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Private Nursing Care Centers May Be Cutting Too Deep

Category: Eldercare

November 16 update (original post -September 27, 2007) — Today the Times reported that congressional hearings are looking into charges that nursing homes. It reported that “Members of the House Ways and Means Health Subcommittee and the Senate Special Committee on Aging proposed measures to require nursing homes to disclose ownership and to require regulators to release information about poorly managed homes.”

September 27 — The New York Times reported this week that investor-owned nursing homes tend to have fewer staff and experience more serious deficiencies and other problems than the national average. The article examined more than 1,200 nursing homes purchased in recent years by large investment groups. The acquired homes scored worse on 12 of 14 indicators used by regulators to assess the well-being of long-term residents.

One of the phenomenons reported is that private homes are more likely to reduce staff headcount, particularly of their nursing professionals. Investor-owned facilities have an average of 20 residents per clinical registered nurse, compared to 13 for the national average.

The active adults who tend to be visitors might not be in the market for a nursing or continuing care facility for themselves – yet. But they well might be shopping for one for a parent or relative. If you are looking, keep these considerations in mind:
– Ask for the current ratio of residents to clinical registered nurses (the national average is 13)
– Ask to see records of serious health deficiencies found by nursing home inspectors. Compare those to national averages at the Department of Health and Human Services.
– Find out who owns the facility. If the ownership scheme is tangled web, be cautious. The Times reports that some investors have retreated to very complex ownership schemes to protect themselves against patient lawsuits.
– Use Medicare’s “Nursing Home Compare” Tool. The primary purpose of this tool is to provide detailed information about the past performance of every Medicare and Medicaid certified nursing home in the country.
– Use
Medline Plus to help find a good facility near you.
– Visit the facility and ask for references. There is no substitute for your instincts and observations.

For further study: How to Persuade Your Elderly Relative It Might Be Time to Move

Posted by Boomer1 on September 27th, 2007


  1. Through an employer that I worked for quite a few years ago I bought Long Term Care Insurance. I still pay premiums though that employer even though I no longer work there. Recently I began thinking about what it actually covered if Hub or I went into a nursing home. The frightening thing is that the nursing home my Mom was in two years ago cost $12,000 a month! We live in CT and not in a upscale area like Greenwich. This facility was really nice and won some kind of awards but I never shopped around but I did find out that the others in the area are similar prices! Let me tell you, in no time you will run out of money at that rate. Fortunately while Mom was in there for 45 days she was covered by Medicare but they were ready to boot her out due to the fact that her rehab was not improving her condition. Medicare was very on top of it and the nursing home had to report her condition on a regular basis. They told me Medicare was going to stop paying for her care. I was going nuts trying to figure out what to do. I thought of renting a condo and hiring a nurse round the clock but when I calculated the cost of that it was more than the nursing home. I checked into a few more things but she needed so much care that the nursing home was really the only answer. It made me sick to my stomach to think all of her hard earned money would go to the nursing home for her care. Mom passed away before any decisions were made on what to do. If she stayed, once her money ran out, she would have been eligible for Medicaid. So getting back to my policy. It pays a maximum of $210 a day or $6,300 a month. Half of what the nursing home in my area charges! My Aunt is in an equivalent award winning nursing home in Tennessee and it costs around $6,000 a month. So, this could be another reason to move to a southern state. My policy would cover the entire monthly cost. I called my insurance company and questioned them if this policy was only for Connecticut or is it good in any State and they said “any State”. Nursing home costs are the scariest expense of all. Do any of you have any experience with Long Term Care policies? Mine also has a maximum of $420K lifetime which at $6,300 a month is about 5 1/2 years. UGH, I don’t even what to think about this stuff…Originally when the hospital suggested my Mother go to rehab they said she could stay up to 100 days. What they didn’t tell me is that if you no longer show improvement with rehab, they kick you out or you pay through the nose to stay.

    by Louise — June 23, 2015

  2. Louise – We went through the nursing home issue with my mother-in-law. She was living with us in NJ but was admitted to the hospital and they recommended she be moved to a nursing home. Because she was transferred from the hospital Medicare picked up a the first 30 days and then she moved to private pay (about $8,000/mo). One of the requirements was she needed to have enough funds to cover her for the first two years and they would then move her to Medicade or the home would not accept her. They would not kick her out once the funds ran out. One of the problems we had was we tried to get her into a few nursing homes but they were full and we had her admitted to one based on the hospital recommendations. Nursing home treatment are usually fine during the day because there is a chance the family would show up. At night was a different story. She was scheduled for a shower in the evening but she only received one every five days and when she did the water was cold. She would press the button to get the aide to help her to the bathroom. At times she would be left on the toilet for over 30 minutes before the aide would come back. When my wife would go there and help her the nursing staff would yell at my wife because she would help her go to the bathroom because she wasn’t “qualified”. At one point the aide came into the room and told my mother-in-law to mess in her pants and she would come back later and clean her up. All this was from a nursing home that had reasonable good ratings. When my mother was in a nursing home I walked in and saw an aide throw my mother into bed. I was outraged and we never saw that aide in my mother’s room again. As you know nursing homes are not cheap but other alternatives are more expensive. I am also curious if the monthly price is lower in the southern states because my wife and I will be retireing either to the Carolinas or Florida in 2 1/2 years.

    by Mike M — June 24, 2015

  3. Mike, I have another Aunt who is in a nursing home in Kentucky. I looked it up on line and it looks very nice and modern. My Cousin told me they are applying for Medicaid because the price is $6,000 a month there too. So it looks as if some of the Southern States offer good care in nice facilities in the $6,000 range. My Mother also suffered indignities at this $12,000 a month nursing home too. Believe me, a nursing home is the last place on earth you will ever want to spend your last days. I had never been in a nursing home before and it was horrifying! So many patients who had dementia were in one wing and just spent the days with glazed looks. There was an Alzheimer’s wing that I never saw because it was under lock and key and you had to have a pass code to get in. Mom was in the ‘rehab’ wing and people either went home or died after a period of time. I went there every day for 45 days and hope I never see the inside of a nursing home again! Even at $12,000 a month, they were short staffed and only had a few RN’s per shift in the rehab area. CNA’s come and go and I see this particular nursing home is constantly having hiring events for CNA’s. Wish there were better options for those who are not rich.

    by Louise — June 24, 2015

  4. Here is a State by State comparison of prices for nursing homes.

    by Louise — June 24, 2015

  5. You might be shocked to see that quality of nursing homes in your area too. Put your city, state and zip code in (link below) and see for yourself how some of the nursing homes in your home town rate. Not many have 5 stars and some are lucky to have one star in certain categories! That is horrifying to think some have such poor quality of care and I even see that some are so bad that they are teeter tottering towards suspension from Medicare and Medicaid! If they have such bad ratings, can you imagine how they treat patients?

    by Louise — June 24, 2015

  6. Louise, There are better options than nursing homes for those of all income level. It’s round-the-clock, in-home care; which has been found to be less expensive (than a nursing home), and provide a better quality-of-life for the patient and family. The problem is the insurance companies and medical industry haven’t caught up with the times yet.

    by ella — June 25, 2015

  7. Thanks for the website on nursing homes and home health care, Louise. It is definitely useful; however i will say again (sorry all, i don’t mean to sound like a broken record) that it’s significantly more meaningful to check the county you’re thinking of moving to rather than an average of the entire state. I won’t go into the details, i’ve done that too many times before and don’t want to bore you all.

    by ella — June 25, 2015

  8. Yes, at home care would be best however to pay $20 an hour or more for a trained caregiver would be $480 a day (24 hours) and times 30 days would be $14,400 per month. If you were only paying $10 an hour you’d still be paying $7,200 a month. There are no easy answers when someone requires lots of care by trained people.

    by Louise — June 25, 2015

  9. Louise, thanks for the websites…the one with nursing home comparison was especially interesting.

    When my mom became became ill and was finally diagnosed with pancreatic cancer, she was put into hospice. I got down to FL and needed to find a place for her quickly. I looked at the homes in Coconut Creek FL and saw many that I looked at. I felt that the evalsation were relatively accurate. But one that seemed out of wack was John Knox Village. They are a Continuing Care facility, but a non-resident could use the nursing home if there was enough space, The only place they had room was the Alzheimer wing. That could be understandable from serving there residents first, but not appropriate for my mom (shaper mind and memory at 94 than I ever had. But I had to wait quite awhile to speak to the approprate person and observed the main area. I found it subpar in staffing (number and friendliness and general cleanliness and generally not a pleasant place. I know that plans to build or expand were underway and perhaps that is the reason for the good ranking.

    When I got back home I looked for places to move her by me. I found the rating about right and sadly not very high. But she was NOT going to leave Florida so we ended up with home care. It was ok, but not ideal.

    by elaine — June 25, 2015

  10. Sadly, I went through the gambit of care options with my spouse. I paid for adult day care (about $80/day-Easter Seals), and a caregiver at home (about $100/day), before he needed nursing home care. Placement was fairly urgent. I had gone through the process of having him determined to be nursing home ready, which was done through our State agency for the elderly. The agency’s social worker basically confirmed he could not be alone and would not take medications without assistance — that step was easy, but it facilitated placement.

    I had gotten on a few waiting lists, but some of the nicer places told me that their waiting lists could be a year or more. Meanwhile, my spouse’s health and behavior were deteriorating and the situation was becoming critical.
    My elder care attorney had made recommendations on what to do if I needed placement quickly. I spoke with our family doctor, who put my spouse in the hospital for “tests.” (Warning me that the hospitals are wise to this, and will push for the patient to be released quickly). Once he was in the hospital, the hospital social worker worked to find open beds in suitable facilities. The cost was between $8-$10K a month (Western PA).

    I told her which facilities we were on waiting lists for, and she started with those. The facilities are required to give a priority to patients being released from a hospital. It took 3 days. The nursing home made me jump through hoops, and said I was competing for an open bed with two other families. They wanted me to fax financial information before they would accept him. Unfortunately, he was at the point where he was confrontational and would not sleep (he would doze on his feet, but he wouldn’t get into a bed). The hospital records that were faxed to the nursing homes therefore showed behavioral problems. Some facilities wouldn’t accept patients with behavior issues. The facility wanted to see that we could self-pay at the full rate (not in writing, but that’s what I had been warned would happen) before applying for Medicare. Once the application for Medicare was made, they couldn’t dun me or bill me for payment. His Social Security was paid to the facility, except for a $40/$45 personal allowance. The waiting list for Medicare patients without self-pay were a LOT longer.

    The facility was great with a few issues. For example, the admissions person slipped a paper in the pile of admissions paperwork that made me personally responsible for payment. My lawyer had warned me to watch out for this, and not to sign it. The admissions officer also told me to call them when my assets dropped to $10,000 or so, and they would then help me apply for Medicare. In fact, the lawyer had told me that in my state I was permitted to retain a spousal allowance that was 10X+ that amount from our joint assets (not counting our home, my 401K and a car) so the admissions officer was disingenuous. I’ll give her the benefit of the doubt and say that she simply didn’t know the law. The lawyer had also told me that I could use assets to pay off debt such as the mortgage the day after admission to reduce assets and qualify for Medicaid immediately.

    There were a few other bumps in the road, such as when he was sent out to a local psychiatric hospital by the nursing home for a behavioral evaluation without telling me. The nursing home was required to save his bed for a few days but didn’t have to accept him back if they weren’t satisfied with the psych hospital’s assessment, which is a tricky way of getting rid of Medicare patients. The psychiatrist wanted to keep him for a month to evaluate his meds, but changed his mind when I told him that only 3 days were covered by my health insurance.

    There was a hearing on whether he could be sent back to the nursing home. Fortunately, the nursing home sent a
    nurse to the hearing who was wonderful, and he was returned to the nursing home. He was there for 4 years before he died.

    There were patients on the same floor, receiving the exact same care as my spouse, who had long term care insurance. After social security payments are applied against the bill, the balance is either self-paid, paid by Medicare, or paid by long-term care insurance. There’s no difference at all. True, some facilities don’t accept any Medicaid patients so long-term insurance is good if you want one of those facilities. And sometimes people are trying to preserve assets for an estate, and want to try to lower self-pay amounts as long as possible. Based on my experience, I’d recommend buying a life insurance policy to replenish an estate instead. My spouse had a small term insurance policy, with no cash value. (Cash value would have counted for Medicaid qualification). The life insurance was not part of his estate, so it wasn’t counted for Medicaid qualification. Of course, by the time someone needs facility care, it’s too late to buy insurance so this won’t work for everyone.

    Hope this story is helpful. Home care wasn’t an option for us by the time we were looking for skilled nursing home care.

    by Kate — June 26, 2015

  11. Kate, Sorry you went through so much when your husband was sick and needed nursing home care. You must have been totally drained to live through 4 years of seeing a loved one so sick and needing nursing home care. Yes, I agree that the hospitals do everything they can to push the patients out the door before they have been there 3 days and 3 nights. It is despicable, but Medicare rules the roost. I too went down the rabbit hole of Medicare rules and it is a very ugly place. I learned a lot of what you can do to spend down the money and it is wise to do so. Things that are legit are new roofs, paying off mortgages, home improvements like new kitchen cabinets, windows, flooring though out the house, siding, painting, and probably other things like new furniture, landscaping and even a new car if it is to help transport the patient. Probably even an addition to the home. Also, prepaying for funeral costs and headstone. Check with an attorney! When my Mom was in the nursing home I was losing my mind and couldn’t even think to do any of those things. Kate, can you expand on what is small term insurance policy with no value? I always thought with life insurance you got a lump sum payment when the insured died.

    by Louise — June 26, 2015

  12. My reference to “small term insurance policy” meant a small (low value) term insurance policy. With term life insurance, the policy doesn’t have any cash value if you cancel it. A “whole life” policy covers you until death whenever death occurs. “Whole life” policies typically have a cash value if you cancel the policy. When qualifying for Medicaid, the cash value of a whole life policy was required to be identified as an asset. I can’t tell you if they could claim the proceeds of a whole life policy after death, since that situation didn’t apply to us.

    My spouse only had a term life policy. His term life policy had no value when listing assets for Medicaid eligibility. The proceeds after the policy were paid after death, and didn’t go through his estate for purposes of Medicaid recovery. This is definitely an area where an elder lawyer is needed for expert advice. Our family would definitely have been in trouble if we relied on the nursing home’s so-called “expert.” And the rules can change from state to state! The $2,500 or so that I spent on legal fees were an absolute bargain considering how much she saved us.

    by Kate — June 26, 2015

  13. Also wanted to add that my original posting is a little confusing because I meant Medicaid instead of Medicare when talking about nursing home admissions. The nursing home wanted to admit someone whose family was going to self-pay for as long as possible, because Medicaid reimbursement is lower. The nursing home admissions person absolutely misrepresented the Medicaid eligibility rules in our state to me, either intentionally or because she didn’t know the law. I’m very glad I had consulted a lawyer and knew she wasn’t telling me the truth! Also — my lawyer had warned that not to spend down assets until after the nursing home admission, since getting my spouse into a good facility would have been a lot harder if we couldn’t hold out the carrot of self-payment. There are a lot of tricks & specialized rules for people dealing with these issues, and they vary from state to state. You definitely need an expert’s help.

    by Kate — June 26, 2015

  14. Kate, Thank you so much for adding more facts and it certainly is very valuable information. I never considered the carrot on the stick but can see how it would apply to entice them with self pay. How is it that the term insurance proceeds do not go into his estate for Medicaid purposes? You have definitely opened my eyes on the value of an attorney versed in elder care laws and rules.
    We all have to remember that most (not all) nursing homes are FOR PROFIT and are ruthless in getting all the money they can squeeze out of you and Medicare/Medicaid. Amazing advise your attorney gave you not to spend down until you were able to get your husband into a nursing facility! Priceless!
    You are kind in giving the person the benefit of the doubt on her supposed ignorance. I highly doubt that was the case and they were hoping you didn’t understand. They deal with tons of patients on a daily basis and know all the loop holes.
    This reminds me of a true story I was told about a car repair place in NY. The boss was training the service manager and asked him “if an old lady comes in and has a car repair that needs to be done and she tells you all she has is her Social Security check to live on for the rest of the month, what do you do?” The service manager was puzzled. The Boss says “you get all her money”. Basically no mercy. Ruthless.

    by Louise — June 26, 2015

  15. The beneficiary of the term insurance policy was not his estate. The policy itself had zero value until after he died, so it wasn’t an asset. I continued to pay the annual premiums on it, and after he passed the proceeds were paid out to the beneficiary. The proceeds never became an asset of his estate.

    Another story — one of my nieces got a job in an Assisted Living Facility when she was in college two years’ ago. Those facilities are not Medicaid eligible, but may be covered by long term care insurance. Many families think they are ideal because the cost is lower than skilled nursing care. Something to keep in mind is that one of the reasons that the cost is lower is that the residents get less care, and staffing is less than skilled nursing. Presumably the residents are able to take care of certain needs themselves. My niece reported that many of the residents were clearly in need of skilled nursing, such as not being able to get out of chairs or beds, needing to be fed, and being unable to dress themselves. There simply wasn’t enough staff for that level of services for the number of residents, but families refused to accept that their family member needed more help to try to keep the cost of their care low. The facility didn’t push patients out either, to keep their occupancy as high as possible. As a prospective RN, my niece was appalled at how no one seemed to care. And this was one a newer, “luxury” Assisted Living facility.

    So if we aren’t worried enough about nursing homes, we can also worry about Assisted Living….I guess I have to be extra-nice to my kids and grandkids. I’m going to need them. 🙂

    by Kate — June 26, 2015

  16. Kate, thanks…very valuable information. I appreciate the clarifaction on Medicare / Medcaid in you first post. I was wondering about that.

    A nursing home can have various payers, but they can certify a wing or other percentage for Medicare and for Medcaid. Not normally a concern. But if they ony have a few beds left in Medicaid (or Medicare), you might have to find a new home.

    by Elaine — June 27, 2015

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