The importance of comparing nursing homes
Scenario: John, a retired teacher, moves into a nursing home with a high staff turnover rate and a poor reputation, but his family brushes off these red flags.
In just a few weeks, John develops bedsores because he isn’t regularly repositioned. The staff ignore his complaints of pain. Eventually, an infection sets in, requiring hospitalization, all because the nursing home fails to provide the basic care he needs.
With an abundance of senior living options, as well as startling stories about senior living conditions, choosing the right nursing home can be a challenge. You want a facility where the residents aren’t merely surviving but are also socializing and thriving.
To catch nursing home red flags, get started by comparing facilities:
— Rely on nursing home ratings from federal and state agencies. Using government websites like Care Compare, you can search by region and view different metrics for nursing homes, long-term care hospitals, in-patient rehabilitation centers and other facilities. You can also try Medicare’s Nursing Home Lookup.
— Research state agencies for similar resources. The California Department of Public Health, for instance, provides the California Health Facility Information Database.
— Check out U.S. News ratings. U.S. News assessed more than 15,000 nursing homes and rated them on short-term rehabilitation and long-term care. You can also search for nursing homes by city or state.
— Look up online reviews. If you notice multiple negative reviews, consider steering clear of that facility. Nursing homes cited for abuse will have an icon showing a white hand within a red circle next to their name on Medicare.gov.
Visit the nursing home in person
Even after sufficient online research, consider visiting a few nursing homes in person. Dr. Tanya Gure, section chief of geriatrics and clinical professor of internal medicine at the Ohio State University Wexner Medical Center in Columbus, says that ratings can lag behind recent updates or improvements a facility has made. On the other hand, a facility could have since taken a turn for the worse.
When you take a tour, what should you look for? Here are 12 signs a nursing home isn’t right for you or your loved one:
1. Short staffing
With growing concern for the health care staffing shortage, having an adequately staffed nursing home is a priority.
Research shows that residents in a properly staffed nursing home have a decreased risk of:
— Pressure ulcers
— Infections
— Uncontrolled pain
— Overuse and improper use of antipsychotic medications
— Hospitalizations
To determine if short-staffing is an issue at a nursing home you’re considering, ask the following questions:
— What is the average time a nurse and aide spend with a resident daily?
— What is the nurse-to-resident ratio and nurse aide-to-resident ratio?
— What is the protocol if a nurse or an aide calls in sick?
There is no one-size-fits-all staffing ratio. It depends on the acuity of the residents and the type of care the facility offers.
2. High turnover among staff
Turnover among certified nursing aides at nursing homes is often near or more than 100% annually, according to researchers. This means that all nurse aides in that facility will likely have quit within a 12-month period and been replaced. Nurse aides are responsible for the majority of a resident’s day-to-day care.
In addition to turnover, look for:
— Nursing care availability overnight
— Procedures that are available in case of emergency
— On-site medical staff, such as a doctor
A high turnover rate among staff does not necessarily mean a nursing home is short-staffed, though it may affect the quality of care. Having the same nurse aide care for your loved one for a long period of time means they will be in tune with their mood, emotional and physical needs and any potential signs of decline.
With high staff turnover, staff don’t get to know their residents and their routines as intimately, and information can get lost between shifts.
3. Disrespectful and evasive staff
You should feel comfortable talking to staff and having your questions or concerns addressed. If you don’t feel comfortable talking to staff, that is a nursing home red flag. Even more serious is when the disrespect becomes elder abuse, which happens to up to 10% of seniors ages 60 and above, many of whom reside in nursing homes, the National Council on Aging reports.
Questions you may need to ask include:
— Have there been any recent changes to my loved one’s care plan?
— Have you seen any growing signs of pain or discomfort in my family member?
— What does my loved one do to stay occupied when I’m not able to visit?
— Lately, I’ve been noticing this particular behavior in my family member. Do you have any concerns about that?
You should also ask yourself questions like:
— Does the facility lack a chain of command to report concerns you may have about your family member?
— Do residents show signs of abuse, such as bedsores, broken eyeglasses, unexplained bruising or behaviors like thumb-sucking, mumbling or rocking?
— Does the staff lack the initiative or support to de-escalate when residents are frustrated?
The care team at the nursing home — including physical or occupational therapists, health care providers, nurses and aides — should all be invested in the well-being of their residents.
A nursing home that cares will validate your questions and allow you to be a collaborator in the care of your family member.
“If you find they are unwilling to answer questions or they behave rudely, consider going elsewhere,” advises Dr. Gary Small, chair of psychiatry at Hackensack University Medical Center and behavioral health physician-in-chief at Hackensack Meridian Health in New Jersey.
4. Long response times
The call light is the link that provides residents access to anything from comfort to immediate life-saving measures. In fact, the Centers for Medicare & Medicaid Services also has regulations on call lights. The most important requirement is that every resident must have their call light within reach, no matter what. If residents don’t have access to their call lights, they don’t have access to proper care.
When visiting a nursing home, take note of the following:
— Active call lights
— How staff prioritize answering call lights. Do they answer them in order? Are the lights color-coded? Do they have a nurse aide find out the needs and then order them accordingly?
— How long the call lights are on until they are addressed
It’s normal for there to be more call lights on at certain times, like during meal times, shift changes or times that are common for medication administration. However, it is a nursing home red flag if there are unanswered call lights on throughout all hours of the day and night. One of those call lights, for example, could be a resident who fell and needs help or is having acute chest pain.
5. “No lift” policies
There is a new trend of nursing homes and senior care facilities employing “no lift” policies. This means when residents fall, the staff aren’t allowed to move them. The staff members call 911 to have emergency medical services do the moving and lifting.
The policy intends to prevent back injuries to staff and the liability of moving injured residents, but it may also lead to problems such as:
— Delay in care for fallen residents
— Overburdening local emergency services and transport staff
— Loss of trust between residents and their caregivers
Ask if the facility has:
— Fall prevention products, like bed alarms
— Training for staff to assist with moving and treating fallen residents
— A strict rounding schedule, so if a resident falls quietly and is unresponsive or unable to call for help, a staff member can encounter them quickly
— Equipment to help with difficult transfers, like Hoyer patient lifts. Equipment like this is expensive, which may be why facilities resort to EMS.
— Procedures to monitor vital signs of a resident post-fall
6. A high number of infections and deaths
Infections have almost become an unfortunate guarantee with any type of senior care facility. According to the Centers for Disease Control and Prevention, there are between 1 and 3 million infections in long-term care settings annually.
Infections can spread into the bloodstream, causing a condition called sepsis. Even a minor infection can become life-threatening to an elderly adult.
Common infections that plague nursing homes include:
— COVID-19
— Methicillin-resistant Staphylococcus aureus, or MRSA
— Clostridium difficile, also known as C. diff
— Scabies
Infections can be transmitted through the air, fecal matter or from direct contact. For this reason, observe the staff in action while touring a facility.
“Do they wash their hands before and after handling a resident? If they don’t, this poses an infection risk, which is a big concern for older adults with weakened immune systems,” Small says.
You should also check:
— Is there a lack of sanitation supplies available, such as clean linens, wipes, masks, gloves and hand sanitizer?
— Are food trays remaining at bedside tables long after meal times?
— Does the facility smell unpleasant, such as smelling of bleach or cleaning supplies covering the smell?
7. Medication mismanagement
Medication management is a key service nursing homes provide to residents to help keep them healthy, but medication errors can be common. Although medication errors are almost always unintentional, as many as 1 in 4 residents may be a victim of some type of medication error, notes a systematic review in the Journal of the American Geriatrics Society.
Nursing home red flags to consider:
— Do medication administration regimens fail to incorporate double-checks to ensure the right resident receives the right medication, dose, route, time and adequate documentation?
— Does the facility fail to notify family members of medication errors?
8. Use of restraints
Misuse of restraints, both chemical and physical, can limit resident communication, facilitate a decline in their physical and cognitive abilities and lead to serious injury or death.
Antipsychotic medications, such as Haldol or Seroquel, for instance, can be necessary to prevent a resident from hurting themselves or to treat a genuine psychiatric condition. Misuse, however, occurs when these medications are used to curb behaviors that are challenging for staff to handle, especially in residents with dementia or Alzheimer’s disease who do not have relevant psychiatric conditions. As a result of this kind of chemical restraint, residents may experience an increased risk in falls, infections, heart disease and mortality.
Physical restraints such as bed rails, scoop mattresses, lap belts and wheelchairs parked against a wall, are designed to prevent wandering or falls. When used improperly, however, they can lead to injuries, emotional trauma and a loss of mobility.
When touring a nursing home, make sure to ask a member of the staff:
— How does the facility handle “difficult” residents?
— How does it conduct psychiatric evaluations?
— Are there policies and procedures in place for when residents become combative or aggressive?
— Does the staff use antipsychotic medication in place of de-escalation and communication with combative residents?
— Does the nursing home use physical restraints and, if so, in what circumstances?
— Are staff members observed when using physical restraints to ensure they’re doing so correctly?
— What are the protocols regarding length of time and monitoring of residents in physical restraints?
9. Limited socializing
When you’re visiting a nursing home, be sure to pay attention to the social enrichment activities available to the residents.
This may include:
— How many residents are up engaging in activities by 11 a.m.
— Availability of nursing home activities, including arts and crafts, clubs and low-impact exercise, like walking or aquatic activities
— The amount of residents who eat in the dining halls during meals
— Whether residents feel comfortable interacting with staff, such as asking questions or socializing at appropriate times
— Availability and quality of outdoor space, as spending time outdoors can improve quality of life for nursing home residents
— Location of the nursing home, ensuring it’s in a safe neighborhood and that outdoor areas are secure to prevent residents from wandering
Social enrichment in these facilities is not just a nice amenity; it’s a necessity. If social activities aren’t a priority, that’s a nursing home red flag. That’s because social isolation and loneliness are linked to mental and physical health conditions. According to the CDC, people who are more socially isolated have an increased risk of developing dementia.
10. Unclean residential rooms
A nursing home doesn’t need to have exquisite interior design or break the bank, but it should be clean. Proper sanitation isn’t just about having tidy living quarters; it’s also about stopping the spread of germs and harmful bacteria.
Older adults have a weaker immune system, so they are more susceptible to infections, Small says. Research also shows that a clean living environment may promote healing.
Signs of unclean rooms include:
— Trash cans that haven’t been emptied
— Food trays that are left in place long after meal time
— Beds that haven’t been made or linens that are soiled
— Clothes, shoes and other items strewn about on the floor
Nursing homes should take pride in having clean and tidy facilities that don’t smell unpleasant. A tour is usually when a nursing home puts its best foot forward to impress you. If you aren’t confident of a facility’s cleanliness on a tour, consider going elsewhere. Also note that their cleanliness could decline if staffing issues arise among the clinical staff or housekeeping department.
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. Not only should the nursing home cater to residents’ likes and dislikes with its dining options, it should also be able to provide meals to meet the needs of residents on special diets, such as:
— Lactose-intolerant diets
— Diets catered for residents to avoid individual food allergens, such as tree nuts
— Meals for those with acid reflux who avoid trigger foods, such as onions or garlic
Unappetizing food or meals that don’t follow dietary needs are a nursing home red flag. This could lead to a loved one not getting the proper nutrition and losing weight.
Consider asking:
— Does the dining room feel like a hospital cafeteria instead of a homey restaurant with appetizing food?
— Are meals stagnant, or are residents able to choose and customize their meals according to their diet and preferences?
— Are meals designed with cost as a priority or with nutrition and taste in mind?
12. Complaints to state inspectors
The state agencies that license and certify nursing homes are required to inspect these facilities at least once a year. Inspectors determine whether facilities are complying with federal and state standards.
One of the goals of these inspections is to ensure that each resident receives appropriate quality care. Inspectors also investigate complaints from residents, family members, ombudsmen or other third parties.
To research a facility, request a copy of the annual state survey and, if relevant, copies of complaint investigations. Complaints that led to investigations could be a red flag.
Gure adds that it can be helpful to learn about the facility’s background. You might have more peace of mind knowing they are associated with a reputable academic medical group.
Watch out for these red flags in nursing homes:
— Short staffing
— High turnover among staff
— Disrespectful and evasive staff
— Long response times
— “No lift” policies
— A high number of infections and deaths
— Medication mismanagement
— Use of restraints
— Limited socializing
— Unclean residential rooms
— Poor and limited food quality
— Complaints to state inspectors
More from U.S. News
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Nursing Home Red Flags You Should Watch Out For originally appeared on usnews.com
Update 10/23/25: This story was published at an earlier date and has been updated with new information.
