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

    • CNA/MAT

      Just to be clear, it’s not always the staff that’s doing the stealing – and missing things aren’t always stolen. When I first began working as a CNA in a nursing home, there was a lady who was very vocal about how people were stealing her things. It turned out that she was hiding them so they wouldn’t be stolen, and then forgetting where she’d hidden them! As her dementia worsened, she began taking other residents’ things. When we had to take the things back to the owner, she would become furious and accuse us of stealing from her.

    • Karen Fay-Matthews

      My brother was in Holly Paterson nursing home in Uniondale NY in the 70′s when he was around 18-19 yrs old. Everything you have ever read about that place is the truth and it was actually 10 times worse than what was reported in the newspapers. The residents were left in wheelchairs for many many hours, crying to go to bed – the aides (and that is all that was working there) used to slam them in their wheelchairs into the heavy doors, scream at them, pinch them and still make them wait. All of my brother’s things were stolen including his TV twice! Who do you think was stealing these things, these people couldn’t even get out of their wheelchairs. They were tied in!

    • Timothy Rigney

      Will nursing homes tell you about the time a nurse’s aide left the dressing of Patricia Rigney’s bedsores which then got contaminated with fecal matter and then did a repeat performance of it the next night even after we, to say the least, drew it to their attention, the way Medford Multicare on Long Island did? Will they tell you about the time they also removed her oxygen monitor from her room because it was “inconveniencing” the nurses, a short time after my Dad walked into her room and found her turning blue?

      • Timothy Rigney

        ps – Don’t be so quick to buy into the “nonprofit” smoke and mirrors. It’s often a cover. St. Johnland’s care center in King’s Park, NY is for example trying to get permission to develop the land across the street from them into a “care center” for “reasonably-well” older people. The reality is that they’re essentially condos. Don’t think for a moment that they’re not going to be getting rich off of that, personally. Meanwhile care in the facility suffers.
        I wouldn’t be surprised if their long-term plan is the sell the entire lot, condos and all – for a considerable uhm – profit.

    • Eric Slyter

      The paperwork I do in my job is not useless. In fact it’s essential to providing good health care as it often is the starting point for issues that need to be addressed. As a CNA, you don’t just have to try and remember what happened during the day and hope for the best in documentation. Just bring a pen and paper with you and write down what you are going to document later if you don’t have time (which is usually the case).

    • Barb Stahlecker

      The statement that you have to buy your LTCi policy in your 40′s and then it only pays $150 per day is absolutely ridiculous. Who is that guy? LTCi policies are available to all ages (one company even goes to 100!) and you can buy anywhere from $1500 per month all the way up to $16,000 per month. Of course, the younger you are when you buy it, the cheaper it is. Most people think they should wait until they are 65 to buy it – that is completely wrong too! It is not in your best interest to wait to buy – run the numbers and you’ll see. Also, insurance companies do not insure burning buildings. So waiting until you have an health issue where you think “Gee – I might actually need some long term care in my future) and then trying to buy it doesn’t work either. We see so many folks where 1 spouse is already sick and both will apply – simply because they FINALLY realize they are going to end up using all of their retirement savings trying to take care of the sick spouse – and they want someone else to pay the bill. When the insurance company discovers information about the sick spouse (and they ALWAYS do) and decline him, the other spouse gets all indignant and says “Well I don’t want my policy either”. Makes absolutely no sense, but we see it all the time. We have a huge crisis coming down the pike here. I don’t know what it’s going to take to wake the American people up.

    • sarah

      Me and my husband has been
      married for about 6years now but have not be able to get pregnant and
      last year his family member want me out of the house because they said i
      was on able to give them a child and they want him to get married to
      someone else i have know where to run to one day a friend of my told me
      about Dr Gboco
      on how powerful he is and how he has also help her with spell so i have
      to contact him immediately on his email: gbocotemple@yahoo.com and he
      told me what i have to do which i did and after 7days i started seeing
      some charges in my body and i have to go and have a test carried out on
      me and find out that i was pregnant and it was just like a dream to me
      and i and my husband are very happy now and even the family member love
      me more than ever before and i had my baby delivered on may this years
      thanks to Dr Gboco.

      • emmalilly

        What nursing home do you reside?

    • ted

      “we have to do something about wages” This probably from the same person who thinks that private pay is far too expensive. Cause and effect people.

    • Christina Honigberg

      Having worked and had a family member in a nursing home I noticed so much stealing from patients my husband included . I was so frustrated I wrote a letter put it in my husbands drawer and I said this. If you are stealing because you are in need please come to me I will help you but if you are not and you take from my husband again I will inform the police. The following day I was informed by the nursing supervisor i had no business doing this . I say to you if you have a member of your family in a nursing home be aware of this . Your loved one only has you to look out for them.

      • Droman

        The important question is, how did the NS find out about the letter?

        There’s something fishy here. It seems to me she had an awfully strong reaction to that letter. Was SHE the one stealing? Maybe she found it and didn’t like the idea of “getting caught”, so to speak. If another resident brought the letter to her, what was that resident doing in your husband’s drawer? And why didn’t she do anything about it?

        I live in a nursing home in NE Los Angeles. As I write this, and the more I think about it, the more I feel the guilt is hers. Just a thought.


    • You gotta discharge-sorry

      I agree with all except the one about the discharge planners. You have to stay 3 midnights in the hospital to get Medicare to cover the care in a long term care facility, but if your condition does not require hospitalization after day three, you do have to discharge the hospital, whether you have found your optimum facility or not. Your statement is extremely misleading. People can’t just hang out in the hospital while taking days and days to shop nursing homes. Right or wrong, that is the reality.

      • choose later

        But once you get to a nursing home, you can shop all you want and move to another one if that is what you want

    • http://www.facebook.com/john.bradley.7359 John Bradley

      As an adviser I try to tell people purchase LTC coverage to help protect your estate and your heirs. It breaks my heart to see families have to liquidate their inheritance to pay for care. It’s a big mistake/little mistake issue. If you have it and don’t need it – little mistake. If you need it and don’t have it – BIG mistake.

      • Julie Cason

        Yes, but my parents’ LTC company went broke, and so many more aren’t writing useful policies anymore. What say you to that?

        • Barb Stahlecker

          I can reply to that. Been in the business 30 years and have only seen 1 company “go broke” – and that’s not really what happened. However, when that company was in its hey-day we routinely advised against it. My company never sold one of them. To anyone with any understanding of the industry, it was clear that the policies were underpriced and that there would be trouble down the road. Those policies were purchased by people who only considered premium and didn’t look at company strength. The LTC industry pays billions of dollars a year in claims – with Genworth paying more in a day than some companies pay in a year. Every industry has bad apples. If your parents company truly goes broke, your state also has a Guaranty Fund that can be used for benefits. Most funds will cover up to $300K in health claims.

      • icvampires

        Does it also break your heart when your elderly clients’ LTC premiums go up by 85 percent in one year? What do you advise on that?

        • Barb Stahlecker

          That client needs to get with a specialist and see what options are available. I would guess she’s got a 5% Compound cost of living rider and/or lifetime benefits. The first thing she should do is get rid of that COLA rider. She could swap it out for a 5% Simple or something else – it would depend on what was available at the time she bought her policy. The next thing she could do is lower her benefit from Lifetime to something less – like 10 years. This insurance was never meant to pay the entire cost of long term care – but the client should be able to rely on it to pay the bulk of the cost. It’s just that back in the 90′s or early 2000′s the insurance was so cheap many people bought these giant policies. Now that the rates are adjusting (and this has more to do with the stock market than any other factor) folks find they can’t afford a full-blown policy. It’s OK to adjust it down – some coverage is better than none and frankly, 3-5 years is plenty for the majority of people.