How to start a skilled nursing facility in Washington

Washington requires a Nursing home license from Washington Department of Social and Health Services, Aging and Long-Term Support Administration — Residential Care Services to operate a skilled nursing facility.

License required

Yes

License

Nursing home license

Issuing agency

Washington Department of Social and Health Services, Aging and Long-Term Support Administration — Residential Care Services

Certificate of need

Required

Medicare certification

Separate from the state license. The state survey agency runs an unannounced standard health survey, a Life Safety Code survey and an emergency-preparedness survey against 42 CFR Part 483 Subpart B. For a Medicare SNF the state certifies and the CMS Location decides Medicare participation; for a Medicaid-only NF the state's certification is final and the state Medicaid agency decides participation.

Regulation

Chapter 388-97 WAC (nursing homes); Chapter 246-310 WAC (certificate of need), WAC 246-310-380 (nursing home bed need)

1. Obtain a Certificate of Need from the Department of Health for nursing home beds; DOH applies annual bed-need projections by planning area (WAC 246-310-380) in concurrent review cycles
2. Complete DOH Construction Review Services plan review
3. Apply to DSHS for a nursing home license under chapter 388-97 WAC
4. Pass DSHS licensure inspection; for Medicare/Medicaid complete federal certification and contract with DSHS/HCA

Program

Washington Apple Health (Medicaid), Washington State Health Care Authority (HCA)

Enrollment portal

ProviderOne

Application fee

Under the federal rule (42 CFR 455.460), institutional providers pay the CMS application fee when they first enroll, re-enroll or revalidate. The fee is $750 for calendar year 2026. Individual physicians and non-physician practitioners do not pay it. A fee already paid to Medicare or to another state's Medicaid program counts. HCA's enrollment and revalidation pages do not list a separate state fee.

Fingerprinting

Under federal rules (42 CFR 455.434 and 455.450), the state places provider types in 'limited', 'moderate' or 'high' risk levels. High-risk providers, and anyone who owns 5% or more of one, must submit fingerprints for a criminal background check. HCA's enrollment and revalidation pages do not describe a separate state fingerprint process.

Site visit

Under federal rule (42 CFR 455.432), the state must visit moderate- and high-risk providers before and after enrollment. Every enrolled provider must allow unannounced on-site inspections. HCA's enrollment and revalidation pages do not describe a separate state site visit process.

Revalidation

HCA revalidates providers every five years under 42 CFR 455 and mails one letter per group or facility to the ProviderOne mailing address. The provider has 30 days from the notice date. After that a deactivation notice is sent and the provider gets 90 more days before billing privileges are affected. Billing providers revalidate through ProviderOne's 'Manage Provider Information' Business Process Wizard. They update ownership, managing-employee and controlling-interest disclosures and submit the Core Provider Agreement, Debarment Statement, W-9 and type-specific documents. Nonbilling providers use the nonbilling forms and the HCA support portal or fax. HCA and DSHS are doing off-cycle revalidations of certain providers by June 5, 2028.

Full Washington Medicaid enrollment guide →

For this business

Required (licensing source)

CON program

Yes

Program

Certificate of Need

Agency

Washington State Department of Health, Certificate of Need Program

Services covered

• new health care facilities: hospitals, behavioral health hospitals, nursing homes, hospices and hospice care centers, home health agencies, kidney disease treatment centers, ambulatory surgical facilities
• sale, purchase or lease of an existing hospital
• nursing home capital expenditures above the expenditure minimum or that substantially change services
• bed capacity increases and redistribution among acute, nursing home and assisted living care
• new tertiary health services
• added dialysis stations

Washington certificate of need details →

State minimum wage

$17.13 an hour

Effective

2026-01-01

Scheduled increases

Rises to $17.73 on 2027-01-01 (CPI-W indexing; no tip credit).

Rate pass-through

When individual-provider home care wages and benefits change under the collective bargaining agreement, DSHS adds the per-quarter-hour amount to the home care agency vendor rate, and agencies must use any increase only for direct-care workers' wages, benefits and related employer costs. From FY2028 a set share of the vendor rate is dedicated to compensation, with verification of agency spending from 2027-07-01.

HCBS 80/20 rule

Federal baseline: 42 CFR 441.302(k) requires the state to show that each provider spends at least 80% of Medicaid payments for homemaker, home health aide and personal care services under 1915(c) waivers on direct care worker pay and benefits. Compliance starts 2030-07-09 (for managed care, the first rating period starting on or after that date); annual payment-adequacy reporting under 441.311(e) starts 2028-07-09. A state may set a lower share for state-defined small providers and exempt providers facing hardship, each only through a public notice-and-comment process. The eCFR text has not changed since 2024-07-09. No state-published 80/20 implementation step (small-provider criteria, hardship exemption or reporting guidance) was found for this state in the official sources reviewed.

Skilled nursing facilities — active organization NPIs (NPPES)

512 (as of Sep 13, 2026)

Medicare/Medicaid-certified nursing homes (CMS Care Compare)

193 (as of Aug 1, 2026)

Total Medicaid and CHIP enrollment (latest reported month)

1,781,187 (as of Jun 1, 2026)

All Washington Skilled nursing Medicaid rates, ranked →