Nursing Home Red Flags You Should Watch Out for

The importance of visiting nursing homes

Choosing the right nursing home for yourself or a loved one is a challenging task. You want to find a facility where residents are treated with respect and where the level of care is high. Nursing home ratings from federal and state agencies can help you see how different facilities stack up on important measures like staffing and other issues.

For example, the federally run Care Compare website provides tools where you can search by region and view different metrics for nursing homes, long-term care hospitals, in-patient rehabilitation centers and other facilities. The website provides, for instance, a tool that allows you to see the percentage of patients with complications like pressure ulcers or pressure injuries that are new or worsened and compare a particular facility’s rate to the national average.

Many state agencies provide similar resources. For instance, the California Department of Public Health provides the California Health Facilities Information Database.

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 2021, 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.

O’Rourke says consumers should ask nursing home managers and staff members 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.

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 all nursing homes will have a turnover of 94%, and half will be below that figure. A turnover rate is the percentage of employees who leave a place of employment over a period of time, typically over the course of a year, O’Rourke says.

The main reason turnover is so high in nursing homes is that working in these facilities is hard.

“Staff takes 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 necessarily 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.

Activities that can help nursing home residents stay engaged and in good spirits include:

— Arts and crafts.

— Clubs, like language or book groups.

— Gardening.

— Low-impact exercise, like walking, tai chi and aquatic 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, or NCBI, a branch of the National Institutes of Health. Inspectors determine whether facilities are complying with federal and state standards and conditions.

Typically, a team of inspectors from the state’s Department of Health Services or a similar department conduct the inspections, says Joshua Johnson, an adjunct professor of gerontology at the USC Leonard Davis School of Gerontology in Los Angeles. The inspection team includes nurses who work for the state and go to a facility for several days to review the different quality-of-care measures.

For instance, they would typically review what percentage of residents have had bedsores and read documentation to ensure treatments and prescription medications were administered correctly, at the right time and in the appropriate dosage, he says. Inspectors will interview many staff members during their visit.

There will also be teams of inspectors that will review other aspects of care, such as the food and social programs at the facility, O’Rourke says. They’ll typically remain on site for several days to observe the staff and how they interact with residents. During the time they are conducting their inspections, inspectors display signs letting residents and visitors know they are conducting an inspection and are open to receiving comments.

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.

Unfortunately, some nursing home residents have been subjected to elder abuse. Such neglect could include withholding food and/or medications or not providing access to health care.

Signs that a resident is being physically abused include:

— Broken eyeglasses.

— Disruption in the resident’s medication routine.

— Unexplained bruising.

Possible indications of emotional abuse among residents include:

— Thumb-sucking, mumbling or rocking.

— Harsh treatment by a staff caregiver, which could include belittling or intimidating the resident.

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, the Louis Block Professor of Public Health Sciences and the College 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 adds.

Different states have different standards for staff-to-resident ratios, O’Rourke says. The standards typically require two to three hours of patient care per 24 hours. That means within a 24-hour period, all the care you need, including but not limited to getting a bath, going to the bathroom, getting your three meals a day and getting medicine, are tended to in that period of time, she says.

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

Failure to promptly clean up incontinent residents can make them more susceptible to pressure sores and skin rashes, Johnson says. “The goal is to keep residents as dry and clean as possible to mitigate chances of developing sores or skin rashes.” It’s important that staff members clean up after incontinent residents not only for their comfort, but for their health.

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 in residents with dementia or Alzheimer’s.

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. The same is true of the lobby, the day room and the dining room. If they aren’t clean, that may suggest the facility is insufficiently staffed or cleaning is not a priority, O’Rourke says.

Signs of unclean rooms include:

— Trash cans that haven’t been emptied.

— Food trays that are left in place without being cleared promptly.

— Beds that haven’t been made.

— Clothes, shoes and other items that are 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.

For example, some residents may be on a low-sodium regimen, and others could be lactose intolerant, so they can’t consume dairy products. Unappetizing food of poor quality could lead to a loved one not getting the proper nutrition and losing weight.

Watch out for these red flags 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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Nursing Home Red Flags You Should Watch Out for originally appeared on

Update 01/10/23: This story was previously published at an earlier date and has been updated with new information.

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