The Role of the Speech-Language Pathologist in a Skilled Nursing Facility
The Knowledge Gap
Approximately 6% of speech-language pathologists (SLPs) work primarily in skilled nursing facilities (SNFs), representing roughly 12,000 SLPs nationwide based on current ASHA workforce data (ASHA, 2025). Graduate school teaches us how to be SLPs, but not necessarily how to be SLPs in skilled nursing facilities. Speech-language pathologists working in skilled nursing facilities have access to extensive continuing education in individual clinical areas such as dysphagia and dementia, but far fewer resources directly address the SNF as a practice setting itself. The knowledge gap is not just clinical. It also includes understanding how skilled nursing facilities operate and how rules and regulations influence the everyday practice of a SNF SLP.
What Makes SNFs Uniquely Difficult?
Skilled nursing facilities have a reputation for being a difficult setting for a variety of reasons. First, skilled nursing facilities have low staffing ratios that often impact the carryover of an SLP’s recommendations. In April 2024, CMS finalized the first national minimum staffing standards for nursing homes participating in Medicare and Medicaid. The rule established: 2.45 hours of CNA care per day per resident (U.S. Centers for Medicare & Medicaid Services, 2024). Yet, many of these residents are dependent for a lot of care, including getting dressed, toileting, and transfers, before even considering any assistance they may need at mealtimes. And since then, the minimum staffing rule has been repealed.
Additionally, many of the staff who work in a skilled nursing facility receive little to no training on dysphagia or cognitive communication impairments. Nurses, nursing assistants, activities staff, kitchen managers, and dietary aides all interact with residents on a daily basis, but likely don’t have a thorough understanding of their needs and deficits.
Finally, skilled nursing facilities are traditionally a very risk-averse environment. The facility is often motivated by patient safety and regulatory pressure, which causes ethical conflicts between patient autonomy, beneficence, and institutional risk. Patients have the right to decline any medical intervention and be involved in their care planning (Resident Rights, 2026). However, patient safety, risk reduction, institutional liability, and patient quality of life often become conflated, especially in the context of dysphagia and diet textures. This risk-averse culture changes clinical decision-making across the whole interdisciplinary team (IDT), as the goal is inadvertently shifted from patient-centered care to institutional risk reduction.
Why Does This Matter?
In order to succeed in a skilled nursing facility, a speech-language pathologist needs to understand the environment we are trying to work in. If we do not understand why things are the way they are, and how this environment came to be, we cannot make meaningful progress and change for our residents. And this starts with understanding the role of the SLP in skilled nursing facilities as well. This is a unique SLP role, and misunderstanding of the SLP role in a skilled nursing facility can often lead to burnout.
Dysphagia in the SNF
When you think of dysphagia in a skilled nursing facility, what comes to mind? Modified diets, thickened liquids, 1:1 supervision… What should come to mind is residents enjoying mealtimes, eating their favorite foods, and participating in holiday meals with their families. Traditionally, the rest of the IDT may see the role of the speech-language pathologist as modifying diets and stopping coughing at meals. However, our field has evolved significantly. Dysphagia management in a skilled nursing facility should aim to help a resident maintain adequate nutrition and hydration through PO intake, assess risk factors for aspiration pneumonia and choking, and most importantly, facilitate a resident’s ability to enjoy eating and drinking.
All dysphagia plans of care should start with this one question: What are the resident’s goals? The resident’s goals should inform the entire plan of care and be directly reflected in the goals you write in your evaluation.
Bedside swallow evaluations need to be more than PO trials of whatever snacks you can find. Standardized measures such as the Yale Swallow Protocol, Test of Mastication and Swallowing Solids, and Oral Health Assessment Tool should be used to objectively measure concerns related to swallowing. It is also important that SNFs have access to MBSS or FEES, which is something many facilities still do not have. However, we cannot determine if someone has pharyngeal dysphagia during a bedside evaluation. Access to MBSS or FEES can actually reduce the cost of care for residents, as thickened liquids, modified diets, and re-hospitalizations due to pneumonia all cost facilities thousands of dollars per year.
Cognitive Communication in the SNF
“They have dementia, there’s nothing I can do to help them” is something you may have heard someone else say about a resident with dementia. But this is so far from the truth. A good plan of care targeting cognitive communication skills for a resident with dementia starts with the same question: What are the resident’s goals? If the resident’s goal is important to them, you are more likely to make progress. Remember that principle of neuroplasticity: salience (Kleim & Jones, 2008; Ries, 2022). If your goal is for the resident to be able to recall four random words after a five-minute delay, and they don’t care, they are far less likely to make meaningful gains.
Something that is often overlooked is the Global Deterioration Scale (GDS; Reisberg et al., 1982). Determining the GDS stage for your resident is essential to writing functional, meaningful goals. If someone is GDS stage 6, it is likely not appropriate to be targeting orientation due to the severity of their deficits. At this point, your plan of care should focus on developing compensatory strategies to improve participation in functional activities and then training caregivers. However, if someone is GDS stage 4, it may be more appropriate to train compensatory strategies to re-orient someone to time, if it matters to them.
A resident’s goals typically aren’t going to be “improve my sequencing” or “improve my short-term memory.” Their goals are more likely to be “remember when my husband is coming” or “transfer by myself.” The goals can be even more elusive: I had a resident with word search books in her room, but declined to look at them with me. Upon further probing, I got the response, “It’s just too hard now.” The word searches were something she used to do every day that she enjoyed as a hobby. Breaking down that preferred task together in speech therapy and finding a way for her to do it independently again with compensatory strategies ended up bringing her a lot of joy.
With residents who have later stages of dementia, asking caregivers what the resident needs to be able to do, or wants to be able to do, is a great starting point for identifying meaningful activities. Oftentimes when residents with dementia are labeled “difficult,” there are actually communication breakdowns occurring. If a resident “never wants to shower” or hasn’t changed their clothes in a few days, go evaluate the caregiver’s approach and communication style with the resident. This is often a role for the SLP that is overlooked, but so important. We need to be thinking in terms of function: understanding directions within a functional context, sequencing transfers, remembering which door is the bathroom, utilizing the call button, attending and participating in activities, and anything else that they want to do during their day-to-day life.
And A Little Bit of Just About Everything Else
While dysphagia and cognitive communication intervention often make up the majority of a caseload in a skilled nursing facility, SLPs also need to be prepared to address communication deficits in the form of aphasia, dysarthria, apraxia, and voice. Again, with these areas, it all comes down to what the patient’s goals are. SLPs also need to be prepared to do frequent caregiver education to the whole team: nursing, families, physical therapy, occupational therapy, doctors, nurse practitioners… anyone and everyone.
How Am I Going to Make Change in This Environment?
While skilled nursing facilities have several systemic issues, you can make meaningful change through teamwork and patience. If you give a recommendation and notice that it is not being carried over, remember that everyone is trying their best with the limited resources we have. Give them grace and then try to identify where the breakdown is. Ask, “I noticed this isn’t happening… Can you tell me why?” It may be timing, it may be not enough staff, it may simply be that the message did not pass between shifts! And once you know the barrier, you can work as a team to improve the system. If messages are not being passed between shifts, is there somewhere you can write important recommendations for patients on your caseload? If there isn’t enough time in the morning, is it something that could be done after lunch? Work as a team with everyone else in your building, because usually the lack of carryover is not malicious, but due to a lack of resources in the environment we all share.
Bringing It All Together
Working in a skilled nursing facility is not just knowing how to evaluate and treat dysphagia, cognition, and communication. You must be able to look past the impairment and ask what actually matters to the resident sitting in front of you. You also need to understand the environment you are working in, the people you work alongside, and the systems that affect your residents every day.
You are probably not going to fix every problem in your building. But you can advocate for your residents, educate the people you work with, and make small changes that improve your residents’ lives. Ultimately, our role in a skilled nursing facility is to help residents maintain as much independence, participation, and quality of life as possible.
Additional Resources
For a more comprehensive overview, explore the course The Role of SLPs in Skilled Nursing Facilities.
For more resources for working in skilled nursing facilities, I created SNF Toolkit to help fill some of the gaps that come with working in this setting. You’ll find practical resources on dysphagia, dementia and cognitive communication, SNF systems, and everyday challenges. Visit snftoolkit.com to learn more.
References
American Speech-Language-Hearing Association. (2025). 2025 SLP health care survey: Survey summary report.
Kleim, J. A., & Jones, T. A. (2008). Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech, Language, and Hearing Research, 51(1), S225–S239.
Ries, J. D. (2022). A framework for rehabilitation for older adults living with dementia. Archives of Physiotherapy, 12, Article 9. https://doi.org/10.1186/s40945-022-00134-5
Reisberg, B., Ferris, S. H., de Leon, M. J., & Crook, T. (1982). The Global Deterioration Scale for assessment of primary degenerative dementia. American Journal of Psychiatry, 139(9), 1136–1139.
U.S. Centers for Medicare & Medicaid Services. (2024, April 22). Medicare and Medicaid programs: Minimum staffing standards for long-term care facilities and Medicaid institutional payment transparency reporting final rule (CMS 3442-F).
Resident rights, 42 C.F.R. § 483.10 (2026)
