11 Red Flags to Look for When Choosing a Nursing Home

The importance of visiting nursing homes

Choosing the right nursing home for yourself or a loved one is a challenging task. Nursing home ratings can help you see how different facilities stack up on important measures like staffing. Medicare’s Nursing Home Lookup also provides ratings on an array of issues, like staffing and whether a home is meeting state health and safety standards.

But it’s still crucial to visit facilities you’re considering, says Amy Cameron O’Rourke, a licensed nursing home care administrator with 40 years of experience in the field. O’Rourke is based in Orlando, Florida, and she’s the author of “The Fragile Years: Proven Strategies for the Care of Aging Loved Ones,” which was published in July 2021.

“The biggest decision you are about to make is moving to a skilled nursing facility. They’ll see you at your most vulnerable state, bathing you, feeding you and helping you get dressed and undressed,” she says. “Would you pick a home without seeing it?”

Here are 11 signs a nursing home isn’t right for you or your loved one:

1. A high number of COVID-19 infections and deaths

In August, the Biden administration announced it would require all health care workers in facilities that receive funding from the Centers for Medicare & Medicaid Services — including nursing homes — to be vaccinated against COVID-19. Vaccinations provide an important layer of safety. The CMS is expected to roll out details of the mandate in coming weeks.

O’Rourke says consumers should ask these questions:

— What percentage of the nursing home staff is currently vaccinated?

— How many residents and staff have died of COVID-19 in the last year?

— Are staff members, vendors and visitors required to wear masks?

— How often has the nursing home been on a quarantine lockdown since the pandemic began?

Nursing home staff members aren’t required to answer these questions from consumers. “However, it would be telling to me as a consumer how easily they talked about their experience (with COVID-19),” O’Rourke says. She suggests asking nursing home staff members open-ended questions, like, “How has your staff dealt with the loss of residents to COVID-19?” or “Have you created memorials for the people who died?” Questions like this may help establish a connection and lead to the staff member becoming more open.

“Management might hedge on the number and history, but front-line staff would be more forthcoming,” she says. “Asking a unit nurse or certified nursing assistant how they fared during (the COVID-19 pandemic) might bring more information. If a facility was hit hard in the beginning and made great improvements and were transparent about the transition they went through, it would create a sense of confidence that I would know upfront what I needed to know to ensure my loved one was well-cared for. Give them an opportunity to brag about what they learned in this crisis.”

2. High turnover among management

High turnover of management at nursing homes is likely to be detrimental to the quality of care, O’Rourke says. Turnover among certified nursing aides at nursing homes is often near or over 100% annually. Research published in the journal Health Affairs in March 2021 says the median rate of staff turnover at nursing homes is about 94%; that means half of nursing homes will have a turnover of 94% and half will be below that figure.

The main reasons turnover is so high in nursing homes is because working in these facilities is hard. “Staff take care of 10 or more patients on a shift, wages are very low (below $15 an hour in some areas) and there’s no room for advancement,” O’Rourke says.

A high turnover rate among staff does not necessary mean a nursing home is short-staffed, though it may affect the quality of care. “The high turnover just means that they’re constantly hiring new people or hiring temp help,” O’Rourke says. “When you have constant turnover, you’re always having to recruit, place ads and now see if they’ve had vaccinations. Meanwhile, the staff working can get worn out taking care of so many people with bathing, toileting and simply taking care of dependent patients who might be very confused, resistant to care, even combative.”

3. Limited late-morning activity

When you’re visiting a nursing home, make note of how many residents are still in bed at 11 a.m., rather than engaging in activities. “If there are many residents still in bed or still in their room at that time, it’s a good indicator there’s not enough staff to provide care for them, or even to get residents up, dressed and out of their rooms for lunch,” O’Rourke says.

4. Complaints to state inspectors

The state agencies that license and certify nursing homes inspect these facilities at least once a year, according to the National Center for Biotechnology Information, a branch of the National Institutes of Health. Inspectors determine whether facilities are complying with federal standards and conditions. One of the goals of these inspections is to assure “each resident is receiving appropriate care of adequate quality,” according to the NCBI. Inspectors also investigate complaints from residents, family members, ombudsmen or other third parties.

Request a copy of the annual state survey and, if relevant, copies of complaint investigations, O’Rourke says. Complaints that led to investigations could be a red flag.

5. Long response times

When you visit a nursing home, pay attention to whether residents’ requests and needs are attended to promptly, says R. Tamara Konetzka, a nursing home and long-term care facility researcher at the University of Chicago. “Are residents pressing their call buttons or calling out and not getting a response?” she says. “Are residents in wheelchairs lined up in hallways for long periods before and after meals and activities because there aren’t enough staff to take them back and forth? These are warning signs that the home may not have enough staff to meet basic needs.”

There’s no widely accepted standard regarding staff-to-resident ratios at nursing homes, she says. Konetzka notes that one two-decade-old study suggested each resident should get more than four hours of direct care per day. Some experts point to that as an aspirational standard, “but the vast majority of nursing homes don’t meet that level. Identifying a true standard is difficult because the level of need varies across facilities according to the case-mix of the resident population. That’s why it’s good to see in person whether the home seems understaffed.”

6. Odor of urine

While all nursing homes take care of residents who may be incontinent, the better ones attend to toileting and cleaning issues faster and minimize foul odors in the home, Konetzka says. Failure to promptly clean residents who have soiled themselves could be a sign of understaffing.

7. Disrespectful staff

The way nursing home staff and residents interact says a lot about life at a long-term care facility, says Farida Ejaz, a senior research scientist at the Benjamin Rose Institute on Aging in Cleveland. “Do the staff members know the residents’ names? Do they respond promptly (to residents)? Does the respect go both ways?”

It’s important for staff members to ask residents how they’d like to be addressed, she says. “Many residents come from a generation where it was important to address them by their surnames, such as ‘Mrs. X’ or ‘Mr. Z.’ Sometimes staff address residents as ‘sweetie’ and ‘honey’ and this can be inappropriate. Similarly, residents can call out to staff using terms like ‘girl’ or swearing at them, which is also unacceptable.”

8. An unsafe neighborhood

While nursing home residents tend to spend most of their time inside, the neighborhood still matters, since getting outside safely can make a big difference in their mental health. “Wandering helps calm you down … rather than being restricted or drugged and sitting in a wheelchair all day long,” Ejaz says.

Look for outdoor space that’s secure so that residents don’t get lost, she adds. A secure location will also help loved ones feel better about visiting.

9. Unresponsive residents

If many residents during your visit seem unresponsive, it may be because some have been prescribed antipsychotic medication without an underlying condition that warrants such drugs, O’Rourke says. This can be a sign that the facility is understaffed and resorting to these medications as a way to curb behaviors that are challenging for staff to handle, especially residents with dementia.

10. Unclean residential rooms

If residents’ rooms look like they haven’t been cleaned in a while, that could be another sign of inadequate staffing or other problems.

Signs of unclean rooms include:

— Trash cans that haven’t been emptied.

— Food trays left in place without being cleared promptly.

— Beds that haven’t been made.

— Clothes, shoes and other items strewn about on the floor.

11. Poor and limited food quality

No one expects a nursing home cafeteria to offer a five-star menu, but it does need to provide healthy food that meets the nutritional needs of its older residents. The nursing home should also be able to provide meals to meet the needs of residents on special diets. Unappetizing food of poor quality could lead to a loved one not getting the proper nutrition and losing weight.

To recap, here are 11 red flags to look for in nursing homes:

— A high number of COVID-19 infections and deaths.

— High turnover in management.

— Limited late-morning activity.

— Complaints to state inspectors.

— Long response times.

— Odor of urine.

— Disrespectful staff.

— An unsafe neighborhood.

— Unresponsive residents.

— Unclean residential rooms.

— Poor and limited food quality.

More from U.S. News

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9 Rewards of Caregiving

7 Ways to Prevent Medical Errors

11 Red Flags to Look for When Choosing a Nursing Home originally appeared on usnews.com

Update 10/07/21: This story was previously published at an earlier date and has been updated with new information.

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