When visiting a nursing facility, you are often greeted with a friendly tour. A staff member guides you through the corridors, introduces you to attentive nursing personnel, and highlights various amenities aimed at ensuring comfort for residents. You leave with a sense of reassurance and positive vibes.

However, it’s essential to recognize that no one, including the tour guide, expects you to believe that these places compare to luxury hotels.

The purpose of the tour is to provide comfort, suggesting that while nursing home care may not be ideal, it is still an acceptable option. It adheres to basic standards of decency and quality of life, and can even appear welcoming during tours.

A similar performance occurs when state inspectors visit, which speaks volumes about the situation.

Through my extensive experience working in nursing homes, I’ve come to learn that there are numerous aspects they often fail to disclose before you commit. Below is a collection of insights I’ve gathered, along with advice on how to safeguard yourself and your loved ones. My hope is that this provides you with valuable questions to consider during your visits or while evaluating different facilities.

Before diving in, I’d like to clarify that my role as a consulting psychologist has led me to various facilities operated by different parent companies. Therefore, no specific assumptions should be made about any individual location. For every poorly managed facility, there is another that excels. The best way to differentiate is to take tours, ask challenging questions, and review Medicare star ratings.

Prohibited Items. Residents are often prohibited from possessing a range of items (including appliances like microwaves and coffee makers), yet staff may struggle to stop certain items from entering. I’ve witnessed residents with alcohol, cigarettes, and illicit drugs stashed in their rooms. There are countless instances where residents have been found smoking near oxygen tanks.

Medical Records. Patients may receive diagnoses in their medical records without their awareness. This is often done to justify new medications, which staff may fail to communicate properly. Additionally, they might alter dosages without informing the resident.

Costs. While insurance covers some nursing home expenses, residents are often responsible for a significant portion of the daily $300 cost. This creates disparities, as not everyone can afford the same amount for the same services. For example, paying $3,000/month out of pocket can yield the same room as someone who pays only $1,000/month through social security. Medicaid recipients are left with merely $30-$50/month for personal expenses after their funds are allocated to the facility.

Theft. Unfortunately, theft is common in nursing homes. I’ve seen staff dismissed for stealing residents' belongings, although fellow residents are often the culprits. The most frequent thefts occur when residents are hospitalized and leave their possessions unattended. While facilities may replace lost items, they often require proof of purchase.

Room Assignments. Private rooms are infrequent and come with a higher price. Once personal funds are depleted and Medicaid takes over, residents are moved into shared accommodations, meaning they’ll have at least one roommate. The process of reassigning residents can be burdensome, and initial room assignments are frequently based on availability rather than compatibility. If conflicts arise, it is often the resident who raises concerns that has to relocate, not the one causing the issue.

Privileges. Residents' privileges can be revoked with minimal explanation. Such decisions are usually made for safety or medical reasons but can be handled insensitively. For instance, if a resident is injured outside, they might lose their freedom to move around without staff supervision. A motorized wheelchair may be taken away if deemed unsafe. Residents attempting to leave the facility may even find themselves in locked units.

Discharge Policies. Nursing homes have vague guidelines for discharging challenging patients. While this protects vulnerable individuals, it can negatively impact the facility. Severe physical aggression is not tolerated, but verbal aggression may be overlooked. Discharging someone without medical clearance can lead to penalties, forcing facilities to readmit problematic patients, resulting in behavioral issues persisting.

Problematic Facilities. Due to the challenges of discharging residents with behavioral issues, some nursing home companies resort to creative solutions. I have heard that a company owning several facilities may transfer difficult patients to one specific site, effectively creating a "black sheep facility." This allows the other facilities to maintain higher ratings and receive more funding while the problem facility suffers from penalties and a lack of resources.

Staffing Ratios. The ratio of staff to residents is alarmingly inadequate, a situation exacerbated by the COVID-19 pandemic. It's common for one aide to manage care for over 20 residents at once, leading to long waits for assistance with personal hygiene. To cut costs, nursing home companies may hire fewer staff, disregarding the risks to residents.

Overnight and Kitchen Staffing. The night shift—between 11 pm and 7 am—is often understaffed, making it difficult for residents to receive timely help. The kitchen staff tends to have high turnover as well.

Psychiatric Care. The lack of specialized geriatric care in the U.S. makes it difficult for nursing homes to find appropriate placements for patients with severe mental health issues. While it’s easier to find units for either geriatric or psychiatric care, few exist for both. Consequently, patients in crisis may be taken to emergency rooms, only to return to the facility without proper treatment.

Misdiagnosis. Emergency rooms frequently misdiagnose patients with dementia when they may actually be experiencing short-term delirium. While dementia is a chronic condition, delirium can resolve once the underlying issue is treated. Unfortunately, many patients are inaccurately labeled with dementia, which carries stigma and can affect their treatment plans.

What options do you have in these scenarios? Quite a few! Conditions have been improving since the pandemic, and many staff genuinely care about their residents. Until policy changes occur at state and federal levels, here are steps you can take to maintain your agency.

Be Proactive. While it’s not about being disruptive, residents who advocate for themselves tend to receive better treatment. Familiarize yourself with the facility’s director and make regular visits. The director holds significant influence and is motivated to address problems promptly.

Encourage Visitors. Regular visitors—be it family, friends, or faith community members—often receive better treatment. The presence of an outsider alone can promote accountability among staff.

Make Inquiries. Don’t hesitate to ask for things. Request copies of your medical records and medication lists, and inquire about healthier food options. Engage with social services if you wish to transfer to another facility. Persistent requests can yield results, as staff members appreciate gentle reminders.

Report Concerns. While rare, instances of abuse or neglect can occur. If you witness or experience harmful practices, identify a nurse practitioner, social worker, or psychologist (preferably not employed by the facility) to report your concerns. Mandated reporters are legally obligated to notify state authorities about abuse or neglect.

Contact State Authorities. There are patient advocates available, but they may be difficult to locate or bogged down in bureaucracy. You can directly contact the state oversight body to voice your concerns about care quality. Use this as a last resort, as it may lead to significant consequences for the facility. Look up your state’s office of the Inspector General for their contact information.

In conclusion, while many long-term nursing facilities offer a comfortable environment, being informed and prepared is vital. There are always avenues to pursue if issues arise.

Take care.

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