Rural Skilled Nursing Facilities: Recruiting Leadership Outside Metro Markets

For rural skilled nursing operators, leadership searches can become extremely time-consuming. The same NHA search that takes 60 days in a metro market can take six months or longer when the facility is located outside of a major central hub. During this period, the facility still needs to run every single day. Staff need leadership, residents need care, and operational demands don’t pause just because the position is still unfilled.

The biggest issue isn’t necessarily that rural leadership roles are unattractive. In fact, many are far from it. Instead, the issue is most often that operators are applying the wrong hiring tactics. They post locally, rely on nearby professional networks, and wait for qualified candidates, when the best talent for the job is located hours away rather than a 20-minute commute.

In order to help you find the best candidate, we will explore why interim leadership coverage and access to a national search network can often determine whether your rural facility will spend months waiting for the right candidate or keep moving forward until the perfect leader for your team is found.

The Structural Obstacles to Recruiting Rural Skilled Nursing Executives

Rural skilled nursing operators are not struggling to fill leadership roles because of their failure to recruit aggressively enough. In fact, you can put all of your effort into the same marketing techniques you would typically use in a metro market and still see minimal results.

You may be posting open job listings, reaching out through local networks, and even discussing the position with existing contacts, but have very few qualified applicants looking to fill the position. This is because the underlying constraints are a structural issue, rather than a matter of effort.

A Thin Local Candidate Pool

When recruiting within a metro market, it’s fairly easy to come across hundreds of qualified, licensed administrators and experienced DONs within a 45-minute commute of your facility. A more rural market, on the other hand, may only have a handful.

• Most qualified healthcare professionals (not just limited to those in leadership positions) located in rural areas are already employed locally, either at the local hospital or other nearby facilities. Because of this, there is much less talent readily available and looking for work specifically within the area where your facility is located.
• Aside from this already thin local candidate pool, it’s worth noting that the working-age population in many rural counties has been shrinking in recent years. With professionals becoming highly skilled at what they do, they know they can easily find great, high-paying opportunities in more central areas. That doesn’t mean that they wouldn’t be interested in the open position at your facility, but it does mean that they wouldn’t necessarily be actively seeking it out.
• Not only is there already a limited number of people looking for work in rural areas, but once you filter for skilled individuals with nursing experience, this talent pool becomes even smaller. While some applicants may still be relevant, it’s important to note that they’re not all qualified to fill the position you’re hiring for. For example, an experienced acute-care nurse leader does not necessarily have the required skill set to run a five-star skilled nursing facility.

To find appropriate staff who have the experience to excel at the job, you’ll need to cast your net a little wider than the local candidate pool.

Few Licensed Administrators Within Commuting Distance

NHA searches are difficult no matter where you’re searching. This is due to the licensing constraint that can make recruiting for this role so much more difficult than a simple, straightforward hire. For an NHA role, applicants must have an active, state-specific license, so candidates cannot easily just move in from out of state to start the role.

Requirements for the job role vary by state, so those applying from out of state must take extra measures if they hope to land the position. Out-of-state candidates may need endorsement from previous employers, complete extra coursework, or even sit a state exam to demonstrate that they’re qualified for the role.

If you’re looking to recruit an NHA for a rural facility, it’s best to be open to candidates willing to relocate from out of state. For this reason, licensure timelines should be built into the search plan from day one. This can help to accommodate the most appropriate candidate, rather than force you to settle for a more convenient option.

Limited Spousal Employment and Family Considerations

When recruiting any highly skilled professional for a role in a rural area, many employers run into an issue known as the ‘trailing spouse problem’. This is when skilled professionals must also bring with them their partner (who may rely on them as the breadwinner) and the rest of their family when relocating. While this isn’t inherently an issue, it can certainly become one if the area the candidate is relocating to does not have enough job opportunities for their spouse.

The trailing spouse problem is one reason many highly skilled candidates decline offers to join companies with rural locations. This happens for a number of reasons:

• Not wanting to leave close family behind.
• Not wanting to leave their employer.
• Having fewer career opportunities in a rural area.
• Potentially having to work for a lower wage.

Even when a candidate would like to accept the job, this doesn’t erase the trailing spouse problem, or all the other issues that can come with relocating a whole family. Other issues a strong candidate may decline include:

• Lower quality of schools for their children.
• Availability of childcare options.
• Proximity to aging parents.
• Access to healthcare providers.

Unless the recruiter raises these issues early, these objections usually come up later on in the process, derailing many talent searches right by the finish line. For this reason, it’s a good idea to bring them up with clients early on, to help prevent the need to extend the search period.

Competition from Metro Facilities and Hospital Systems

Rural SNFs are not only competing with one another, but also with metro SNF operators, regional hospital systems, and other health systems that can not only pay more, but also offer clearer advancement paths. This is why it’s important to not only be aware of this, but also to keep your expectations realistic when hiring NHA for a rural facility.

Hospital systems all pull talent directly from the same Directors of Nursing (DON) and nurse leadership pool, and this means that ultimately, highly qualified clients get to pick and choose where they want to work. Hospitals with better brand recognition and employee benefits generally win out when it comes to attracting the best members of staff.

When a talented professional in search of a new position is located between facilities, they will typically choose the commute to the metro hospital. This is usually because the hospital located in the main hub of the city can boast better future career opportunities, better employee benefits, and oftentimes a more notable reputation. As a rural operator looking to recruit these same candidates that are typically drawn to metro hospitals, it’s important to have a counterargument for why your facility should be their top choice, beyond just the salary you provide.

Role-Specific Challenges: NHA, DON, and MDS

Depending on which specific role you’re recruiting for, there may be different obstacles standing in the way of securing the right candidate. Since the obstacles differ, so should the hiring strategy you use to find applicants.

• NHA: An NHA, or Nursing Home Administrator, can be difficult to recruit, as one of the biggest constraints that comes with hiring an NHA is that they need to be licensed. Relocation is almost always required when hiring an NHA, and this is even more likely the case when recruiting from a rural area. For these reasons, it’s important to set a lengthy timeline for recruitment to accommodate those applying from out of state, and advertise the opening to those located further afield, rather than the small pool of local talent that may be available in the area.
• DON: A DON or Director of Nursing is difficult to recruit, as this position puts you in direct competition with hospital nurse leadership roles. The candidate must be available to work on-site, and is the most difficult role to cover with flexible arrangements. In order to account for this, your company should be able to offer great employee incentives and a role that makes relocating worth it.
• MDS Coordinator: An MDS coordinator is somewhat easier to recruit for a rural facility. Despite requiring a highly specialized candidate in order to perform the role effectively, this position can often be performed remotely or as part of a hybrid working setup. This means that even clients who are unable to relocate may be able to perform this role. Keeping your options open to a remote MDS Coordinator when recruiting could make you much more successful in finding the perfect candidate.

As each of these roles is a leadership position in healthcare, many employers make the same, costly mistake of treating all three as one generic leadership search, instead of tailoring the recruitment process to be more specific to the role. By doing this, they miss out on reaching qualified, experienced candidates who may be the perfect fit.

Why Rural Vacancies Carry Higher Stakes Than Metro Vacancies

Due to their many challenges, rural vacancies often take much longer to fill than vacancies for positions in Metro areas. This longer timeframe means a longer exposure window for compliance, census, and staff retention. Without interim leadership during this period, MDS submission deadlines and reimbursement accuracy can become harder to manage, and frontline hiring can stall when there is no leader in place available to approve, onboard, or support new members of staff.

Rural facilities also face a unique setback in terms of potential reputational issues. Should an issue arise, word spreads much faster in a tight-knit community. This can affect family confidence, referral relationships, and the facility’s reputation amongst prospective employees. This makes the cost of a wrong hire especially high, as the effect of this can spread much further than the inside of the facility, which means having a strong search strategy is imperative from the get-go.

Should you hire the wrong person, then replacing an unsuccessful leader means you will need to restart the candidate search in a market where the qualified talent pool is already very limited. This makes a second rural search far more costly in all the ways that matter, from the time it takes to the money it costs, and even the cost of operational distribution.

Practical Strategies for Recruiting Leadership Outside Metro Markets

Rural searches for leadership roles have a number of challenges, but this doesn’t mean they’re not winnable. In order to stand the best chance of hiring the perfect candidate for the position, you’ll need a different recruitment search strategy than simply posting the role and waiting for the right person to find you. Instead, there are a number of different strategies you can include in your search toolkit in order to help reach even more qualified candidates who may be interested in the role.

Build a Real Relocation and Housing Package

When looking for a new position, the last thing most clients want to come across is a great job that will require a lot of extra legwork for them when it comes to relocating. Simply stating “We’ll help with relocation” in the job description is not enough. Instead, candidates need specifics they can plan around to make their life easier, should they be accepted for the role.

Not only should the job description address the need for relocation, but it should also cover plenty of the concrete components. Be sure to stipulate the relocation stipend, offer temporary housing for the first 60-90 days of their stay, cover the cost of house-hunting trips, and cover lease-break coverage. Helping successful applicants navigate a rural housing market may also be incredibly beneficial, as available options may be more limited than what they are otherwise used to.

In some markets, employer-owned or employer-leased housing has become a popular and legitimate tool. It is a top choice in areas where rental stock is almost non-existent, and provides a helpful, relatively stress-free alternative to new hires having to figure out the relocation aspect of accepting a position in a rural location.

The housing package should be properly defined before the search for a candidate begins. This way, recruiters can lead with what they’re willing to offer, rather than have to negotiate under pressure once a suitable candidate has been found.

Offer Flexible, Split-Schedule, or Remote Arrangements Where the Role Allows

Some roles, such as an MDS Coordinator or certain corporate/clerical support roles, can often be performed remotely or in a hybrid setup. As such, this should be accommodated for when possible to ensure you’re hiring the right candidate, rather than just the most convenient one.

Of course, this isn’t the case with all roles. NHA and DON roles cannot generally be performed by hybrid workers, but split-week or shared-coverage models allow staff to work across multiple nearby buildings. Many operators with smaller facilities use multi-site models where the same leader performs their role across two different rural buildings at the same company. This can create increased flexibility for some candidates who don’t wish to relocate permanently.

No matter what type of flexibility you’re willing to offer, it’s important to ensure that it is well structured and has been thoroughly documented. If not, it can erode accountability and create survey exposure, putting your company’s reputation at risk.

Partner with State Associations and AIT Programs

When you run a rural facility, there will always be times when you need new members of staff. Instead of competing with many attractive hospitals and facilities in Metro areas for finished candidates, many rural facilities find it more helpful to create their own pipeline. While this may be a long-game strategy, it can help ensure that you’re getting first access to qualified candidates before they even have a chance to consider looking to perform the same role elsewhere.

• One way of setting up this pipeline is through Administrator-in-Training programs, otherwise known as simply AIT programs. Becoming a preceptor site allows a rural facility to train up future NHAs. Once trained at a facility, they have great familiarity with their colleagues, community, and the building itself. This makes them more likely to take on future employment as an NHA here, rather than leave once they are qualified to perform the role.
• Partnering with State Healthcare Associations can also be advantageous in finding qualified candidates early on in the recruitment process. Chapter meetings, workforce committees, and conferences are all great spots for rural operators to meet candidates who already have the valid state licensing for the position.
• There are also plenty of regional nursing programs and community colleges that your facility can partner with that serve as a route into DON. While the prospective candidates are completing their training at one of these facilities, being in partnership with them can allow your facility to provide hands-on experience and the opportunity for a career after the completion of their course.

If you’re looking to fill a position quickly, it’s important to be aware that this strategy may not be the right one for you. This is because it is a long-term strategy that can take 12 to 24 months to have a qualified candidate ready to fill the role. This is one of the reasons it should run alongside active searches, rather than act as a replacement for them.

Recruit Candidates with Rural Roots and Regional Ties

One of the most successful targeting strategies in rural search is to aim to employ qualified candidates who grew up in the area, attended a nearby school, or have family within driving distance. These candidates may still need to relocate, but the move resembles that of a homecoming rather than a sacrifice of their life prior to this role.

Hiring a candidate with ties to the rural community your facility is located in can help reduce some of the setbacks faced by other candidates that make filling the role difficult. With ties to the town you’re located in, many candidates find that family and spousal objections are already resolved. This makes their move easier, more straightforward, and less daunting than if they were moving into the town for the first time.

To target qualified individuals with ties to the area specifically, it’s a good idea to look through alumni networks from local colleges and state license rosters. Searching for those working in metro markets who list rural hometowns, and those with long-standing relationships with local recruiters can also help you find candidates who may be more open to relocating to your specific rural facility.

Rethink the Offer Beyond Base Salary

A small salary bump isn’t always enough to attract qualified candidates to leadership positions at your rural facility. In fact, there are actually a lot of other important factors that may make them more attracted to a job. Outlining predictable schedules, genuine autonomy, a clear path to regional roles, tuition and licensure reimbursement, and retention bonuses tied to 12- and 24-month milestones can make for a much more attractive offer than a simple increase in salary.

Some of these incentives are much more attractive than some recruiters give them credit for, and all too often, this results in not enough emphasis being placed on the factors that actually draw candidates to a role. For example, outlining the expectations for genuine autonomy in the job description upfront can really help attract skilled individuals who may be feeling somewhat trapped in similar roles at other facilities. Many strong leaders choose to leave metro operators because they want to actually run a building, and a rural facility can actually give them a chance to do this and use their talents, rather than be stuck with less autonomy.

Sell the Community, Not Just the Job

Professional candidates applying for this position aren’t just considering the job itself. Due to the likely need to relocate, they’re also evaluating a whole new life change. With a new location, community, and neighborhood, the recruiting materials should reflect that the decision to accept this role is about far more than just a job.

In order to keep your recruitment materials persuasive and inviting, it’s a good idea to involve local leaders and the mayor’s office or chamber of commerce in promotional materials for the facility. Connect the candidate to local families, and provide up-front, clear information about the cost of living and the realities of the commute they might be able to expect after relocation.

While it is important to paint a clear picture of the life healthcare leaders can expect to have whilst working at your facility, it’s equally as important not to oversell the location. Painting the area, community, or locale as something that it isn’t in hopes of attracting more staff can cause new employees to leave after a short amount of time, increasing the turnover rate of staff at your facility, and potentially harming its reputation. Instead, you should be sure to be informative and straightforward, allowing applicants to make an unbiased decision about the move.

Why Interim Leadership Often Makes Sense in Rural Markets

Searches for talented staff might take longer in a rural market than in a metro market, and during that time, your facility remains uncovered. This can create compliance, staffing, and census damage that can far outlast the vacancy itself.

Thankfully, experienced interim leaders arrive survey-ready and can help to stabilize operations while the search for a permanent member of staff continues to run. This can help keep your facility functioning at its best while you look for the most appropriate professional to join your team, without you needing to simply settle for the applicant who can fill the position the fastest.

Having interim coverage can help to remove the pressure that can lead to hiring the first available candidate, or the one that is the most convenient. Interim coverage can also allow candidates to experience the facility, the staff, the location, and the surrounding neighborhood and community before they make a decision, as part of a relocation trial period. Your organization also has the opportunity to see their performance in action, rather than just infer it from interviews, before committing to relocating a new hire.

A meaningful share of interim placements can convert to permanent roles in the rural communities that hired them. Instead of just sufficing as a stopgap, they serve as a legitimate rural recruitment pipeline.

Why Rural Searches Require a National Network, Not a Local Posting Strategy

When recruiting for healthcare leadership roles in a rural market, no amount of local posting will attract the right candidate if they do not live within commuting distance already. All too often this is the case, as many highly qualified candidates are located in metro markets or are already employed elsewhere.

In order to find the right candidate without narrowing your search to what is available locally, it’s important to search a national network. National networks are one of the top ways of finding experienced and highly qualified professionals suitable for leadership roles in nursing. In contrast, generalist recruiters and job boards often don’t measure up, as these only surface applicants, as opposed to specially selected candidates. They also have no access to SNF-specific readiness or licensure pathways, meaning you may be wasting your time sifting through unqualified applicants if you choose to use these more traditional and well-known methods of recruitment.

In a rural facility with no leadership backup, cultural fit and self-sufficiency are what matter the most. These are not easily assessed via a resume, but more often through personal relationships and experience working together. For this reason, a national network is one of the best ways of finding a specialist.

MedBest: Executive Search for Rural Skilled Nursing Facilities

Rural leadership searches are much harder than those that take place in metro markets for many structural reasons. They are not easy to resolve, but can be made a little easier by widening the candidate pool nationally, rather than targeting local talent, removing the friction of relocation, and covering the building with interim staff while the search for the right candidate takes place.

At MedBest, we pride ourselves on being a national executive search firm exclusive to senior living and long-term care. We help to provide both permanent and interim solutions for NHA, DON, and MDS roles. All of our care goes into finding the best candidates, assessing their abilities, and building great relationships with them, so we can ensure we’ve got the right hire for your workplace every time.

If you’re looking to fill a position either with a permanent hire or get some interim talent to help out during your search, be sure to reach out to the recruitment team at MedBest today. We can help keep your organization running without the stress that having a gap in your leadership team can cause, helping your facility run to the standard you’re used to.

FAQs About Recruiting Leadership for Rural Skilled Nursing Facilities

Why Is It So Hard to Find a Nursing Home Administrator in a Rural Area?

The main obstacle is licensure combined with geography. Nursing home administrators must hold an active, state-specific license, and in rural markets, there are often only a handful of licensed NHAs within commuting distance — most of whom are already employed. Recruiting from outside the area means addressing relocation, spousal employment, and, in many cases, a state licensure endorsement process, all of which extend the timeline unless they are planned for at the start of the search.

How Long Does It Take to Fill a Leadership Role at a Rural Skilled Nursing Facility?

Rural leadership searches typically take longer than comparable metro searches, often several months rather than several weeks. The timeline depends on the role, the state’s licensure requirements, and how far the operator is willing to look geographically. Facilities that pair a national search with interim coverage generally see less operational disruption, because the building stays stable while the permanent search runs at the pace it actually requires.

Can MDS Coordinator Roles Be Filled Remotely?

In many cases, yes. MDS Coordinator work is documentation- and assessment-driven, which makes it one of the few skilled nursing leadership roles that can support remote or hybrid arrangements, depending on state requirements and the facility’s own policies. For rural operators, this is significant — allowing remote or split-schedule work removes the geographic constraint entirely and opens the search to a national pool of experienced coordinators.

What Relocation Support Should a Rural Skilled Nursing Facility Offer?

At a minimum, a defined relocation stipend and temporary housing for the first 60 to 90 days. Stronger packages also include house-hunting trips, lease-break coverage, and practical help navigating a limited local housing market. Because spousal employment is one of the most common reasons rural offers are declined, it is worth connecting candidates to local employers or the area chamber of commerce early in the process rather than after an offer is on the table.

Is an Interim Administrator a Good Option for a Rural Facility?

For most rural operators, yes. An experienced interim administrator keeps the building covered, survey-ready, and operationally stable during a search that may take months, which removes the pressure to hire the first available candidate. Interim assignments also give both sides a low-risk way to evaluate fit, and a meaningful number of interim placements ultimately convert into permanent hires at the same community.

Why Should a Rural Facility Use a National Recruiter Instead of Posting Locally?

Because in most rural markets, the qualified candidate does not live nearby. Local job postings can only reach the people already in the area, which is precisely the pool that has already been exhausted. A national executive search firm can identify licensed, currently employed candidates across state lines, target those with existing ties to the region, and manage the relocation and licensure logistics that determine whether a rural offer is actually accepted.