25 things nursing homes don’t want you to know

As a physical therapist who has worked with numerous elderly patients transitioning into and living in nursing homes over my 30-year career, I have witnessed some questionable practices and concerning trends within the long-term care industry. While many nursing facilities provide quality care, others seem more focused on profits than patients.

In this post, I plan to shine a light on 20 common secrets nursing homes don’t want consumers to know. My goal is to educate and empower readers so you can make the most informed decision for yourself or your loved one.

25 Things That Nursing Homes Hide

1. Nursing homes have a financial incentive to discharge patients as soon as possible. Under current Medicare reimbursement rules, nursing facilities receive higher payments for short-term rehab patients than for long-term residents. This motivates some shady facilities to prematurely discharge patients before they can fully recover.
2. Facilities may limit the information given at discharge. Some nursing homes provide only a basic discharge summary and withhold more detailed clinical progress notes from the patient. This lack of transparency is likely to avoid scrutiny over the decision to discharge.
3. Most post-discharge services are not arranged by the nursing facility. While federal law requires nursing homes to develop an appropriate discharge plan for each resident, most do the bare minimum by simply handing patients a list of local providers. Very few actually set up and coordinate needed home health, outpatient rehab, or primary care to ensure a smooth transition.
4. Staffing levels are often below state minimum requirements. Most states mandate nursing home minimum staffing levels per patient. However, government surveys show nearly 20% of facilities do not comply on any given day. And staffing ratios are almost always lower on weekends and nights.
5. Nursing assistant (CNA) turnover is extremely high. The national turnover rate for CNAs is over 100% annually. Low pay, a lack of training, and tough working conditions all contribute to poor retention. With such frequent staff churn, nursing home residents rarely benefit from consistent, specialized care.
6. Report cards and star ratings can be misleading. The federal 5-star rating system makes it seem as though top-rated nursing homes have superior staff. In reality, 40% of “5-star facilities” actually provide worse staffing than 1-star nursing homes. Consider ratings as a very crude snapshot.
7. Medication errors are more common than you think. Research shows medication errors happen on average at least once per patient per month in most nursing homes. With complex medical conditions and an average of over 8 medications per resident, overworked nurses struggle to maintain accuracy.
8. Sufficient therapy is not always provided. Despite federal rules requiring nursing homes to provide all necessary rehab services, residents only receive about 30 minutes of physical, occupational, or speech therapy per day on average. For optimal recovery after injury or surgery, most older adults require 60+ minutes per day.
9. Malnutrition is a common, yet overlooked, problem. Up to half of all nursing home residents suffer from malnutrition or unwanted weight loss due to poor appetite, digestive issues, underlying illnesses, and more. Unfortunately, busy staff fail to record accurate meal intake or address the reasons why patients cannot eat.
10. Basic infection prevention rules may be ignored. Nursing home residents with weakened immune systems are extremely vulnerable to infections, which account for 20–40% of all nursing home deaths annually. Yet recent investigations found 73% of facilities failed to follow proper hand hygiene and isolation precautions for contagious outbreaks like the COVID-19 flu or norovirus.
11. Patients may not have full decision-making rights. Nursing homes can designate a resident as incompetent, allowing the facility to make decisions about care, finances, and more against the patient’s wishes. Getting this designation reversed is an uphill legal battle for most residents.
12. Residents risk losing their personal possessions. Theft of hearing aids, dentures, eyeglasses, jewelry, and clothing happens routinely in nursing homes since staff often have unsupervised access to resident rooms and belongings.
13. Privacy rights may be violated. Basic privacy rights like closing one’s door or using bedside curtains are often denied in nursing homes due to staff convenience or safety concerns. Residents report feeling exposed and losing all sense of dignity.
14. Consent is not always obtained for antipsychotic drugs. Federal studies indicate 20–30% of nursing home residents given antipsychotic medications do not have appropriate clinical indications like schizophrenia or bipolar disorder. Instead, these dangerous tranquilizers are illegally used as “chemical restraints” for behavior management.
15. Restraints are frequently misused and overused. Both physical and chemical restraints are only supposed to be employed as a last resort for brief periods of time. Yet violations are rampant in nursing homes, where chronic use of restraints for staff convenience or punishment is common.
16. Family calls may be deliberately ignored. When nursing home staff feel overwhelmed by resident needs or difficult family member requests, some deliberately avoid returning phone calls. This leaves families stressed and uninformed about their loved one’s status.
17. Staff tend not to report minor falls or injuries. Since falls are considered an adverse safety “event” that nursing homes must report and track quality metrics on, some staff fail to disclose minor falls to family members or physicians out of negligence or convenience. Only major injuries get appropriately reported.
18. Language barriers impact care quality. With increasing immigrant populations in long-term care, administrators seek staff who speak the preferred languages of those residents. However, staff fluency claims can be exaggerated or falsified since language proficiency is rarely verified. This results in dangerous miscommunications about resident health status and needs.
19. Photos on websites and brochures misrepresent reality. Nursing homes showcase pristine images of hotel-like exteriors and amenities like spa bathrooms, fine dining, and lavish lounges. What you see inside most facilities is far less glamorous. It’s wise to visit in person.
20. Promises of customized care are usually empty. Marketing materials describe specialized programming like dementia care, dialysis, cardiopulmonary services, and more. But “specialized” turns out to be only rudimentary interventions. Few facilities provide the intensive resources required for high-acuity conditions.
21. Resources spent on appearances divert funds from care. Many nursing homes construct marble lobbies, concierge desks, and posh dining venues to appeal to prospective residents. But the proportion spent on direct patient care staff amounts to less than 60% in these facilities.
22. Rehab gyms rarely live up to the hype. Photos on websites and hallway posters showcase state-of-the-art rehab gyms with the latest therapeutic gear. The reality is usually a tiny shared room with outdated, worn equipment and minimal amenities to adequately meet the rehabilitation needs of dozens of patients trying to regain function.
23. Food budgets are shockingly low. Most nursing homes allot less than $5 per day for three nutritious meals customized to therapeutic diets for every resident. Few facilities can offer quality dining at this rate, with the majority resorting to unhealthy, highly processed bulk items to control costs.
24. Near falls and injuries may go undocumented to limit liability. To avoid risk management scrutiny and litigation, some nursing home staff deliberately do not record minor slips or trips without injury or report events witnessed by others outside formal shift change reports.
25. Deficiencies in state inspections are rarely made public. Results from rigorous annual state health department licensing surveys show health and safety deficiencies are conveniently excluded from nursing home websites and promotional information packets. Facilities do not make it easy to access these damaging reports that are a matter of public record.

The Bottom Line

The sad truth is that many nursing facilities actively work to keep patients, families, and community discharge planners in the dark on issues that matter most. As you scout options for yourself or a loved one, I encourage you to thoroughly vet any nursing home under consideration. Show up unannounced, talk to staff and residents, ask direct questions, investigate state health department surveys, and don’t let glitzy marketing sway your opinion.

Only by being an assertive advocate can you determine if a nursing home truly provides patient-centered ethical care or merely pretends to when it serves them.

I’m happy to offer more plain-language consumer advice on avoiding pitfalls in nursing home care. Please share any insights from your own vetting experiences in the comments!