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Nearly every state’s legislature will begin their 2013 session this month. So January is the appropriate month to offer my five point agenda for nursing home reform. My hope is that state nursing home reform groups and individuals concerned with nursing home problems will lobby their legislators about these matters. My belief is that these five points can, at a reasonable cost to taxpayers and to nursing homes, help improve the quality of the care provided to residents.

Suggestion #1: Have each state mandate an INCREASE in the percentage of inspections (more frequently known as “surveys’) that MUST take place outside of regular business hours on weekdays. This standard should apply to both annual inspections (inspections the state conducts approximately once each year at all licensed nursing homes) as well as to surprise inspections (these are inspections that take place in response to complaints the state receives about a particular nursing home.

In many states at least 10% of nursing home inspections must begin at night or on the weekend. That means that 90% of inspections are likely done during 23% of time that accounts for regular weekday business hours. I believe that if state law would mandate a minimum of 25% – 33% of inspections begin on weekends and during hours when administrators are not normally at work the inspectors would get a more accurate view of the low quality of care that goes on in nursing homes on weekends, 2nd and 3rd shift and on holidays — the times when administrators are rarely on the job. As a family member of a nursing home resident, it was “after hours” that my mother experienced the worst neglect by her caregivers. These are the hours when the staffing levels are usually at their lowest and when management isn’t present to see for themselves what’s going on.

Inspections that take place during weekday first shift hours get a skewed picture of the care being offered. When nursing home owners and management get the message that the state CAN and WILL be showing up UNexpectedly more often, then I believe we’ll see improved staffing levels on second and third shift and on weekends and holidays.

Suggestion #2: Require management personnel to work staggered shits ALL THE TIME, not just when state inspectors are in their building. In large facilities that have an Assistant Administrator (or equivalent position), the state should mandate that the Administrator and their assistant must not be allowed to work identical shifts. In fact, I believe the state should require that the shifts for management can not overlap more than four hours per day (Example: Administrator works 8:00am – 4:30pm, while the Assistant Administrator is scheduled to work 12:30pm – 9:00pm).

The majority of nursing homes are too small to be able to afford an Assistant Administrator. Yet even these facilities MUST have a full-time Director of Nursing on staff. In these nursing homes the same “staggered shifts” rule should be in place for the Administrator and Director of Nursing.

Why suggest this legislative mandate? For much of the same reason that I made my first suggestion: after management is out of the building the quality of care given often suffers. As the cliche goes, “When the cat is away, the mouse will play!” And “play” they often do (e.g., taking excessive smoke breaks, ignoring call lights, talking on their personal cell phone instead of checking on or responding to their residents). One third shift nursing staff member at an Indiana facility where my mother lived admitted to me that she “preferred” to work overnight so “the big shots” couldn’t get in her way of doing her job the way she wanted to do it. Scary! One of CNAs who worked with this individual on third shift shared with me that this nurse took an average of seven (7) smoke breaks, OFF THE UNIT, per hour! This clearly wouldn’t be allowed by either the state or sane nursing home management — but how could the state or management know this was problem existed if they aren’t in the building at night? Residents with dementia likely aren’t capable of reporting such problems. Family members can’t stay with their loved one 24’7 non-stop to monitor this. Placement of a “Granny Cam” inside the room is incapable of documenting problems that take place outside of the resident’s rooms (as in documenting a lack of staffing at the nurse’s station caused by staff taking an excessive number of smoke breaks).

If it is impossible to have management in the building 24/7, then the state should mandate their presence a minimum of 12 hours per day on non-holiday weekdays and 4 hours (or more) per day on holidays and weekends.

Suggestion #3: When the state shows up for an any type of inspection (annual or in response to a complaint) the inspectors (a/k/a “surveyors”) should IMMEDIATELY seize payroll data to (before it can be altered) to verify staffing levels for the 14 continuous days immediately prior to the inspection. With this information in hand, inspectors should have the legal authority to insist that while they are in the building that the staffing level can NOT exceed the average staffing level for the previous 14 days.

Why would I suggest this issue requires a legislative intervention? Because calling in off-duty nursing staff during an inspection or even bring in temporary employees is one of the biggest (and most deceptive) things nursing home management does to make it appear that resident needs are being taken care of in a timely and appropriate manner — when the reality is that they aren’t being responded to in either a timely and/or appropriate manner when the state inspectors are not around. “Putting on a show” for state inspectors should be against the law! Inspectors should see and judge the quality of care based on the REALITY of ACTUAL staffing levels.

Suggestion #4: Pass legislation that prohibits nursing homes from either outright banning or limiting visits of residents by their family and friends. Once  nursing home staff identify a resident’s family member(s) or friend(s) as a “trouble maker” (e.g., that we really have the courage to report their facility to the state, as is our LEGAL RIGHT AND MORAL RESPONSIBILITY TO DO) then you can count on the facility to begin setting traps (coming up with schemes) to make it look like we are the bad guy), thus justifying prohibiting (or at least limiting) visits. Some facilities have even limited visits from family and friends from taking place on the unit where the resident resides — allowing, for instance, visits to only take place in the lobby. This way family and friends can’t observe the substandard care the resident is receiving, thus preventing them from being able to observe (and thus report to the state) problems with care.

Attempts to prevent family and friends from visiting nursing home residents (when no harm is being caused to the resident as the result of the visit and when the resident wants to receive visits from such individuals) is clearly a violation of nursing home resident’s civil rights! We activists must get through to these corrupt nursing home owners and managers that their facility is the HOME of the resident and therefore the SAME rights of visitation residents had at their house, apartment on condo apply inside the nursing home facility! Strongly worded legislation is clearly the only hope we have to prevent nursing homes from taking their residents hostage!

Suggestion #5: We need legislation that will mandate increased fines against nursing homes that are found guilty of abusing resident’s rights, especially with regard to forcing residents to move to another facility. Many nursing home residents find themselves being forced out of their facility as retaliation against the resident or their family for sticking up for their rights. This type of abuse of resident’s rights must stop! It is truly a twisted, dysfunctional way of thinking when a nursing home’s only way of handling it’s problems is to punish their residents (or the resident’s family) by forcing the resident to leave their facility. How many residents must suffer “eviction” before a facility is finally forced to look inside itself and make the changes needed to resolve their real problems?

How can you help to make these five changes happen within the state where you reside? Contacting your state legislators would be a good start. Also request the support of your local or state Long-Term Care Ombudsman to help promote this reform agenda. If your area or state doesn’t have a nursing home reform organization then start one! I’ll be glad to help you start and promote such an organization.

I believe that together we CAN make meaningful, important and positive changes take place within the nursing home industry. While the industry clearly has the big bucks to spend on maintaining the status quo, we have more than enough individuals on our side to make change HAPPEN!


Earlier this afternoon I received a very important reminder from an individual who inspects (a/k/a surveys) nursing homes. Each state has a “survey agency”  that is in charge of inspecting nursing homes. The name of the agency is different in each state (in Kentucky this agency works through the Office of Inspector General, while in Indiana and many other states this agency is part of the state Board of Health). Whatever they call this agency in your state, these folks need to hear from family members of nursing home residents and nursing home staff regarding unsafe staffing level and any other care concerns.  Your calls to your state agency (and regional Long-Term Care Ombudsman) are essential in order for problems to be identified and corrective action to be taken! The state survey manager who contacted me wrote,

“When you (and this goes for both families of nursing home residents and nursing home staff) have concerns about the care of a resident or unsafe staffing levels, be sure to CALL your state survey agency! Their number is REQUIRED to be posted in all Medicare / Medicaid-certified nursing homes. We surveyors (inspectors) are here to protect the residents of nursing homes and assure they are getting quality care.

We surveyors (inspectors) are on the side of the residents and staff. Although we are constantly lied to by facility staff and Administrators, we can get to the truth.

In addition to contacting your state survey agency, be sure to get the Ombudsmen involved too! They can be a great resource.

The bottom line is that if we (regulators) don’t know about your concerns, we may not be able to pick up on these issues. Complain to your State survey agency to get your issues investigated and also help prevent others from receiving poor care!”

Some nursing homes have signs posted that ask family members to speak to the facilities administrator when they have concerns (I’ve seen one such sign that practically begged family members to NOT call the state survey agency before talking to the administrator). While this is an appropriate action to take in most circumstances, I believe the state survey agency and Ombudsman should be contacted FIRST when resident safety and well-being is at risk. If speaking to the nursing home’s administrator doesn’t resolve your concern, then by all means call the state agency and Ombudsman!

Except for the goofy spam messages I receive, I truly appreciate all of the comments I receive in response to my NursingHomeReality blog. I read every one of them and add many of them to my blog. Of the comments I post to my blog, I’m especially careful to protect the identity when the writer is a family member of a nursing home resident or a nursing home staff member writing about problems in the facility where they work, so as to protect these individuals (and/or their family members) from retaliation.

Occasionally I receive comments from nursing home staff members (administrators, nurses, CNAs and others) that scold me for daring to point out problems involving abusive, negligent and/or dishonest nursing home staff members. They assume that I have used my blog to condemn all staff members. In reality I have NEVER accused ALL nursing home staff members of bad behavior. In fact, I have occasionally pointed out that many nursing home staff members (particularly nurses and CNAs) are great people doing wonderful things for their residents. I even devoted one post to discuss the intense pressure that administrators face, showing that while I’ve often found things to criticize about nursing home management that I nonetheless am sensitive to the pressures management personnel face that discourage them from doing the right (let alone honest) thing in dealing with problems in their facility.

So if you (nursing home staff reading this blog) want to mischaracterize my comments, go ahead. If you aren’t doing so to manipulate me into becoming silent, I respectfully suggest that you take some time and look over the many entries I’ve written over the past few years so as to get a fairer perspective of what NursingHomeReality is all about.

Allow me to point out that the nursing home industry — proving their intensely evil nature — does everything it can to silence it’s critics. A more mature approach would be to have enough integrity to be introspective enough to learn and grow from their critics. But instead, they just want all of us to shut up and go away.

MY RESPONSE TO THE CORRUPT NURSING HOME  INDUSTRY: I WONT SHUT UP. I WONT STOP POSTING TO THIS BLOG ABOUT THE OBVIOUSLY BAD THINGS THAT GO ON IN NURSING HOMES. You can’t make me shut up and I wont shut up. I wont be silenced by the “soft fascism” of your evil attempts to silence your critics. If this blog were to ever shut down, I’d have no problem immediately finding another webhost that would respect and protect my freedom of speech.

What does it tell you about an industry when they feel that they are above criticism? It makes me think they have LOTS to hide.

At least government officials in Texas, Illinois and Iowa haven’t totally sold old to the big bucks of the nursing home industry (like some have in Kentucky and Indiana)!  Kudos go to three states that have recently made progress in terms of advancing the nursing home reform agenda.

The Texas Department of Aging and Disability Services (DADS), that state’s agency charged with oversight of the nursing home industry, recognized the urgent need for more investigators to address a backlog of complaints facilities.

DADS has a record of responding to 99 percent of the most serious complaints about nursing homes within 24 hours. But the agency has only been able to respond to one-third of the less serious complaints within the 14 days required by state guidelines. Still, a DADS spokesman acknowledged to the media recently that even “less serious” complaints included the potentially dangerous issue of inappropriate care of bed sores.

To speed response to nursing home complaints, 35 new investigators (a 10% increase) are being hired this month. The agency also plans to complete 1,550 investigations during a two-week statewide blitz to help catch up on the backlog of complaints until the new inspectors can be hired and trained.

Governor Pat Quinn recently received a final report that contains many recommendations to ensure improved safety of nursing home residents in Illinois. Among the Nursing Home Safety Task Force recommendations:

  • Reform the admissions and assessment of people in need of care to ensure they are referred to the residential setting most appropriate to their individual needs.
  • Raise and enforce higher standards of treatment in all residential settings.
  • Expand residential options and services in home and community-based settings to allow each individual to achieve his or her highest level of independent functioning and ensure that only those people who require 24-hour care are placed in nursing homes.

It’s now up to state legislators to translate report findings into new regulations for nursing homes located in Illinois.  So if you live in Illinois, please contact your state senator and state representative to make sure report findings are followed.

One of the big changes coming to Illinois nursing homes, thanks in part to the study report and pressure from the public and Chicago news media, is that thousands of mentally ill individuals who have been housed alongside elderly nursing home residents will now be given the opportunity to be placed in facilities more appropriate to meeting their unique needs. Tragically it took several incidents of elderly nursing home residents being beaten by mentally ill individuals before this problem (and other concerns) were addressed by the Governor’s study commission.

State nursing home regulators are finally getting serious about imposing stiff fines against Iowa facilities that have been found guilty of retaliating against caregivers who have the courage to report problems.

Two Iowa nursing homes have each been fined $5,000 by the Department of Inspections and Appeals. An assisted living center was also recently fined $1,000. The three facilities were accused of threatening, demoting or firing employees who reported concerns about resident care to the inspections department.

Iowa’s mandatory reporter law, which is designed to protect the state’s 40,000 care facility residents, makes it a crime for caregivers to keep silent about suspected abuse or neglect. Retaliation against whistle-blowers is barred by law, but advocates for seniors have complained that care facilities are rarely if ever penalized for the offense.

If I were living in Iowa I would contact the Department of Inspections and Appeals and demand that they be consistent in enforcing the laws already in place.  Sure, they are to be commended for finally taking appropriate action, but we have to wonder what took them so long?

I can’t speak for foreign countries, but here in the United States every part of every state has someone (sometimes several persons) to help nuring home residents and concerned loved ones to assist when concerns about nursing home care (or lack of care) arrise.  These helpful individuals, known as long-term care ombudsmen, are often times underpaid and overworked.  Some ombudsmen are  unpaid volunteers who are supervised by paid ombudsmen.   Their service is FREE to nursing home residents, family members and concerned friends of residents.

When is it appropriate to contact an ombudsman?  In a non-emergency situation, it is best to contact them after the concerned party has been unable to resolve their concerns with nursing home management.

If you feel you have an urgent or emergency situation involving the safety or welfare of a nursing home resident, then immediately contacting an ombudsman (without trying to resolve matters with the facility) may be entirely appropriate.  However when you have an emergency situation and time is of the essence, the best place to turn for help is the state agency responsible for regulating nursing homes within their jurisdictions (in Indiana the agency is the state Board of Health, within Kentucky it is the Office of the Inspector General — all nursing homes must provide those who ask with contact information for the state agency responsible for regulating them.  Nursing homes must also provide the phone number for the nearest long-term care ombudsman.  Most states require nursing homes post this information in a prominent place, such as near the main entrance of a facility or at/near a nurse’s station.  The bottom line is that if you ask facility staff for contact information for the ombudsman or state nursing home regulatory agency, they MUST provide you with that information, which should include a phone number.

In many states it is also entirely appropriate to contact the local office of Adult Protective Services when you feel the safety, rights or welfare of a nursing home resident is threatened.  Call your local police or sheriff’s department to find the number for the Adult Protective Services office that serves your area.

My experience (and that of many other loved ones of nursing home residents) is that nursing home staff and management will often feel threatened and become overtly hostile when they become aware that an ombudsman, state regulartory agency or an Adult Protective Services office has been contacted about problems at their facility.  Big deal!  If they (e.g., nursing home staff and managment) are doing their job (let alone doing it correctly), then they have NO reason to fear the state’s intervention!  Please don’t allow nursing home staff or management to intimidate you into silence!  You have a legal right and a moral responsibility to request state intervention on behalf of a nursing home resident!

To find contact information for the Long-Term Care Ombudsman in your corner of the United States, please visit the website of the National Citizen’s Coalition for Nursing Home Reform ( On the left side of every major page of their website you’ll find a button with the words “Locate An Ombudsman”. Click on that button to find the information you need. In addition to ombudsmen, you’ll also find listings for each state’s nursing home regulatory agency and other agencies that respond to concerns related to nursing home care.

I need to point out that while ombudsmen are available to investigate concerns and offer advice, they do not have the legal authority to force nursing homes to do anything. Only the state agency entrusted with long-term care facility oversight has such power.  Adult Protective Services employees also have legal authority that ombudsmen do not have. At the same time, ombudsmen will be able to render a responsible opinion regarding when it is appropriate to contact the state, in case you aren’t sure if this the right option to pursue.  Their wisdom and experience is an invaluable tool in protecting your loved one.

I am frequently shocked by accounts I hear about how badly UNDERstaffing that exists in many nursing homes.  I’m a family member, so it is easy for nursing home owners and management to dismiss my concerns (and those of other family members) by claiming our expectations are too high. Management acts as if we family members are too dumb to realize that their facility does have “adequate staffing” — yet we often  witness our loved one (and other residents as well) not having their needs met, because the resident-to-staff ratio is woefully INadequate.

So please don’t take my word about the evil of nursing home UNDERstaffing.  Instead, please take the word of a newly-hired Certified Nurses Aide-In-Training.  Her insider account of the facility where she works should make you angry and to realize that ALL of us have a responsibility to work to bring about ethical and sane staffing standards.

This visitor to our blog wrote the following, her name and location are kept confidential for the purposes of this account…

“I just started working at a nursing home as Certified Nurses Aide “in training” –read: no formal training.

On my own on a recent night I was the only aide working and was responsible for the care of 45 residents. The only other nursing staff member on duty in this unit was the nurse (who couldn’t be bothered about resident’s needs).

I ran all night, couldn’t keep up, just wanted to keep the residents clean and comfortable. So many! 3/4  of the residents are incontinent, 1/2 have motion sensors on them due to fall risk. 1/3 needed some extra compassion, and more every night with signs of infection. I cry every time I walk out. I get yelled at and shunned because I take too long, when all they want is a drink, a clean blanket, and maybe even a hug. I thought that was what anyone needed, but apparently, only if they can get it themselves. I have NO TRAINING and I was ALONE for an eight hour overnight shift. In addition to direct resident care, I also have to wash wheelchairs and chart those bowel movements.

Again, I have NO formal training yet, aside from the training I have given myself through research and hands on care. I followed a couple of aides around for a few days, only one of them was actually certified.

I have spent a total of four days in training for “corporate understanding”, which involves travelling to another town to hear about how great this company is, then going home to work a night shift.

I had two nights of “supervised” work, which meant that depending on who I was supervised by, I was either on my own or frantically looking for someone that knew what to do. However, I have been walking around in the same scrubs that certified aides wear, and when a resident sees me, they think help has arrived. I quickly learned to give up on finding someone else (more experienced) and just help them any way I can.

I spent the night trying to get her to help me with a resident that was screaming and pulling at her catheter, only to find that the nurses “help” was to go into the room and tell the resident, “Shame on you!”

I literally ran up and down the halls, trying to help everyone, trying in earnest to turn everyone every two hours, change everyone when soiled, strip and make beds with people still in them, lift and transfer residents alone on my own and dress them all starting at 3:30am to be gotten out of bed no later than 5:00am.

I tried to inform the nurse about a resident who had recently had a medication change and could no longer transport themselves to bathroom.  The resident was vomiting and had diarrea.  The nurse ordered me to “stop taking so long in there”.

A resident on Hospice needed a bed bath, I gave it, hour later, thought he may have been dying since he was panting and grunting. I went in to check on him and he took my hand and wouldn’t let go.. The nurse’s response, “That’s because you messed with him”.

This is all tip of iceberg. I thought I wanted to be a nurse, I have a good head for medicine, and a big heart. Now I think that that may be why I cannot go into this field. I will fight tooth and nail before admitting my mother to a nursing home. I know there are times it is needed, but people need it so they can get BETTER care, not so they can be institutionalized, ignored and treated like a piece of meat.

These resodemts don’t need much, but what they need is so important!  Why couldn’t management hire two more nurses aids on third shift?  I only get minimum wage for crying out loud!

I want to quit, and yet, who else will do this?”

May God richly bless our friend Bernie Vonderheide, founder of Kentuckians for Nursing Home Reform, for his hard work on behalf of creating positive changes in nursing homes within the Commonwealth of Kentucky! His commitment is truly inspiring and his organization is one that I urge all of my fellow Kentuckians to support.

Bernie shares the following words of encouragement as we start this blog…

Congratulations on starting an important educational blog.

One of the biggest problems in nursing home reform is that most people do not understand the problems unless that have been there and actually seen it.  That is why education is such an important part of our mission.

We encourage everyone to share their experiences with the public through this new blog.

Looking forward to being a daily reader, and congratulations once again.

Thanks Bernie for those thoughtful words!

Allow me to remind you that while Bernie and others of us are very much public figures in the area of nursing home industry reform, we will respect your request for anonymity should you chose to share your story for publication. We will also keep your e-mail address completely confidential.

In addition to publishing your story of nursing home neglect and abuse, this blog also exists to share links to websites of interest to those of us who support reform of the nursing home industry. We will also reprint editorials and other material related to the topic of making positive changes in long-term care facilities. Links can be found under the BlogRoll section on the right side of this page.

Please submit links of interest to and type Link Suggestion in the subject line of your message.

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