose tablets at bedtime.
D. Restricting the resident's fluid intake after dinner to reduce nocturnal urination.
Correct Answer: B
Rationale: The best answer is B. Three nighttime hypoglycemic episodes in a month is a pattern that
needs clinical investigation, not just a band-aid fix. The team needs to look at whether the insulin
regimen itself is the problem—maybe the basal dose is too high, or the timing doesn't match the
resident's metabolism. This is a medication management issue that requires physician collaboration, not
just dietary tweaks. This matches the standard of care for diabetes management in long-term care and
the requirement under §483.45 that medication regimens be monitored for effectiveness and safety.
, Q5: A nursing home is implementing a new falls prevention program. Which of the following
interventions is most strongly supported by evidence-based practice for reducing falls in long-term care?
A. Installing bed alarms on every resident's bed to alert staff when someone tries to get up unassisted.
B. Conducting individualized multifactorial risk assessments and implementing tailored interventions
such as strength and balance exercises, medication review, environmental modifications, and toileting
schedules. [CORRECT]
C. Requiring all residents to use wheelchairs for mobility to reduce the risk of ambulation-related falls.
D. Increasing the use of physical restraints on residents identified as high fall risk.
Correct Answer: B
Rationale: The best answer is B. Bed alarms have mixed evidence and can actually increase fall risk if
staff become dependent on them or if residents rush to get up before someone arrives. The real
evidence points to multifactorial approaches—looking at each resident's specific risks and addressing
them holistically. That means reviewing medications that cause orthostatic hypotension, doing strength
training, fixing environmental hazards, and scheduling toileting so residents aren't rushing to the
bathroom. This aligns with CMS guidance on falls prevention and the culture of safety approach.
Q6: A resident with a Stage 2 pressure injury on the sacrum is being turned every two hours per the care
plan. The wound care nurse notes that the wound has not improved in three weeks and the resident has
lost 8 pounds during that time. What is the most appropriate next step?
A. Continue the current turning schedule and add a donut cushion for sitting.
B. Reassess the resident's nutritional status, protein intake, and hydration, and involve the dietitian and
physician in revising the care plan. [CORRECT]
C. Increase the turning frequency to every hour and apply a moisture barrier cream.
D. Transfer the resident to the hospital for surgical debridement.
Correct Answer: B
Rationale: The best answer is B. When a pressure injury isn't healing and the resident is losing weight,
you have to look at the whole picture. Nutrition is absolutely critical for wound healing—if the resident
isn't getting enough protein, calories, and fluids, the wound won't close no matter how often you turn
them. The dietitian needs to assess intake and recommend supplements or diet changes, and the
physician may need to order labs. This is basic wound care protocol and aligns with the interdisciplinary
approach required under §483.25 for pressure injury prevention and management.
Q7: A resident with schizophrenia has been stable on their antipsychotic medication for two years. The
attending physician wants to taper the medication to see if it's still needed. According to CMS
guidelines, what is required before initiating this gradual dose reduction (GDR)?
Exam 2026/2027 — Complete Study
Guide & Practice Questions
This comprehensive study guide and practice examination contains questions drawn from actual
National Nursing Home Administrator Licensing Examination content, covering all five NAB domains:
resident care and quality of life, regulatory compliance and survey processes, human resources and
staffing, financial management and business operations, and physical environment and safety. The
questions reflect real-world nursing home administration scenarios, survey findings, and operational
challenges that candidates must master for licensure, and are designed to serve as a complete self-
assessment and study tool.
Resident Care, Quality of Life & Clinical Services – Addresses the administrator's role in ensuring
comprehensive resident care, MDS 3.0 assessment and care planning, quality measurement and
improvement, dementia and behavioral health care, medication management, nutrition and hydration,
skin integrity and falls prevention, resident rights and quality of life, and psychosocial and spiritual
support.
Regulatory Compliance & Survey Process – Covers federal requirements for nursing homes under 42 CFR
Part 483, survey protocols and processes, F-tag identification and deficiency classification, plans of
correction, enforcement remedies, resident rights and protections, HIPAA, and OSHA standards, along
with state-specific licensing requirements and their interaction with federal regulations.
Human Resources, Staffing & Employee Relations – Focuses on recruitment and retention, staff
development and training, CNA certification and competency evaluation, mandatory in-service
education, performance management, compliance with labor laws (FLSA, FMLA, ADA), scheduling and
ratios, disciplinary actions, staff safety and workplace violence prevention, and ethical leadership in
long-term care.
Financial Management & Business Operations – Examines budget development, revenue cycle
management, Medicare and Medicaid reimbursement systems, PDPM and case mix, financial reporting
and cost control, procurement and contracting, marketing and census development, and business
planning and sustainability in long-term care.
Physical Environment, Safety & Risk Management – Covers life safety code compliance (NFPA 101),
maintenance and environmental safety, emergency preparedness and disaster planning, infection
preventionist programs, OSHA workplace safety, risk mitigation, liability prevention, incident reporting
and investigation, root cause analysis, and the administrator's role in fostering a culture of safety.
,Section 1: Resident Care, Quality of Life & Clinical Services – Questions 1–35
Q1: A nursing home resident with moderate dementia has been refusing meals for three days and
becoming increasingly agitated during mealtimes. The interdisciplinary team meets to revise the care
plan. Which team member should take the lead in assessing whether the resident's refusal is related to
cognitive changes versus a potential medical issue such as dysphagia or infection?
A. The social worker, since behavioral changes always indicate psychosocial needs first.
B. The director of nursing, who can delegate the assessment to the charge nurse on the evening shift.
C. The speech-language pathologist, who can evaluate swallowing function and work with the dietitian
and physician to rule out medical causes while the social worker addresses behavioral supports.
[CORRECT]
D. The activities director, who can create a distraction during meals to improve intake.
Correct Answer: C
Rationale: The best answer is C. When a resident with dementia refuses meals, you need to rule out
medical causes before assuming it's purely behavioral. The speech-language pathologist is the right
professional to assess dysphagia and swallowing safety, and this needs to be a coordinated effort with
the dietitian looking at nutrition and the physician ruling out infection or other medical issues. The social
worker still has an important role in addressing the behavioral piece, but you don't start there when
there's a sudden change in eating patterns. This aligns with person-centered care principles and the
requirement that care planning be truly interdisciplinary under 42 CFR §483.21.
Q2: Under the MDS 3.0 Resident Assessment Instrument, how frequently must a comprehensive
assessment be completed for a long-stay nursing home resident who has no significant change in
condition?
A. Every 30 days
B. Every 90 days [CORRECT]
C. Every 180 days
D. Annually
Correct Answer: B
Rationale: The best answer is B. The comprehensive MDS assessment is required every 90 days for long-
stay residents as part of the standard assessment schedule, with quarterly assessments in between. This
matches the regulatory requirement that keeps the resident's care plan current and drives
reimbursement under PDPM. Some folks confuse this with the annual requirement or think it's only
done on admission, but the 90-day cycle is what CMS mandates.
,Q3: A resident with end-stage congestive heart failure has a physician's order for a 2-gram sodium diet.
At lunch, the resident asks the CNA for an extra packet of salt for their soup. The CNA knows the
resident is on a restricted sodium diet. What is the most appropriate action for the CNA to take?
A. Give the resident the salt packet because resident rights include the right to make choices about their
diet.
B. Refuse the salt packet and remind the resident they are on a restricted diet, then walk away.
C. Explain gently that the doctor has ordered a low-sodium diet for their heart condition, offer to get the
nurse to discuss it further, and document the interaction. [CORRECT]
D. Give the salt packet but don't tell anyone, since the resident has the right to privacy.
Correct Answer: C
Rationale: The best answer is C. This is a classic situation where resident rights and clinical orders
intersect. The CNA shouldn't just hand over the salt without addressing the medical order, but they also
shouldn't be dismissive or secretive. The right approach is to acknowledge the resident's request,
explain the clinical reason in a respectful way, and get the nurse involved so the resident can have a
fuller conversation about their preferences and the risks. This aligns with resident rights under §483.10
while maintaining clinical accountability.
Q4: During a quarterly care plan review, the interdisciplinary team notes that a resident with diabetes
has had three episodes of hypoglycemia in the past month, all occurring between 2:00 and 4:00 a.m.
The resident is on a sliding scale insulin regimen. What should the team prioritize in revising the care
plan?
A. Increasing the resident's evening snack to prevent nighttime lows.
B. Reviewing the insulin orders with the physician and considering whether the basal insulin dose needs
adjustment or timing changes. [CORRECT]
C. Adding a standing order for oral glucose tablets at bedtime.
D. Restricting the resident's fluid intake after dinner to reduce nocturnal urination.
Correct Answer: B
Rationale: The best answer is B. Three nighttime hypoglycemic episodes in a month is a pattern that
needs clinical investigation, not just a band-aid fix. The team needs to look at whether the insulin
regimen itself is the problem—maybe the basal dose is too high, or the timing doesn't match the
resident's metabolism. This is a medication management issue that requires physician collaboration, not
just dietary tweaks. This matches the standard of care for diabetes management in long-term care and
the requirement under §483.45 that medication regimens be monitored for effectiveness and safety.
, Q5: A nursing home is implementing a new falls prevention program. Which of the following
interventions is most strongly supported by evidence-based practice for reducing falls in long-term care?
A. Installing bed alarms on every resident's bed to alert staff when someone tries to get up unassisted.
B. Conducting individualized multifactorial risk assessments and implementing tailored interventions
such as strength and balance exercises, medication review, environmental modifications, and toileting
schedules. [CORRECT]
C. Requiring all residents to use wheelchairs for mobility to reduce the risk of ambulation-related falls.
D. Increasing the use of physical restraints on residents identified as high fall risk.
Correct Answer: B
Rationale: The best answer is B. Bed alarms have mixed evidence and can actually increase fall risk if
staff become dependent on them or if residents rush to get up before someone arrives. The real
evidence points to multifactorial approaches—looking at each resident's specific risks and addressing
them holistically. That means reviewing medications that cause orthostatic hypotension, doing strength
training, fixing environmental hazards, and scheduling toileting so residents aren't rushing to the
bathroom. This aligns with CMS guidance on falls prevention and the culture of safety approach.
Q6: A resident with a Stage 2 pressure injury on the sacrum is being turned every two hours per the care
plan. The wound care nurse notes that the wound has not improved in three weeks and the resident has
lost 8 pounds during that time. What is the most appropriate next step?
A. Continue the current turning schedule and add a donut cushion for sitting.
B. Reassess the resident's nutritional status, protein intake, and hydration, and involve the dietitian and
physician in revising the care plan. [CORRECT]
C. Increase the turning frequency to every hour and apply a moisture barrier cream.
D. Transfer the resident to the hospital for surgical debridement.
Correct Answer: B
Rationale: The best answer is B. When a pressure injury isn't healing and the resident is losing weight,
you have to look at the whole picture. Nutrition is absolutely critical for wound healing—if the resident
isn't getting enough protein, calories, and fluids, the wound won't close no matter how often you turn
them. The dietitian needs to assess intake and recommend supplements or diet changes, and the
physician may need to order labs. This is basic wound care protocol and aligns with the interdisciplinary
approach required under §483.25 for pressure injury prevention and management.
Q7: A resident with schizophrenia has been stable on their antipsychotic medication for two years. The
attending physician wants to taper the medication to see if it's still needed. According to CMS
guidelines, what is required before initiating this gradual dose reduction (GDR)?
