This chapter discusses the historical development of the skilled nursing facility (SNF) in the United States. It describes SNF facility and resident characteristics. The chapter provides federal and state regulations that govern SNF operations. It also describes nursing home revenue streams and ownership structures. The chapter explains nursing home staffing, and outlines measures of nursing home quality. It explores emerging subpopulations of U.S. nursing home residents. Omnibus Budget Reconciliation Act (OBRA) holds considerable authority in nursing home operations and culture throughout the country. Medicare reimburses SNFs for Medicare beneficiaries who are admitted to a nursing home after a minimum 3-night stay in an acute care hospital, and require “skilled” nursing care on a daily basis. Nursing home quality is measured with three commonly accepted national quality metrics: the federal Nursing Home Compare and Five-Star rating system, the National Quality Forum (NQF) nursing home quality measures, and the standard recertification survey.