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Nursing Homes

(Skilled Nursing Facilities)

By

Debra Bakerjian

, PhD, APRN, Betty Irene Moore School of Nursing, UC Davis

Last full review/revision Jul 2020| Content last modified Jul 2020
Click here for the Professional Version
NOTE: This is the Consumer Version. DOCTORS: Click here for the Professional Version
Click here for the Professional Version
Topic Resources

Nursing homes are for people who need help with health care for chronic conditions but do not need to be hospitalized. The decision to move to a nursing home may be triggered by a change in circumstances. A disorder may suddenly worsen, or an injury may occur. Function may deteriorate suddenly or slowly but steadily. Family circumstances may change, making care at home difficult.

“Nursing home” is sometimes used as a general term for any long-term care facility. But it specifically refers to facilities licensed by the state that can provide both basic and skilled nursing care. “Skilled” indicates that some of the care included can be provided only by trained health care practitioners. “Nursing” indicates that nurses provide most of the care in the facility. Nurses give residents their drugs, monitor disorders, supervise treatments, consult with doctors about care, and organize most of the activities in the nursing home. The nursing staff includes registered nurses (the most highly trained), licensed practical nurses, nursing assistants, and a director of nursing, who oversees nursing care in the home.

Supervision of care

Each nursing home also has a medical director, a doctor who oversees the medical care. In some nursing homes, the medical director is the only doctor who provides medical care. But in most nursing homes, several doctors, often working with nurse practitioners or physician assistants, provide care. Sometimes a doctor who has been taking care of the person before the move continues to provide care. Otherwise, the person chooses or is assigned a doctor. According to regulations, a doctor, nurse practitioner, or physician assistant must see every nursing home resident at least once every other month. Many residents see a health care practitioner more often because they need treatment for chronic disorders or they develop additional disorders, such as infections or confusion. Also, nurses may call a doctor to discuss problems and changes in treatments.

Types of care and services

Many nursing homes provide services previously thought to occur only in hospitals such as continuous administration of oxygen and fluids or drugs given by vein (intravenous therapies).

Almost all nursing homes provide rehabilitation, including physical, occupational, respiratory, and speech therapy. Many people are admitted to nursing homes specifically for rehabilitation, then are discharged to their home after several weeks.

Dentists and medical specialists, such as podiatrists, ophthalmologists, neurologists, or psychiatrists, may examine and treat residents on site. But most often, people with a specific problem have to be transported to a different site for treatment.

Some nursing homes have special units for people with dementia. These units are staffed by specially trained nurses. Many nursing homes provide hospice care for people who are dying.

All nursing homes provide access to members of the facility's interdisciplinary team including doctors, nurses, social workers, and pharmacists. Social workers help residents adjust to the nursing home and, when appropriate, help residents return to their own home or to a lower level of care. They identify residents who are lonely and withdrawn and help residents, staff members, and family members communicate with each other. They may also help residents and family members make financial arrangements. For example, they may show family members how to apply for Medicare and Medicaid coverage. Social workers often help coordinate the care provided by the different health care practitioners in a nursing home. These practitioners work together to enable each resident to function as well as possible and to have the best possible quality of life.

Did You Know...

  • State departments of health regularly evaluate nursing homes, and nursing homes must make these evaluations available to residents and their family members.

Although some nursing homes resemble hospitals rather than homes, many nursing homes are trying to change from a more institutional environment with rules and regulations to a more homelike environment that gives residents more control over their care. Some nursing homes permit pets, encourage residents to maintain existing hobbies or develop new ones, and provide many opportunities for contact between residents and people of all ages who live in the community around the nursing home. Providing this kind of environment is complicated because the residents of nursing homes are usually sick and frail. Many nursing homes have dining rooms, recreation rooms, beauty salons, patios, and gardens. All nursing homes provide recreational and social activities.

Nursing homes are highly regulated by the government. To monitor and evaluate quality in nursing homes, state health departments conduct surveys and inspections and interview residents and staff members. A copy of this evaluation is kept at the nursing home and can be reviewed by residents and their family members. Nursing homes also use other programs that monitor and help improve the quality of care.

Selection

Even though nursing homes are monitored and regulated by government, they vary considerably in quality, personality, and cost. So people or family members who are interested in a nursing home should try to get as much information as possible. They can ask the administrator of the nursing home to see the state’s evaluation of the home.

Medicare's nursing home comparison tool also provides detailed information about every Medicare and Medicaid certified nursing home. The Centers for Medicare and Medicaid Services created the Five-Star Quality Rating System to help people needing care, their families, and caregivers compare nursing homes more easily. This rating system includes information regarding how well nursing homes are caring for their residents’ physical and clinical needs, including looking at problems that commonly develop or worsen in residents of nursing homes, including the following:

  • A decline in the ability to do daily activities

  • Undernutrition

  • Weight loss

  • Pressure sores

  • Incontinence

  • Pain management

  • Constipation

  • Infections

  • Depression

  • Use of too many drugs

Whether these evaluations are valid is debated. Nonetheless, they provide information that can help people better compare nursing homes.

Other important questions to ask the administrator include

  • Whether the nursing home is certified to provide Medicare and Medicaid coverage

  • How often care of residents is reviewed

  • What type of medical care is available

  • Whether residents and family members are included in the review of care

  • Whether there is a family and/or resident council

For some questions, the administrator may direct people to the nursing home’s medical director or director of nursing.

Talking to other people who are familiar with the home is helpful. Such people include long-term care ombudsmen (who visit nursing homes and investigate complaints), doctors, clergy, family members of residents, residents, and employees of the nursing home. Some homes have resident organizations, consisting of family members and friends of residents who meet to discuss issues that come up in the nursing home. These organizations can provide family members of prospective residents with helpful information. However, making an unscheduled visit to a home for several hours is usually the best way to determine whether the quality of services is good and whether the home will be a good place for a loved one.

Choosing a Nursing Home

Philosophy of Care

  • Does the home simply provide custodial care (such as bathing, feeding, and dressing), or does it try to optimize residents' ability to care for themselves?

Environment

  • Is the nursing home attractive, friendly, homelike, and relaxed?

  • Are there any unpleasant odors? Is the nursing home clean and well maintained?

  • Are the dining room and other common areas bright, cheery, and pleasant?

  • How is the noise level in common areas monitored to prevent it from disturbing residents whose rooms are nearby?

  • Are there safe, accessible walking paths on the grounds?

  • Is there a garden or patio?

  • Does the nursing home have appropriate safety devices, such as fire alarms and sprinklers? What are the plans for emergencies, such as fires?

Residents

  • Is the nursing home accepting new residents?

  • Do the residents seem reasonably happy and active, or are they wandering aimlessly or sitting and doing nothing?

  • Are the residents clean and appropriately dressed?

  • Are any of the residents restrained?

Staff Members

  • Do the staff members treat the residents with respect, patience, and friendliness?

  • Are staff members experienced and qualified?

  • Do the residents see the same staff members on a daily basis?

  • Is there a high turnover in staff members?

  • Do staff members respond to requests for help in a reasonable amount of time?

  • What is the ratio of staff members to residents?

Rooms

  • Is there enough storage or closet space?

  • Are the residents’ rooms bright and cheery?

  • Are private rooms available?

  • How are roommates selected?

  • How are private items stored or secured?

  • Can residents have their own telephone, television, and internet access?

  • Is water available and within reach for residents who need it?

  • Can residents decorate their rooms with personal items?

  • Are there safety features, such as grab bars and pull cords (to call for help)?

Meals

  • What time are meals served?

  • Are meals served hot?

  • Are snacks available between meals?

  • Can residents get from their room to the dining area easily?

  • Can meals be provided in a resident’s room if needed?

  • Are the meals tasty and nutritious?

  • How are special dining or menu requests handled? Are choices available at meals?

  • Can the nursing home provide special diets when needed? Is there an additional cost?

  • Are staff members available to help with feeding during meals?

  • Is there a registered dietitian on staff?

Health Care

  • Can residents keep their own doctor rather than use the nursing home’s doctor?

  • How often is the nursing home’s doctor available, and where?

  • Does the nursing home have an arrangement with a nearby hospital?

  • If residents have to be hospitalized, will a bed be available afterward?

  • Are other health care practitioners (such as dentists, podiatrists, physical therapists, optometrists, counselors, and social workers) available?

  • Are therapy programs (such as physical, occupational, or speech therapy) provided?

  • Does the nursing home have special programs for people who have disorders such as Alzheimer disease or HIV infection?

  • What services does the nursing home provide for residents with a terminal disorder?

  • How are prescription drugs ordered and given to residents? How is the use of drugs monitored?

  • What is the policy on residents keeping nonprescription drugs?

  • Are residents and family members encouraged to participate in developing a plan for care?

Services

  • Is help with daily dental care provided?

  • How is personal laundry done?

  • Is reading material available?

Visiting

  • Is the nursing home conveniently located for frequent visits by family members and friends?

  • Can family members visit any time?

Activities

  • What activities are offered?

  • Are residents encouraged to participate? How are the residents informed of the activities?

  • Is there an activity director?

  • Does participation in activities cost extra?

  • Are there rooms for other activities, such as a TV or game room?

  • Are religious services held on the premises?

Costs

  • Are all the services that residents need covered in the basic charge?

  • What services (such as beauty salons or laundry) cost extra, and what is the cost?

Residents’ Rights and Privacy

  • Does the nursing home have an active resident or family council or both?

  • Are residents allowed to go in and out as they please?

  • Are restraints used? When and why?

  • Is there a lock on the door to private rooms? Do staff members knock before entering?

  • Can married couples live together? Are they given privacy?

  • Are the sexual needs of residents respected?

  • How often are residents bathed? Can residents have a bath or shower whenever they want? Are bath and shower areas kept warm enough? How much privacy is provided in these areas?

  • Are pets allowed? Can visitors bring pets?

  • Can residents keep food or alcohol in their rooms?

  • What is the nursing home’s policy on lost or missing valuables?

  • Who contacts family members in case of an emergency?

  • If residents wish to leave, what are the policies on giving notice or refunds?

Financial issues

In the United States, Medicaid and private funds pay for most nursing home care. Medicare pays for rehabilitative care for a short time in certified nursing homes if skilled care is needed daily after a hospital stay lasting 3 days or more. People are eligible for up to 100 days of Medicare coverage as long as they show continued improvement. Medicare pays all costs for 20 days, then requires a co-payment for the remaining 80 days. After 100 days, payment is either with private funds or, if the person is qualified, through Medicaid.

More Information

The following are some English-language resources that may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

  • Nursing Home Compare: Provides detailed information about every Medicare and Medicaid-certified nursing home

  • LongTermCare.gov: The Administration for Community Living combined information from the Administration on Aging, the Administration on Intellectual and Developmental Disabilities, and the Department of Health and Human Services Office on Disability to provide information on long-term care access and cost

NOTE: This is the Consumer Version. DOCTORS: Click here for the Professional Version
Click here for the Professional Version
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