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• The number of LTCF residents transferred to hospitals is increasing worldwide. • An AD for not hospitalizing decreased hospital transfers. • Discussions and documentation are necessary to provide care in line with resident's preferences. With the rapidly aging population, the number of residents transferred to hospitals from long-term care facilities (LTCFs) is increasing globally. The objective of this study was to investigate the association between family involvement and an advance directive (AD) for not hospitalizing and hospital transfers among LTCF residents with dementia. Using the InterRAI assessment database from September 2014 to June 2019, we included 874 residents from 16 LTCFs in Japan. Of the 874 participants, 19.0% had an AD for not hospitalizing, and 20.5% were transferred to hospitals. An AD for not hospitalizing decreased the likelihood of hospital transfers (p = 0.005). Multilevel logistic regression analysis showed that family involvement was not associated with hospital transfers (odds ratio [OR]: 1.18; 95% confidence interval [CI]: 0.77–1.80), while an AD for not hospitalizing was significantly associated with decreased hospital transfers (OR: 0.50; 95% CI: 0.28–0.89) among the LTCF residents. Although ADs are not legally defined in Japan, we found that an AD for not hospitalizing decreased hospital transfers. Given that many older people tend to hesitate to express their wishes in clinical decision-making situations in Japan, regular discussions are necessary to help them express their care preferences while also documenting the discussions to ensure the residents receive high-quality care. [ABSTRACT FROM AUTHOR]