Questions About Nursing Homes Answered

  • "Don't ever put me in a nursing home!"


    How often have we heard that? And how many of us have fallen prey to making a promise not to let this happen?


    Generally, the elder asking you to make this promise is remembering a visit to a friend or relative, often years back, and has decided all nursing homes are dreadful places. Unfortunately, some still are. But nursing homes, originally modeled after military hospitals and - yes - prisons, were arranged for efficiency of staff. They were set up to take care of people with as little staff time as possible. People have had good reason to fear living in a nursing home.

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    Yet, for some, there isn't much choice. And it is far wiser for the caregiver to say, "I'll always take care of you in the best way that I can," than to make that promise. Because the day could come when the best way to care for a loved one is to share the care with a nursing home. You will still be honoring the promise.


    And nursing homes are changing. Too, slowly, for our liking, but most are changing. 

    The new model for nursing homes is resident oriented. Laws in most states prevent restraints, sometimes to the dismay of family members more worried about a broken bone than a broken spirit. Studies show anti-psychotics are still overused in many facilities, and some nursing homes are still not much above the standards of a prison hospital from the 40s. However, on the whole, most homes have greatly improved.


    If you want to read a wonderful book on the transformation devoted people are pushing through the nursing home industry, read Beth Baker's "Old Age in a New Age," which I reviewed on this site.


    Improvements aside, there is still a long way to go before most nursing homes are what they should be. Five of the seven elders I cared for lived in a nursing home, with their time there ranging from a few weeks to over ten years. For the most part, it was a very good home. I visited Rosewood to see my loved ones nearly every day for over 15 years and I saw the center change ownership three times.


    I've got some good personal feelings about nursing homes, but I've also heard horror stories about them. There are some that are splendid, some that should be immediately shut down while the owners are prosecuted, and most - well, most are mediocre, but trying to improve. Resources are limited. Staffing is a huge issue. But they are trying.


    Here, I'll answer some of the questions I've encountered about nursing homes. However, as with any agency that cares for vulnerable people, there is nothing that will substitute for in-person visits.


    Q. I've always heard the "smell test" is a good way to choose a home. Is it?


    A. That's an old adage, and may have had some validity at one time. Of course, if you go into a home and it always smells either like human waste or antiseptic, you may want look further. But please be fair to any center. If you go in a morning while they are cleaning people up (and I advise visiting at different times of the day), you may find the hallway doesn't smell very good. A good center will be getting the dirty laundry out of the way quickly. Things will be clean and soon smell fresh, but early morning cleanup, getting diapers and/or dirty sheets changed and people bathed, takes time.  Also, consider that a person near you, as your visit in the afternoon, could have had an "accident." The smell test is okay, but don't make it your first rule.


    Q. Is the Medicare Rating a good tool?


    The nursing home rating system found on is a tool, and only a tool. I wrote about it as such in the post titled, "Use New Medicare Facility Ranking System as a Tool Not a Rule." The gist of that post is that several of the categories are self-reported by the homes, and the others are taken from inspections with each state doing the inspection having different standards. What one state would deem a one-star center, another may give a four-star rating. I'm not saying it's not useful - it's a jumping off place. But I advise printing out the ranking of a home you are interested in and bringing it to the administrator. Ask questions. Why did you get a low rating in this particular field? Give them a chance to tell you.

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    Q. How would you personally choose a home for your mom or dad?


    The first time I had to make a decision about a home, it was for my neighbor. I wanted to be able to visit him daily as I had for years, and my kids were young. I knew a home nearby was supposed to be good, but I didn't know much about nursing homes. It turned out okay, and Joe only lived about six weeks before he died from complications after his hip fracture.  After that, my uncle had strokes that rendered nursing care necessary, and my family chose the same home, again because of its convenient location, but also it had a good reputation as nursing homes went at the time. Years went by and then my dad, my mother-in-law and eventually my mother all lived at the home.


    I liked the staff at the home, and staff is still my first gauge of care center quality. At Rosewood, the nurses treated the hands-on aides (CNAs) with courtesy. There was common respect for each other among the staff. Of course, I'm sure there were personality conflicts, but those were not evident even to someone like me who visited daily. More importantly, it didn't show in the quality of resident care.


    Over the years, I saw the ownership of Rosewood change three times, but they were always progressive in their thinking. The home was kept clean. Chips were painted. Decorating was kept current, within reason. The staff was efficient, caring and friendly to family involvement.


    Efforts were made to find out the interests of residents. They had regular entertainment, exercise and activities. They had care meetings with the families, but the family members were welcome at any time. I was called about any change in medication. I was called about a fall or an illness or any condition change. I was told what was needed in clothing, such as underclothing I didn't always see.


    I liked the kindness and respect shown by the staff toward residents. I liked the forward looking administration and owners - especially the last (and current) owners - who always strive to improve and work hard for a more homelike quality. When my loved ones were there, the physical home was not as up-to-date as I would have liked, but has since been totally remodeled. However, it was the staff that mattered most.


    Was the care perfect? No. Even a family caregiver isn't perfect. But it was a very good place. Respect for the residents and respect for each other is what I put first on my list.


    Q. Will Medicare pay for a nursing home stay?


    A. Medicare rules are constantly changing, but generally speaking, Medicare will pay for a certain number of days if the person goes to the home from the hospital. They will not pay if the person enters from a home situation. The days they pay for are not many.


    Q. Will Medicaid pay for nursing homes?


    A. Medicaid is for people whose funds have been depleted or who never had many assets to start with. Often people go into nursing homes with private funds, but unless they are very wealthy, if they have no long-term care insurance they will eventually run out of money and then go on Medicaid assistance.

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    Tougher laws went into effect a couple of years ago that provide for a 5 year "look back" period, meaning that the Medicaid people will want to see financial records going back five years to make sure the elder didn't give away assets to become "impoverished" so that Medicaid would pay. If you are caring for an elder, be very careful to keep good records of everything spent. Then, if the elder goes into a nursing home and their money runs out, you can prove where the money went and there should be no problem getting the elder on Medicaid.


    This doesn't go down well with a lot of people who have nothing to inherit because of long nursing home stays by their parents, but that is how it is. Our parent's money is there to take care of them. If there is anything left, then the heirs inherit what's left. If the nursing home stay is long, what is left is often nothing.


    Q. How do you qualify for a private room?


    A. If the home has some private rooms, then that is a wonderful perk for most elders. It's hard to get used to a roommate when you are 80 and have Alzheimer's disease. But a private room is generally more expensive. When my mother was in her private room it was an extra $500 a month. The care center, the state where it's located, and an increase in the price of everything now will make that figure a moving target. Still, if at all possible, try a private room for the time a person can most benefit from it. When my mother went into Rosewood, her mind was fairly good, even if she was forgetful. Having a private room made her feel more like she was still in her apartment.  She needed the nursing care for physical problems. The adjustment for her would have been far worse had she not had a private room. But, yes, it's expensive.


    Q. What do you do if you are unhappy with the care in a home where your loved one lives?


    A. First talk with the person who is doing something you don't like (this is, of course, unless you suspect actual abuse). It could simply be a misunderstanding. I generally favor going through "the ranks." If, say, the CNA is not taking care of your mother's needs the way you think she should, you could make some gentle suggestions. If that doesn't work, talk with the floor nurse. If you still aren't satisfied, and the problem warrants it, talk with the administrator. And every state has an ombudsman who is independent of the homes. If you have a serious problem, you have a representative ready to help you. Contact your state aging services and ask how to contact your ombudsman.


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    I am a huge believer in making friends with the staff. You can solve a lot of problems by making it known that you are part of the team, not an adversary. However, you are also the advocate for your elder, so you must make sure there is no abuse or neglect. Be reasonable. Go through channels when possible. Work with the staff. But take care of your elder.


    Q. Do people ever leave a nursing home (alive)?


    A. Yes. These days many nursing homes are used in ways that hospitals once used "swing beds" or care rooms where the patients weren't sick enough for the hospital but weren't ready to go home. Now, many nursing homes serve that purpose. Not everyone goes to a home to live long-term. Many go to the hospital, need nursing home care for a few weeks (often covered by Medicare), and then they go home.


    Q. How long do you have to wait to get into a home?


    A. If you have any reason to think your elder or spouse will need a nursing home in the near future, start touring early. Visit homes at different times of day. See how the residents are cared for. Make assessments. Then, when you know something about each center, get your loved one on one or more lists. You can always say no if a room opens up and you aren't ready to take it. But it's hard to get your loved one in the home you want if you haven't made prior arrangements. The best homes are the hardest to get into. If there is any reason to think a nursing home may be in your loved one's future, it's good to plan ahead.


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Published On: April 13, 2009