12 Nursing Home Red Flags: Warning Signs to Watch for on a Facility Tour

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.

Taking a tour, when you can examine a nursing home firsthand, can spotlight both the good and the bad.

Let’s walk through 12 nursing home red flags that indicate a nursing home isn’t right for you or your loved one.

Red Flag 1: Inadequate Staffing Ratios and Shortages

With growing concern for the healthcare 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

— Emergency room visits

— Hospitalizations

— Unnecessary restraints

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.

[READ: Nursing Homes vs. Assisted Living.]

Red Flag 2: High Staff Turnover

Turnover among certified nursing aides at nursing homes is often near or more than 100% annually, according to a 2022 study published in Health Affairs. 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.

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. Inconsistent staffing, on the other hand, can result in staff not knowing their residents and their routines as intimately, and information can get lost between shifts.

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

[READ: Nursing Home Costs in 2026: A Complete Guide to Payment Options]

Red Flag 3: Long Response Times

The call light is the link that provides residents access to a range of care, from comfort to immediate life-saving measures. In fact, the Centers for Medicare & Medicaid Services 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, such as 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.

[READ: How to Stay Connected to Your Loved One in a Nursing Home.]

Red Flag 4: 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 (EMS) 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, such as 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, such as 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

Red Flag 5: Disrespectful and Evasive Staff

You should feel comfortable talking to staff and having your questions or concerns addressed. It’s a nursing home red flag if you’re uncomfortable in these interactions. Even more serious is when the disrespect becomes elder abuse, which happens to up to 20% of seniors age 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 I may have about my family member?

— Do residents show signs of abuse or neglect, 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, 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, director of behavioral health breakthrough therapies and professor of psychiatry and behavioral health at Hackensack Meridian Health in Edison, New Jersey.

Red Flag 6: Overuse 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, though, 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?

Red Flag 7: Mismanaged Medications

Medication management is a key service nursing homes provide to residents to help keep them healthy, but medication errors can be common. Although these 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?

Red Flag 8: Frequent 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

— Pneumonia

— Urinary tract infections

— Norovirus

— Clostridium difficile (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? Do you detect the scent of bleach or cleaning supplies covering the smell?

Red Flag 9: 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 suggests that a clean living environment may promote healing.

Signs of unclean rooms include:

— Trash cans that haven’t been emptied

— 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.

Red Flag 10: Poor Food Quality and Lack of Dietary Accommodations

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:

— Low-sodium diets

— Lactose-intolerant diets

— Gluten-free 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. A lack of quality food 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?

Red Flag 11: Limited Social Enrichment

When you’re visiting a nursing home, be sure to pay attention to the social enrichment activities available to the residents.

Factors to keep an eye out for include:

— How many residents are engaging in activities by 11 a.m.

— The availability of nursing home activities, including arts and crafts, clubs and low-impact exercise, such as walking or aquatic activities

— The number 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

— The availability and quality of outdoor space as spending time outdoors can improve quality of life for nursing home residents

— The 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. It’s a nursing home red flag if social activities aren’t a priority. 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.

Red Flag 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, ombudsman 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.

Quick-Reference Checklist for Nursing Home Visits

Before you go on your tour, print or bookmark the matrix below to have it handy as a reference.

Warning Sign Category	What to Look or Listen For on a Tour	Risk Level	Immediate Follow-Up Action
Response and care	Multiple active call lights ringing unanswered for more than 10 minutes; residents left unattended in hallways	Critical	Ask: “What is your shift nurse-to-resident ratio right now?”
Physical safety	Visible bruising, skin tears, bedsores or residents in physical restraints, such as lap belts or locked wheels	Critical	Check the Medicare Care Compare database for an active abuse icon.
Clinical integrity	Staff failing to wash hands between rooms; medical trays left out in common areas, medication carts with drawers left open or medications unattended	Critical	Ask for the facility’s most recent annual state survey report.
Environmental health	Strong chemical bleach smells masking odors; unemptied bedroom trash bins or soiled linens	High	Take an unannounced tour outside of regular hours, if you can.
Quality of life	Stagnant, institutional meal trays; zero resident activities or engagement by late morning	Moderate	Ask to speak with the resident council president, an activities director or the head of dining.