50 Secrets a Nursing Home Won’t Tell You

What you need to know—but probably don't—to ensure that your loved one is happy, cared for, and safe.

By Michelle Crouch from Reader's Digest Magazine | April 2013
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    • How do you know it’s time to start looking at nursing homes for a loved one?

    "If you have concerns about safety, about his being able to keep track of his medications, about whether he’s eating enough and eating healthfully, he’s probably ready to go. It gets to a point where you have to say, ‘This can’t go on any longer.’ ”—Richard L. Peck, former editor of Long-Term Living magazine and author of The Big Surprise: Caring for Mom and Dad

    • "The best time to visit a nursing home you’re considering is 6 p.m. on a Saturday. Dinner has been served, few if any managers will be in the facility, and it’s likely that no marketing people will be there. You’ll get a true picture. Talk to staff and family members of residents about what they like and don’t like.”—A California nursing home administrator

    • “Consider the noise level. Most nursing homes have double rooms, with two patients, each with her own TV, often with dueling channels on, blaring. Sometimes you’ll hear odd cries and calls from residents. Older homes have overhead paging systems that everyone can hear; newer ones have wireless devices that are much less obtrusive. Take a moment on your tour to just listen.”—Richard L. Peck

    • “What should you look for? I always say staffing, staffing, staffing. Our recommendation for a daytime staff-to-patient ratio is one to five. One should be a direct caregiver, like an aide. We recommend one to ten during the evening shift, and one to 15 overnight. If you have residents with dementia who need lots of monitoring, you need to staff up.”—Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care

    • “If it smells like urine, that’s obviously a bad sign. But if all you smell is pine cleaner, I’d be a little suspicious about that, too, wondering what odors it’s covering. What you want the place to smell like is a clean home, with no strong scent that’s good or bad.”—Richard L. Peck

    • Make sure you also visit during mealtime, since in some places it’s so busy that it’s common for residents to not get enough food or drink.

    "Otherwise, it may take several weeks for you to figure that out, and your loved one may already have lost weight and be undernourished.”—Charlene Harrington, RN, PhD, professor emerita of sociology and nursing at the UCSF School of Nursing

    • “Check out the activity calendar. It shouldn’t have only bingo and movies with popcorn. I personally love to see entertainers listed, especially comedians and musicians. And the musicians should sing more than ‘Row, Row, Row Your Boat’ and other children’s songs.”—Marc Halpert, vice president of business development at Extended Care Consulting in Evanston, Illinois, who works with 15 nursing homes

    • “Hospital discharge planners will tell you you’ve got 24 to 48 hours to find a nursing home and get out. That’s not true; they need to give you time to make appropriate arrangements. They’re trying to get you out the door because the hospital is paid a flat fee, so if you stay five days instead of three, it’s going to cost the hospital more money. Take the extra time to find a place that offers high-quality care.”—Charlene Harrington

    • “The marketing person or admissions director will probably give you the tour, but try to meet the director of nursing, the administrator, and the executive director too. Ask how long they’ve worked there. Ask how long their predecessors were there. If it’s less than six months, and you see a pattern, that should be a concern; high administrator turnover can be an indicator of a lower quality of care.”—Jody Gastfriend, Vice President of Senior Care Services at Care.com

    • "Nonprofit nursing homes and government-owned facilities have better staffing, pay better wages, and offer better quality care than for-profit nursing homes. I analyzed all types of nursing homes across the country, and the large, for-profit chains had the worst staffing and were cited for the highest number of deficiencies and severe deficiencies.”— Charlene Harrington

    • I’ve worked at for-profit and nonprofit nursing homes.

    "If a resident of a for-profit facility says, ‘I’m a Medicaid recipient, and I need a new battery for my wheelchair,’ I have to go through an extensive process—and, in the end, Medicaid still might not cover it. At a nonprofit, I can just go buy it.”—Matthew Maupin, health facility administrator at Lutheran Life Villages in Fort Wayne, Indiana

    • “They say you’re not supposed to become attached, but you can’t help it. You do. A lot of times, the CNAs [certified nursing assistants] are fighting for the resident’s rights. If a resident needs help walking, we’ll be the ones pushing for physical therapy.”—A CNA in Wisconsin

    • “There was one lady who came from a very poor family. The only gift they’d been able to buy her growing up was rock candy. Because she remembered that so clearly, every time we would give her a sucker, she was absolutely delighted. So we got a giant bag of suckers and gave her one at least three times a day because we loved to see her eyes light up.”—A CNA in Wisconsin

    • “I had a patient with ALS, or Lou Gehrig’s disease. She couldn’t talk, had difficulty swallowing, and was on a pureed diet. But she loved crab Rangoon, and we would order Chinese food. We weren’t supposed to give it to her, but she knew the risks and that’s what she wanted. She was always so thankful, and her family thanked me too. Sometimes, at the end, you have to go for quality of life, not quantity of life.”—Registered nurse who worked in a Massachusetts nursing home for two years

    • “Right now, federal law requires 75 hours of initial training for a CNA, though some states require more. Dog groomers get more training; nail technicians get more training.”—Robyn Grant

    • The staffing information collected by Medicare and included in the Nursing Home Compare database is self-reported and not audited.

    "That’s like asking people to self-report their highway driving speeds.”—A California nursing home administrator

    • “Many nursing home employees are so poor they receive Medicaid for their own health care. The low salary forces a lot of them to work two jobs, so they may finish the day shift at one nursing home and report to another facility to work the night shift.”—A California nursing home administrator

    • “Find out if the nursing home uses agency nurses and how often. Nursing homes usually use them when they’re desperate for staffing. Sometimes, the nurses have never been oriented in that facility, and they come in and have to care for 30 or 40 residents they’ve never met before.”—Registered nurse who worked in a Massachusetts nursing home for two years

    • “Some facilities have an unwritten rule that if a nurse or CNA calls in sick, that person is not replaced. That saves facilities money on their largest expense: staffing.”—A California nursing home administrator

    • “We have to do something about wages. These are the people who are responsible for the lives of our parents and grandparents, and we’re paying them as little as $8.50 an hour.”—Martin Bayne, a longtime advocate for the aging who entered an assisted living facility at 53 after he was diagnosed with Parkinson’s disease

    A nursing home should never tell you that you need to hire your own private aide.

    "The home is required to provide all necessary care. If you need extra help, administrators are obligated to provide it.”—Eric Carlson, directing attorney with the National Senior Citizens Law Center

    • “Nursing homes certified for Medicare and Medicaid are not supposed to discriminate based on ability to pay. But they’re allowed to take only people for whom they can provide adequate care. So if you say your mother can afford only one month of private pay, and someone else says he can do private pay for six months, who do you think they’re going to take?” —Pat McGinnis, executive director of California Advocates for Nursing Home Reform

    • “People don’t realize that Medicare does not cover most nursing home stays, just acute-illness episodes [after hospitalization] up to 100 days. If your loved one needs anything more than that, she’s paying out of pocket, almost $90,000 a year—basically until she’s poor and qualifies for Medicaid.”—Richard L. Peck

    • “Long-term-care insurance can make sense, but, unfortunately, it’s best to buy it in your 40s, when you have kids to support, college tuition to save for, and the inevitable home and car payments. By the time you really start thinking about it and you’re around 60, you’re talking about $3,000 a year in premiums or more. And then it really pays only $150 a day, which often is not adequate.”—Richard L. Peck

    • “In some states, a nursing home can say, ‘We have 100 beds, and we want only 20 of them to be in the Medicaid program.’ So if you run out of money, and those 20 beds are full, you may have to leave, even though you’re in a Medicaid- certified facility. So as you get closer to the time when you need to apply for Medicaid, talk to staff about whether there will be a bed available.”—Robyn Grant

    If your mom goes into a nursing home, it can’t require you to pay out of your pocket for her.

    "Still, nursing homes will send relatives a bill and say, ‘You have to pay us,’ and families don’t know—so all too often, they pay.”—Robyn Grant

    • “My No. 1 piece of advice? Visit often. Research shows that residents whose families are involved get better care.”—Jody Gastfriend

    • “The nursing home has to develop a care plan for each resident. Ask the staff to hold care plan meetings, and make sure you participate. Have them put into the plan any promises they make, even simple things like giving your loved one a baked potato once a week.”—Brian Lee, executive director of Families for Better Care

    • “Elect one family member to be the representative to the nursing home, even if that person doesn’t legally have power of attorney. Otherwise, we’re not sure whom to communicate with.”—Matthew Maupin

    • “At some nursing homes, your loved one may see a different caregiver almost every day. What you want is the same caregivers assigned to your loved one on an ongoing basis. When that happens, the aides get to know the resident’s needs, and it translates into better care.”•Robyn Grant

    Medication errors are a big issue.

    "Residents who are mentally competent should ask before they ingest anything, ‘What is this? How much are you giving me?’ Know what your relative is taking, how often they’re supposed to get it, and who’s giving it to them.”—Pat McGinnis

    • “Nursing home doctors can have hundreds of patients; they usually visit each nursing home once a month. So the nurses line up the charts, and the doctors sign a bunch of orders and make quick visits. Most of the medicine practiced in nursing homes is over the phone.”—A California nursing home administrator

    • “Families and residents talk themselves out of complaining because they don’t want to create trouble. Remember, the nursing home is getting paid thousands of dollars a month by you or someone on your behalf. You shouldn’t apologize for wanting some attention and a high level of care.”—Eric Carlson

    • “Once you go into a nursing home, you probably won’t be able to see your favorite doctor anymore. Usually, the physician assigned to the facility takes over. Ask how often the physician sees residents, what happens if there’s an emergency, and if the physician is easily available.”—Jody Gastfriend

    • “Ask about the pain management policy. Some nursing homes are wary about giving strong medications for pain, and unnecessary pain is a common problem. You want to hear that they do take active steps to decrease pain and that they’re not afraid to use narcotic medications in cases of acute need.”—Richard L. Peck

    When you’re moving in loved ones, make sure they bring their own pillows and their own bedding.

    "I’ve even had families bring an entire bed or a much-loved recliner. Whatever they love most in their home, bring those things if you can.”—Marc Halpert

    • “Try to display interesting items in the room to stimulate conversation. That way, when a staff member comes into the room, he’s not just talking about care and when the next shower will be. He can ask about your loved one’s military service or the dog she has a picture of.”—Matthew Maupin

    • “It’s a good idea not to visit for the first two weeks, especially if your relative has dementia. Just call, or write a letter if you want to. That gives her time to build relationships with the staff and other residents and get used to the fact that this is her home. Otherwise, every time she sees you, she’ll think she’s going home, and when you leave, she’ll get really upset. It ends up taking longer for her to adjust.”—A CNA in Wisconsin

    • “This is your loved one’s home. He should be able to get up and go to bed when he wants to, to eat dinner when he wants to. A big difference between a mediocre or bad nursing facility and a good one is the extent to which residents have their preferences accommodated.”—Eric Carlson

    • “We can anticipate with reasonable certainty when we’re going to have our next annual inspection. So some facilities staff up and buff up—paint, wash the windows, get flowers—because they know they have company coming.”—A California nursing home administrator

    That paperwork we do? It’s really useless.

    "The way it’s supposed to work is that every time you do something, you check it off a list. But there’s no time for that. So you do your job all day long, and then, at the end of the day, you try to remember everything you did so you can go back and check each thing.”—A former CNA who worked in nursing homes in North Carolina and Massachusetts

    • “Theft and loss are a big problem in nursing homes. Rings are taken off people’s fingers. Or you give your relative a new nightgown for Christmas, and then it’s gone. Make sure you put your loved one’s name on everything, and that everything is listed in inventory and in the records.”—Pat McGinnis

    • “Here’s a big secret: Some nursing homes don’t tell families that having a hospice worker come in is an option because the reimbursement rate goes down if the home has to share the money with hospice.”—Diane Carbo, RN, a nurse in California who worked in nursing homes and assisted facilities for over 20 years

    • “Some nursing homes don’t have liability insurance, so it’s difficult to make a recovery if your loved one is harmed or killed, even if you have a good case. Also, the way these facilities are set up makes it difficult to recover anything from the owner. Often, the guy who’s making millions from the facility is virtually untouchable.”—Jonathan Rosenfeld, a Chicago attorney who specializes in nursing home cases

    • “When you receive your stack of admissions paperwork, you’ll find the nursing home has snuck in these things called binding arbitration agreements. Basically, the home asks you to sign away your constitutional right to due process, your right to sue if anything happens. So don’t sign it, or say you’ll sign it only after your attorney reviews it.”—Brian Lee

    One of the best-kept secrets is the long-term-care ombudsman program.

    "There’s one in every state, and the ombudsman is your personal advocate to help you in these situations and answer your questions. All the services are free.”—Brian Lee

    • “The baby boomers as a growing aging population have very different expectations from the residents we were accustomed to taking care of. We’ve had to start serving stir-fry and taco salads in the dining room, and I have residents who come in with iPads and cell phones who listen to rock ’n’ roll and hip-hop music.”—Matthew Maupin

    • “One of the big trends in nursing homes is changing the culture to get away from the institutional perception. We don’t use the word facility, we’re a community. We don’t have a dietary department, we have a dining services department. And instead of units, we have neighborhoods.”—Matthew Maupin

    • “People have this image of the nursing home as cold and institutional, and they think, ‘I’m not going there.’ But some are excellent, and I’ve thought, ‘I could live here myself.’ There is warmth and support, company, decent food, and activity directors who keep people engaged and active.”—Richard L. Peck

    • “The notion that you get to a certain age and lose your capacity couldn’t be further from the truth. All you have to do is sit down and talk to some of our residents, and you’ll be blown away by their knowledge. I played Scrabble against a 107-year-old resident last year. She was one of my most challenging opponents ever.”—Matthew Maupin

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    Your Comments

    • Donna Fairchild

      1:15 staffing at night? How about 1:60 if someone calls in sick?

    • Airport Taxi

      Thanks for your excellent posting. I really enjoyed reading this blog.

    • Jassy

      I just wish people would spend a few days in a nursing home to see what really goes on. Yes there are some bad nurses, it comes with any job but in all honesty the goods one never last long because of the mistreatment they receive. Families forget or never see how their loved ones are for more than a few hours per week, nurses are spat on, hit, abused, accused of things such as stealing things that weren’t even there to begin with or that the resident has hidden themselves. Nurses are understaffed, underpaid and as much as we would like to spend time with each resident you’re job is constantly at risk if things aren’t done promptly. I am looking for work elsewhere, I love helping the elderly but I think it is disgusting all nurses are vilified for a job many people wouldn’t last a day in, most do the best they can to make sure your loved ones are as comfortable as possible, instead of abusing them how about advocating for change, encourage the home to hire more staff, address issues and concerns with both staff and managers don’t just yell at staff most of the time they’ve just come on shift and have to pick up the slack of the other nurses or maybe someone passed away and they had to deal with that before they could care for your family member. If it is an ongoing issue then yes get mad but look at the bigger picture, the bigger the nursing home often the less individual attention your loved one will receive so if you can find a home with a lower nurse to staff member ratio and better activities. Please recognise there are people who really are trying to do the best they can.

    • DAH

      The info about the Non-Profit homes are misleading. Non-Profit facilities are making a bounty off the misconception that they are some how “better” than For-Profit nursing homes. They began at the admission process to weed out Medicaid residents referrals. Most often their Medicaid beds are full and they only have private or Medicare rooms available. The truth is when you have Medicaid insurance paying for your long-term care, it’s at the insurances’ discretion what services they will cover, not the nursing home.

      • kraty

        I have worked in nursing homes >20years, CNA, nurse then manager.
        I would not put my dog in any nursing home. If you all only knew.

        • LNHA

          Kraty, you are responsible for the care that you provide. As a manager in a LTC facility that leads you to feel this way, you should take an active leadership role in changing the culture of the staff within the facility. As an LNHA, if I learned that one of my staff felt this way about our center, it would alarm me into watching them closely to find out how they are contributing to the problem and not identifying solutions. Stand up for those residents, or leave. But don’t spend 20+ years working in and accepting an environment you wouldn’t “put your dog” in. They way you feel about your center is a direct reflection of the job you do, period.

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