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When and How to Choose a Nursing Home

TJ is a long-time copywriter experienced in the areas of medicine, health, and law.

Is a Nursing Home the Right Choice for Your Loved One Right Now?

I’ve never heard anyone of any age say they hoped to end up spending their golden years in a nursing home. I have heard several people share their worries that they would end up being “put away” and forgotten before they lived out their entire lives. We might even joke with our loved ones about putting them in a nursing home while they are still young and active enough to make the idea humorous.

In the United States, it’s gotten to be a common practice for seniors in a range of circumstances. Sometimes family members, including spouses and adult children, put their loved ones in a nursing home “for their own good.” Sometimes they have a valid reason; other times, it’s a way to get family members the care they need without taking on the responsibility of caring for them themselves.

We don’t embrace our elderly as many other cultures do. Instead of embracing them for their contribution to our lives and society, we cast them aside. Sometimes the choice to seek outside help is unavoidable. But it’s important to know when a nursing home is the right choice for the person whose life it impacts the most.


How Some People Put Their Loved Ones in a Nursing Home Against Their Will

Under some circumstances, a person with a medical power of attorney can place someone in a nursing home. It depends on how broad the POA is. The person must have been mentally competent when they assigned the POA and, even then, it usually only applies when they aren’t mentally competent to make their own medical decisions.

Although staying home is their legal right as long as they are mentally competent to do so, there are several ways that seniors end up in nursing homes against their will. For example...

  • They might “give in” to their relatives’ wishes because they think they don’t have a choice.
  • They don’t want to be a burden on their adult children.
  • Their loved ones might go so far as to use trickery such as making them think they are losing their home to the government to get them to move.
  • They aren’t aware of the in-home options available to them.
  • They’re told the move is “only temporary” until they heal from an illness or injury.

Seniors are prone to falls and fractures along with other health conditions. Sometimes seniors agree to go to the nursing home to heal or for therapy after an illness or injury. Once they become a resident, they never achieve their goal and never return to their home.

Although many of these seniors could return home with some degree of in-home care, they don’t know their rights. If they aren’t in a nursing home that caters to their specific needs, they can end up getting worse instead of getting better.

Society’s Misconception About Caring for Our Seniors

I found it strange during my recent dealings with my friend “Bob” that everyone is so willing to accept the idea that anyone with any level of health issue or disability “belongs” in a nursing home. These facilities haven’t always been around. Also, with ongoing complaints of fraud and abuse in many of America’s nursing home facilities, why are people so quick to accept the idea that they are the best place for anyone to be?

A Brief History on Nursing Homes

Nursing homes are residential facilities that provide people with some level of medical care. They are often called skilled nursing facilities (SNFs) and they vary in the types and degrees of medical care offered. Sometimes people go to a nursing home to recover from an injury or illness. For example, you might go to an SNF for physical therapy after an injury or speech-language therapy following a stroke.

The first version of a nursing home in the United States was with the almshouses brought about by English settlers. These facilities provided care for the elderly, orphans, and the mentally ill. Caring for this diversity of needs was easy; the only services included shelter and daily meals.

The demands on the almshouses became overwhelming during the Great Depression which lasted from 1929 until 1939. The houses lacked the space and funds needed for the very poor people who lived there. It was probably inevitable that diminished living conditions led to criticism and the demand for other options.

Over time, “convalescent homes” which provided the same basic care in a private setting. These homes gave way to the first nursing homes that were open to the public and funded by the state and the federal government. Nursing homes appeared throughout the U.S. by the mid-1960s.

Today’s Nursing Home Resident Has More Rights and More Options for Specialized Care

Modern nursing homes differ today in appearance, level of care, and the legal rights of the residents. During 1987, the Nursing Home Act was introduced, leading to the Residents’ Bill of Rights which defines the services and requirements nursing homes can and must follow.

In addition to the specialty care many SNFs provide today, many offer a “homier” environment. Residents have more personal space and amenities that make them more comfortable and make them feel at home. For adults struggling with the decision to put their loved ones into a nursing home or skilled nursing facility, these features might make the decision seem less like a betrayal.

For those seniors who do go into nursing care, this can have a big impact on the person’s physical and mental well-being. But for those who are still capable of staying in their real home, a virtual home isn’t the same thing! Sometimes a nursing home is the right choice. But it couldn’t be more important to make the right choice at the time and keep the future of your loved one in mind.

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Why Choosing the Right Nursing Home Matters

My recent articles “Think Twice Before You Sign a Power of Attorney” and “The Meaning of Quality of Life for Dogs and Humans” focus on my experiences with a close friend named “Bob.” The quest to get Bob home from the nursing home where his family members placed him has inspired me in several ways. The primary reason for wanting to help get his freedom from a “medical prison” was that he is still mentally competent (sharp as a tack, in fact!) and that’s where he wanted to be.

Consider Your Loved One’s Potential to Improve

The secondary reason is that the nursing home where he was placed didn’t offer near the quality of care he needed. He was recovering from a stroke he had seven months earlier. Except that he wasn’t given any physical therapy beyond the first thirty days of his residence. During that period, he was out of the wheelchair, walking with a footed cane. His biggest disability was his left arm; it still is. But he has regained quite a bit of its use since returning home just two weeks ago.

Bob got himself out of bed and into the wheelchair and vice versa. For the first few weeks, he even made his own bed. He went to the bathroom in his room by himself when needed.

His “room” was half of a semi-private room with a curtain down the middle to divide his and his roommate’s beds. You had to walk through the first half where another older man was always lying in his bed, motionless and silent.

Is the Nursing Home Focused on Rehabilitation?

One of the most important things you can learn about a nursing home is the condition of its residents. Almost everyone in the nursing home where Bob stayed was in similar condition. They sat about on cots, in wheelchairs, and sometimes on benches in the common area lobby. Most were unresponsive and probably didn’t realize the fate they had been dealt.

Nursing homes are expected to provide medical care to those patients who need it on a daily basis. Still, the only medical care the nursing home gave Bob was dispensing his prescribed medications each day. They brought him meals, many of which he sent back. He thought the food tasted awful. They showered him, although I don’t know how often. They provided the clean clothes that Bob dressed himself in. Otherwise, they left him to take care of himself.

There was no attention given to his emotional or psychological well-being. That was one of my biggest areas of concern. When an 82-year-old man is locked away in a small room with nothing to do but stare out the window and watch TV with the volume cranked up and with subtitles, what does that do to his mind?

I’ve been in several nursing homes as a family member of a resident and to serve as a volunteer. They all have that familiar smell of a mixture of urine, feces, and disinfectant in varying degrees. I wonder if it fades over time. Bob never had the chance to go outside into the courtyard during his “incarceration.” The only time he had been outdoors during a seven month period was when they transferred him from one nursing home to another during the cold winter months.

According to his family members who had control over Bob’s life, he could never go home. He wasn’t well enough to take care of himself. He needed 24/7 care and constant supervision. The problem with that theory is that he was never getting that kind of care while he was in the nursing home. The nursing home was located a long way from Bob’s home and his friends. Many of them didn’t even know where he was at.

When I looked up the nursing home reviews online, I found that it was rated below average in every category. In many areas, it received a poor rating overall. I also read reviews from people who had family members there and from one former employee. They all agreed, it wasn’t the best choice for any person at any level. Bob had no hope of recovering because there were no resources there he could count on.


Assisted Living vs Nursing Home: What's the Difference?

There is no shortage of articles online about the differences in these two types of facilities. Unfortunately, most of them provide you with the same information and it doesn’t address some of the most important details.

The Basics

Nursing homes provide medical assistance while assisted living facilities help with daily tasks like bathing, preparing meals, and taking medications. Nursing homes are for people who need greater supervision.

Assisted living is for those who are still fairly independent but who need a little more help performing everyday tasks. Seniors might go to a nursing home when they are no longer able to care for themselves at home efficiently or safely. Sometimes people of any age go into a nursing home to recover from an illness or injury and go through therapy.

Some nursing homes and assisted living facilities also offer specialized dementia care for people with Alzheimer’s and other forms of dementia. They include programs that help stimulate memory and meet their needs for socialization.

Cost is a concern for most people, and it differs between these two types of facilities. It also varies from one location to the next. For seniors on Medicare, nursing homes are covered either partially or in full depending on your state of residence. Some states, such as Kentucky, requires patients with Medicare who stay in the nursing home longer than 30 days to apply for Medicaid to assist with the costs.

Dealing with the Guilt

I've never dealt with an assisted living facility, but I imagine there would be less guilt involved. People in assisted living are usually mentally competent but lack the physical dexterity and/or energy to do everyday tasks. People in the early stages of dementia might enter specialized assisted care, then advance to services that provide more stringent oversight.The still have the mental clarity to enter into assisted living freely early on.

Bob didn’t want to be in the nursing home. He would have preferred to be in his home even if it meant shortening his life span significantly. Many seniors feel the same way. But all of them don’t have the same ability and/or financial means to stay at home.

My Grandmother

I’ve also had a grandmother, mother, and father who spent time in a nursing home. It was also a different scenario for each of them. My grandmother was a large woman. When she became ill, she couldn’t bath herself or get dressed. She developed adult onset diabetes late in life and had to learn to take injections. When she developed congestive heart failure, there was no other choice. She went in the nursing home for care while she received medical treatment. My mother went to stay with her for hours each day. She took her everything she needed and kept her company, so she never felt alone.

My Father

When my father was first diagnosed with Alzheimer’s, my mother took care of him at home. One day, she called me at my home which is about an hour away. He had fallen in the floor and he couldn’t (or wouldn’t!) get up. My mother was a tiny little thing at just five feet tall. It turned out it wasn’t the first time she had wrestled my father back into an upright position.

This time, me, my mother, and my son together couldn’t get my dad to budge from the floor. I noticed his breathing didn’t sound good either. I suggested calling an ambulance to take him to the hospital and get him checked out. It turned out he had bronchitis. Once he was ready to leave the hospital, he went into the nursing home. My mother had worried that me and my sister would be upset with her if she had put him there sooner.

She couldn’t have been more wrong. My sister and I understood that she didn't have the strength to provide the level of care my father needed. It wasn't good for either of them to pretend she did.

He lived his last year of life in the nursing home, with my mother once again visiting the nursing home on a daily basis as she had previously with her mother. My father lost the rest of his memory, his voice, and then his will to eat. My mother crusaded against putting a feeding tube in him to keep him alive longer without any awareness of who he was. I’m thankful she won that battle.

My Mother

When it was my mother’s turn to go into the nursing home, it was with the idea of getting therapy. It was never intended to be a permanent solution and I would never have taken her out of her home. She had gotten sick suddenly with the flu. It was a severe case that landed her in the hospital. I couldn’t understand why she wasn’t able to get up and walk to the bathroom by herself because of the flu that should have passed.

The nursing home they put her in for therapy was about an hour and a half away from me. I was working and didn’t have the flexibility to be there every day. My niece, however, worked close by and always fit visits to the nursing home into her schedule. I don’t know what I would have done without her and her daughter.

My mother had only been in the nursing home for about a week when I received a phone call from a nurse there in the middle of the night. She seemed hesitant to comment on my mother’s condition; yet, she was compelled to let me know something just didn’t seem right. I asked her what I needed to do to get her transported to the hospital. She said I needed to tell her to send her, and I did.

I left my house immediately, and when I arrived about an hour later, they had already resuscitated her twice. She had an order to not resuscitate her, but that’s another story for another time. I told the ER doctor that if there wasn’t any hope, not to revive her again. It wasn’t long before she was gone. An irregular heartbeat she had suffered from her entire life had thrown a blood clot that traveled to her brain.

All of these situations with my loved ones and the one with Bob have taught me a lot about nursing homes. They've also taught me about dealing with guilt. I think it's inevitable to some degree, if only because we all have lives to lead. Most of us are limited in the amount of time we can get away to be at a loved one's bedside.

The best way to stave off guilt is to do everything you can to give your loved one the best quality of life possible. Do your research and consider the steps below before making that all-important decision that will likely determine the quality of life for the rest of their lives.

How to Make the Decision

Step 1: Decide if a nursing home is the best place for your loved one.

Is your loved one mentally competent of making decisions about their medical care and living conditions?

If a person is mentally incompetent, then staying at home might not be practical or safe. It doesn’t even matter if they will be at home alone or not.

People who are mentally incompetent often have some form of dementia. All forms affect memory and they progress through stages until the person dies. There are drugs and games that professionals use to slow the progress. However, the effects of the disease can’t be stopped or reversed.

If your loved one has dementia, their condition is going to progress. During the early stages, the noticeable signs of memory loss might be minimal. Maybe they forget to turn a light out when leaving the room or it takes a few minutes to pull up someone’s name that they know well. As their memory continues to fail, it might progress to leaving the stove on or forgetting which side of the road to drive on.

All types of dementia include memory loss, but that isn’t the only symptom. Some people with some forms of dementia become aggressive; others become withdrawn. They stop taking care of their hygiene, don’t eat regularly, and sometimes wander away from home. Even when there are people around, they are at risk of getting away long enough to cause themselves or someone else harm.

A nursing home with dementia care can help prolong memory and ensure your loved one is in a safe, nurturing environment. Don’t make the mistake of thinking that keeping them home is doing anyone a favor.

Don’t base your choice in a nursing home on their current condition alone. They’re going to get worse. Does the nursing home offer a safe, secure environment that prevents them from wondering off? Do they provide specialized care for the later stages of the disease?

It’s hard enough to make the decision about putting your loved one into a nursing home now. You don’t want to end up making the same decision when their condition outgrows their current residence.

Remember, a nursing home is a business. Their top priority is making money by keeping their facility filled to capacity. The nursing home will give you lots of reasons to put your loved one into their care. Base your decision on what’s best for your loved one both physically and mentally. Instead of depending on them for advice, think about what you would want if you were in your loved one’s place.

Step 2: Determine if care is available if they stay at home.

We all lose some of our strength and flexibility as we age. Although everyone ages differently, there comes a time when you just can’t do the same things that you used to. Some seniors who require personal assistance with things like bathing, hygiene care, and even housework will hire at-home non-medical support to help them. These services provide everything from menu planning and cooking nutritious meals to mailing out bills and walking the family pet.

The only obstacle for some people is that they must pay out-of-pocket. For someone living on a fixed income, even the $15 to $20 per hour these services charge can make a big dent in their household budget. Before you give up on keeping your loved one at home, learn what options you have available. Medicare pays the majority of medical services and they might not need that many hours of support services that they must pay.

Playing the Role of Caregiver

Many adult children or other family members or friends might take on the role of caregiver. Most do not realize the impact it can have on their own lives and their health. If you’re debating whether in-home care or a nursing home is right for your loved one, consider your resources carefully. Make a list of potential chores and determine how many hours per week it will take.

Will you need to do everything yourself or can you count on other friends and relatives to pitch in? Don’t figure in anybody that you can’t count on in a pinch. There are no sick days when it comes to caring for a loved one’s needs.

One obstacle adult children often face is the distance between their homes and that of their aging parent. They live miles away with families and lives of their own. The reality is that most people can’t afford to quit their job and take care of a parent full-time. Those that do often experience serious health issues and have problems with their personal relationships because of the physical and psychological burden.

It Takes a Village

The book written by former first lady Hillary Clinton has come to mind often during my experience with Bob. We had a wheelchair ramp built for him, took him to the doctor, and helped him with a long list of business issues on his first day back home. But we actually live over an hour’s drive from Bob’s home. We can’t just “pop in” when he calls.

Bob has done a great job managing his care. I had no idea the number of friends and neighbors he had around him, ready to come to his aid any time he needs them. Bob knows who to call for what and the best times for everyone. He hasn’t been able to get himself to appointments or to the grocery store, and we were set to go whenever something came up. But he always has someone nearby who can be there in minutes and is free to give him the time he needs.

Does your loved one have that kind of support for the times when you can’t be there?

Step 3: Consider their physical needs.

When we were working so hard to get Bob out of the nursing home and back into his own home, everyone kept telling us he wasn’t able to stay alone. He needed 24/7 care. But other than handing out his medication every day, they didn’t do anything to tend to his physical or emotional health.

In most cases, being reliant on medication isn’t a reason for taking someone out of their home. Most of us take medicine for at least one condition or for prevention. If taking multiple medications during different times of the day gets confusing, a pill organizer is all it takes to sort things out.

I go to Bob’s house and put three weeks’ worth of medications into the daily dispenser marked morning, afternoon, evening, and bedtime. It’s not something new to him. He did the same thing before he had the stroke. Now, he takes a few more medications but he takes them in the same way, and he keeps on track.

Does your loved one need any special accommodations in their home? Bob still spends most of his time in either his wheelchair or scooter. He needed a ramp to get into and out of his home and we took care of that before we brought him home.

He stands well enough to do whatever he needs to in the kitchen. Most of what he eats heats up in the microwave or straight out of the fridge. He also has meals delivered to his home during some days of the week. We make sure he keeps everything he needs stocked including the nutrient shakes that he drinks daily to get the vitamins and calories he needs.

Living at Home with a Disability

Disabilities make it “different” for people who live in their homes. It doesn’t mean they can’t do almost everything they did before. It just means you need to think about what accommodations will make it easier and safer for them, especially if they live alone.

If Bob couldn’t stand or walk at all, things would have been much different. He wouldn’t be able to go to his bathroom by himself or go back and forth between the wheelchair and his bed. But he did those things in the nursing home, proving that he only needed a few accommodations to help him along. The wheelchair ramp and some rails around his toilet are all that he needed to access every foot of him home and his beloved garage.

Step 4: Evaluate if they can afford to stay at home.

This is another point that nursing homes like to make. It costs a lot of money to get in-home care and most seniors on a fixed-income just can’t afford it. At least, that’s what they want you to believe.

Consider this: the average cost for a semi-private room in a nursing home is $7,148 per month. Right now, Bob is getting in-home health care that is covered 100% by Medicare. Soon, the supportive services will begin which will also be offered free of charge. This is a service provided in his state and county.

In those states where these services aren’t offered without cost, the price of assisted-living care ranges from $2,500 to $6,000 per month depending on the state of residence and the amount of care required.

When you compare the high-end of this range with the average cost of a nursing home, you see that living home isn’t the unrealistic expense that nursing homes would have you believe. Cost is a factor for almost everyone. But it shouldn’t be the only consideration in making your decision. Take time to learn about your resources before you determine home care is too expensive.

Step 5: Spend a day or two on the phone.

There are many programs out there to help seniors, people with disabilities, dementia, and nearly any other condition you can name! Many are offered at the state or city level. Others come from organizations devoted to certain groups. These programs can help you get the help you need for your loved one and many of them are free. But they won’t come to you.

Start by calling...

  • Your local social services department
  • Area senior citizens center
  • National Council on Aging
  • National Institute on Aging (AAA)
  • Programs of All-Inclusive Care for the Elderly (PACE)
  • AARP
  • Your loved one’s primary care physician’s office. This is especially valuable since the doctor knows what is available in their area. Some services and medical devices also require an order or prescription from the person’s primary care physician.

Ask them for resources to help provide the services and support products your loved one needs. We got Bob’s wheelchair built for the cost of materials, saving thousands on labor costs. He also gets nursing and physical therapy services twice a week at no charge. In a few weeks, he’ll get an additional service that includes things like doing laundry and cleaning the house.

Once you get the names and numbers of these resources, call each one. Don’t give up. Sometimes it’s the third or fourth call in the chain of referrals that provides the biggest rewards.

Step 6: Do your research and take a tour.

You might think that all nursing homes must meet certain conditions just to stay open. Sadly, many offer minimal services and don’t provide anything of value to patients who still have their mental capacity.

I mentioned already that the only thing Bob had to do every day was watch the TV mounted on the wall turned up to full volume and with the closed caption on. There were no programs to stimulate memory, no physical therapy, and no taking residents outdoors. We did smuggle him a word search puzzle book and a pack of pens that he wasn’t really allowed to have.

No one in their right mind should face waking up in a tiny room every morning with nothing to do but stare at the TV screen or the courtyard outside where they’re never permitted to go. Investigate nursing homes with an even greater intensity than you would if you were about to purchase a new home for yourself. Make up a list of questions to ask including:

  • What programs do you offer to help with my loved one’s conditions?
  • Do you provide medical care and, if so, how often?
  • Do you provide optometrist care or have hearing specialists who visit?
  • What kind of security do you offer to keep residents safe?
  • Do you schedule residents for daily events and care? If so, how much time is spent in each category?
  • How do you prevent pressure sores? This is essential if your loved one is bedridden or only slightly mobile.
  • What happens if my loved one’s condition progresses?
  • How do you keep the risk of infection to a minimum?
  • How do you care for your residents’ emotional and mental well-being?

If caring for your loved one isn’t practical or possible either short-term or long-term, choose a nursing home that is close to you or someone you can depend on. Like they say in Hollywood, Location, Location, Location! Your loved one doesn’t stop needing the support of their family and friends when they get older. They need it more than ever. That includes dementia patients who might not always appear to know you’re there.

Read reviews online and not just on the nursing home’s website. The one where Bob stayed provided pictures of seniors doing crafts and described outings in the courtyards. Not only did we never see any of that taking place; we never saw any resident capable of doing any crafts. Whether it was their condition or their medication, I don’t know.

Step 7: Lay out the options to your loved one.

Why do we tend to treat seniors like children? Do we forget that they are the same people who made the decisions for us from the time we entered this world? Of course, those with dementia or serious medical conditions that cause mental incompetency are different. There is a real reason that they can’t make good decisions about their care.

Let your parent or other loved one know what options are available. Discuss the pros and cons of each choice and the role you will play in each. Don’t promise to be there when you can’t Don’t sugarcoat the care at the nursing home to make it sound like a vacation paradise. If they have the competency to make decisions about their care, try and help them make good ones.

If they decide to stay at home and accept in-home care, accept that there might be some risks. One argument that we got about Bob was that he needed 24/7 care to ensure he wouldn’t fall. He has fallen once since he got home, sliding down into the floor without getting hurt.

In contrast, he fell twice at the nursing home; once toppling out of his wheelchair right after the stroke and again falling into the closet when the strip of wood across the floor broke while he was standing on it to get his own shirt. This time, he hurt his hip and had to get it x-rayed.

Like children, adults can get hurt no matter who is watching or what precautions you take. But shouldn’t their happiness weigh-in on how they spend the rest of their lives?

There was a time when your parents had to let you go and make decisions for yourself. This might be your chance to repay the favor. If you make the decision together based on what is best for your loved one in every way, you’ll have an easier time making a decision that you both can live with.

This article is accurate and true to the best of the author’s knowledge. Content is for informational or entertainment purposes only and does not substitute for personal counsel or professional advice in business, financial, legal, or technical matters.


Lorna Lamon on May 27, 2019:

This is an excellent and informative article with lots to think about. My father was nursed at home until his dementia became too much for my mother to cope with. I think it is definitely worth looking at every option and your article does this in so many ways. Thank you for sharing.

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