Additional Information to " Selecting a Nursing Homes"

(9/10/12)-There are 1.8 million nursing homes in this country. 31.5% of Medicaid's $400 billion in shared federal and state spending goes to long-term care for the elderly and the disabled.

To be eligible for Medicaid, a person typically can have no more than$14,800 in assets. New York has the biggest Medicaid budget of any state at $54 billion, and spends about 41% of it for long term care, almost half on nursing homes. By 2015, New York will start requiring some 78,000 nursing home residents to choose one of several managed care plans or be enrolled randomly in one of them.

Children could be liable for Medicaid expenditures for their parents under pending new laws. A 2009 analysis by the Kaiser Foundation found that direct out-of-pocket sending by individuals and families accounts for 22% of the $178 billion spent on nursing homes.

(8/3/11)- The Centers for Medicare and Medicaid Services has unveiled a six-page discharge planning checklist with more than a dozen questions, including questions on post-discharge care and medical equipment. The pamphlet can be downloaded from

(3/24/10)- The Saturday, March 20th edition of the N.Y. Times contained an article written by Walecia Konrad that might be helpful in selecting a nursing home for a loved one. The article is entitled "Stressful but Vital: Picking a Nursing Home."

In the article the author enhances on using the state ombudsman to help you make the right decision in picking a nursing home for a beloved friend or relative.

The state ombudsman is federally funded, and should be aware of any significant changes in a nursing home operation. The article goes on to state: "This person can tell you if there are state rankings or surveys available in addition to the Medicare rating." The Medicare rating can be found on the Web site under the "nursing home compare" link.

"The ombudsman can also help you find the latest health inspection reports, which are public information, on specific nursing homes."

The article goes on to state: "You can find the ombudsman in your state online at the National Long-Term Care Ombudsman Resource Center."

A study used trained research staff as well as government survey staff to observe mealtime care in 20 nursing homes in five states. The trained research staff proved better at spotting residents that received inadequate feeding assistance than did the government survey staff. This included the fact that less than half of the residents who refused their meals were offered an alternative meal. (Journal of the American Medical directors Association, Oct. 2009)  

(4/29/08)- There are approximately 16,000 nursing homes in this country, in which there were about 1.4 million residents in 2006. According to a study done by the Urban Institute, that was released in 2007, this population in the homes is expected to grow to about 2.7 million by the year 2040. One of the major questions that we may all face in our lifetimes is how do we get data that will help you determine which home is best suited for one of your loved ones.

The federal government is continuing to expand the data available to help you make the determination as to, which home is the one you will choose. We at therubins can not point out strongly enough that the most important ingredient to help you determine which is the "right home" for your choice is determined only after you have personally visited the home yourself.

The federal government recently announced that it was expanding on the data available on the (Nursing Home Compare) site its Special Focus Facilities information. This data identifies nursing homes that rank in the worst 5% to 10% for inspection results in a given state. This information was previously available but the data was not integrated into the site's database.

"Just making that list means they've been a chronic underperformer", says Kerry Weems, acting administrator for the federal Centers for Medicare and Medicaid Services. Nursing Home Compare is updated monthly and it summarizes information form inspections performed by state agencies, as well as data the nursing homes compile and submit to regulators about residents and staffing.

In the last few years a number of consumer oriented sites have arisen that make the data easier to understand for the average layman. One is , which is maintained by a small company in Severna Park, Md. The site, which is free, offers color-coded rating based on the data contained in the federal site.

A company called Health Grades Inc. has a site named, which charges for its reports. The information on this site goes back to earlier periods than does the government site, and is written in an easier to read form than is the government site.

Consumer Reports, from the nonprofit Consumer Union, has a site with a report from 2006. It recommends homes to choose or avoid, and the company hopes to update the site later this year.

Senators Herb Kohl, a Wisconsin Democrat and Charles Grassley, an Iowa Republican plan to sponsor a bill shortly that would require that additional information be revealed by the homes and the federal government.. The senators hope to get the bill passed by the Senate by July 1, 2008.

(1/22/05)-One of the most frequently asked questions that we at therubins receive is the question as to which nursing home it is that we would recommend. That is a very difficult question to answer since it depends on the circumstances of the individuals involved in the matter. Not all nursing homes are good for all potential residents. The following is the most recent such query on this matter that we received. We edited some of the material in the question, as well as the sender of the email, but we feel it is typical of the type of response that we would give to this question.

Email question from a viewer of therubins site

I read with great interest your article about your mother and nursing homes. My mother-in-law had a stroke back in October and is paralyzed on one side and has loss of speech and unable to eat. We had her transferred eventually from the hospital to (edited) in NYC...we are not happy with her care there and unfortunately she has now been hospitalized with an ulcerated foot, pneumonia & urinary tract infection. None of which she had when she went into the home -

We re thinking of putting her in a new home but are not sure which one is best. I understand from your article that your mother was in NYC and if you could recommend good nursing homes here in NYC or close by that would be wonderful. We have a list of homes we are looking at and any input would be greatly appreciated. - (Edited) Thank you so much for your time and understanding.

Dear (Edited)

Response from therubins

We can sense your deep concern about finding a place for your mother-in-law that will meet her needs as well as provide you peace of mind. This is a tall order and probably when you do decide, things will occur that will make you feel guilty about your choice. A nursing home, is not like a personal home. No doubt these are things you already know, but they still need saying.

We would suggest that you consider what is important to your mother-in-law. Your report sub-par care in the home in Manhattan, relating it to the physical condition your Mom developed at the home. What should the home have done to prevent such disabling physical things? Does the home in Riverdale provide the "care" that prevents these events. Only you can determine that by visiting the place, talking to friends and relatives of the residents etc and even then there is no guarantee that things won't happen. It was months before the staff at the home, which we considered "good", discovered a lump on our mother's breast the size of a peach.

Then too, you must consider the time you want to spend at the residence with your mom. Is it a convenient place for you to visit. Frankly, visiting keeps staff on their toes, but can exert an emotional toll on you. Define the things that will give you peace of mind. Remember being in a nursing home is probably a compromise decision, not the ideal place.

The other thing is to check out the violation record of the home and also speak to the ombudsman assigned to the home. Check with FRIA (Friends and Relatives of Institutionalized Adults).

This may not be the answer you are looking for, but we believe it can give you a base to explore and make the hard decision you have to make.

Please feel free to contact us with any further questions.

Best of luck in your search and we hope that your mother-in-law finds the setting that will enhance the quality of her life at this stage of her life.

Harold Rubin


(9/7/04)-The Governmental Accountability Office, an investigative arm of Congress formerly known as the General Accounting Office, upon the request of Senator Charles E. Grassley (Rep.-Io.) and Senator Bill Frist (Rep.-Tenn.) announced the results of its study of nursing homes adherence to federal fire safety standards. The results of this study are very scary to anyone concerned with the risks our loved ones have who live in a nursing home.

The request for the study resulted mainly because of the deaths of 16 people from fire in a nursing home in Hartford, Ct. in February 2003, and 15 people who died seven months later in a fire in a nursing home in Nashville Tenn. "The substantial loss of life in the Hartford and Nashville fires could have been reduced or eliminated by the presence of properly functioning automatic sprinkler systems," was just one of the conclusions that the report detailed.

The federal officials examined fire safety at only 40 of the 871 nursing homes they inspected last year, even though federal law requires that all nursing home be inspected for their fire safety procedures. "No federal assessments of fire safety were conducted in 27 states" was one of the other conclusions of the report.

Many homes have refused to install fire alarms, smoke detectors and sprinkler systems because of the high costs involved in installing such systems. Federal employees visit about 5% of the nations 17,000 nursing homes each year in order to validate the findings of the state inspectors. Medicaid and Medicare spent about $64 billion last year on nursing homes. It is estimated that about 2/3rds of the nations 1.6 million nursing home residents are on Medicaid.

The report found that about 20% to 30% of the nursing homes do not have a sprinkler system even though this is considered a must for the safety of the residents. Representative John B. Larsen (Dem.-Ct.) has drafted a bill that would require every nursing home that receives any payments from either Medicaid or Medicare to be equipped with sprinklers. Under his proposal the federal government would reimburse the nursing homes for the costs of the installation of sprinkler systems installed since September 2003.

Under present law many older nursing homes are not required to have sprinkler systems. Many of these same older nursing homes are not required to have smoke detector systems in the resident's rooms. Under new rules that the CMS is writing, all rooms will be required to have smoke detectors.

Senator Grassley asserted that the study showed that the inspection process "is broken." He went on to say that "in all likelihood, (the system) has been seriously corrupted." Sen. Grassley also stated that state inspectors had told his staff that they often felt political pressure from superiors to minimize or cover up violations.

Safety and security are in the forefront of issues that concern individuals when thinking about nursing home placement. (See our article on "Selecting a Nursing Home"). There are standing committees in Congress that address these issues. We also have a department within the Health and Human Service that is responsible for safety in nursing homes. In the last week, two investigational divisions of congress have issued reports and recommendations in the area of safety and security in nursing homes and reporting abuses.

Information on selecting a nursing home:

The House Committee on Governmental Reform special investigation division has issued a report on the federal web site that had been created to provide consumer information on nursing homes. This is the site that the Health and Human Services (HHS), through its Centers for Medicare and Medicaid Services (CMS-the new name of the HCFA), provides to help consumers choose a nursing home, by listing violations in nursing homes of federal health standards that inspectors find at nursing homes.

The congressional investigators found 25,000 violations that did not appear on the web site. The Wall Street Journal reports that "[D] uring the 15-month period that investigators examined nearly three out of every five ‘immediate jeopardy’ violations cited by state inspectors-those that caused or had the potential to cause death or serious injury to nursing home residents-weren’t disclosed on the web site. A total of 871 nursing homes were cited for ‘immediate jeopardy’ violations during that time, but the Web site didn’t show the violations found at 471 of them."

The study further asks that the screening process for workers in the homes be improved to weed out potential abusers before they are hired by the homes. There is presently no federal law requiring background checks on employees of nursing homes. CMS administrator Tom Scully sent a letter along with the study, stating that the agency would do all in its power to correct some of the abuses uncovered by the study.

The CMS administer, Tom Scully, stated that there was something to the investigation, but that the CMS has to ensure that the complaints were substantiated and that this takes time. They would try to implement procedures to make reporting more timely

Security in a nursing home:

On the heels of the above report comes a report from the General Accounting Office, requested by Sen. Charles Grassley (R., Iowa), the former head of the Senate Special Committee on Aging. This report, using a sample of nursing homes in Georgia, Illinois and Pennsylvania, indicated that about half of the alleged abuses to residents’ reports were submitted at least two days after the facilities learned of the incidents.

This made it harder for the investigators to find evidence of the incident, thus hindering the investigation of the incident. The GAO suggested that the CMS, in its role of overseer of nursing homes, make sure that there is immediate notification of police of any physical and sexual-abuse allegations. It also indicated that there should be a federal requirement that nursing home run background checks on workers, similar to the procedure now being carried out on airport security workers. How this would effect staffing of nursing homes is unknown. Many nursing homes are understaffed.

The nursing-home industry association indicated that it agreed with the GAO recommendation for curbing abuse in nursing homes. Also, Tom Scully, the CMS Administrator, said his agency would cooperate.

The study was the subject of a Senate hearing before the Committee on Aging, chaired by Sen. John Breaux (Dem.-La.) on Monday March 4, 2002. Many of the witnesses testified to the acts of abuse done to their beloved relatives in various nursing homes in the country. Again this hearing pointed out many of the abusive practices occurring in nursing homes. We would like to point out to you that many more of the homes are safe and not subject as a matter of course to the abuses alluded to in the hearing. This only reinforces your need to become familiar with the home before you place your relative in a home

Sen. John Breaux (D., La.), further stated that he would like to adopt a plan like the one in Arkansas requiring every nursing home death be reported to a local coroner. He would also like to appropriate monies for education of police about nursing-home abuse and developing a national registry of nursing-home workers.

The estimate of the cost of this type of program is $450 million over 10 years. This seems a small cost if it adds a level of safety to17, 000 nursing home programs, which house 1.5 million elderly and disabled residents. Sen. Breaux also stated that he would recommend the creation of a national registry of nursing -home workers, including their criminal records, which would cost $450 million over 10 years.


The future:

The investigative reports are in. Now it is up to our elected officials to provide the statutory laws that would enhance the safety of nursing home residents. Our hope is that they do not wait until the "barn door" is open any wider, allowing for greater potential for abuse. This is what most people fear when they opt for nursing home placement for themselves or loved ones. The industry policing itself is of some help, but still it doesn’t eliminate the need for an arms length overseer providing the oversight needed for protection of residents in nursing homes. No system is fool proof, but a system full of gaps is potentially dangerous. As our population ages, this could become a big issue.

We would like to add some further information to the article entitled " Selecting a Nursing Home". Important information includes the training background of the people who work in the facility. This would encompass staff experience and training. Check the other residents functional abilities as well as their capacity to participate in activities within and outside the facility. Also there is a need to know to what extent problem behavior is tolerated. To what extent can residents individualize their routines and influence facilities practices? Giving up independence does not necessarily mean relinquishing one’s individuality.

There is no question that these factors could be valuable components in determining "fit" of an individual to a residence. However, there is also a wide range in the level of functioning of residents in a nursing home. Is it possible to find a compatible group in these new surroundings? In most nursing homes the newcomers will be assigned a double resident room.

The idiosyncrasies of one’s roommate will be an unknown factor for a while. Getting information beyond level of training and years of experience of staff is a challenging concept but can be done in meetings with staff social workers or human resource personnel. The resident needs to be made part of the selection process, if at all possible. This empowerment could make for optimum adjustment to the new home.

Keep in mind that because of the nature of a nursing home, there is always movement within the resident population. We need to support the concept of individual differences and even though this may account for some of the difficulty residents have in conforming to the imposed routine of a nursing home. Nursing homes need to put effort in providing the least restrictive environment while encouraging individual expression and adaptation to a new community. Environmental stimulation is a key factor in the frail elderly well being.

Remember that it is always possible to change roommates, or even the floor if the resident is dissatisfied with the situation. Change is also possible if the resident is dissatisfied with his/her tablemate.

Please also see our article " Revisiting How to Select a Nursing Home".


Allan and Harold Rubin
updated September 10, 2011

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