Nursing Homes

Nursing homes have been providing care for the elderly and infirm since the tenth century. The earliest recorded evidence of a house formally set up to provide care for the poor elderly is in the late 10th century in England. These houses, also called almshouses or poorhouses, were set up for the poor and run primarily by retired nurses or nuns. The rich could hire someone to take care of an aging relative. The poor were left to fend for themselves and only the lucky ones were taken in by the almshouses. Living conditions in these homes were deplorable with poor level of care. Under those conditions, one could say that the lucky ones died early in war or by disease.

Nursing homes have come a long way since those days of the poorhouses and yet, most of the significant reform and improvements in the care provided in nursing facilities have been made in the last 25 years. It has taken enactment of several legislative bills to get us where we are today, with the Omnibus Budget Reconciliation Act (OBRA) of 1987 being the most extensive enactment of federal regulations to date.

OBRA of 1987 brought about many needed changes in the way nursing facilities provided care to their consumers. The Act brought about sweeping federal legislation designed to significantly improve quality of care and it did, but as with most government intervention, it took years to implement and yet there is still substandard care in some nursing facilities. This is one of the reasons I have started this website; to help you, the consumer, become aware that you do have choices in who and where you or your loved one will be cared for. I also want to show you that there are big differences in the quality of care provided by nursing facilities and how you can discern for yourself, if a particular home is the right choice for you and your loved one.

What is Nursing Home Care

Nursing facilities provide custodial care or long term care to individuals requiring assistance with activities of daily living, such as bathing, toileting, ambulation, transfer from bed to chair or assistance with eating. These facilities have full-time staff around the clock to provide assistance to their residents. 

Full-time care means providing around-the-clock care 24/7. These facilities have been known by several names. You may have heard them called old folks homes or rest homes. Today they are more commonly called Nursing Facilities.

Today, many healthcare organizations have several types of care housed in the same building. They may have a wing that is licensed for assisted living, another wing licensed for custodial care and another licensed for skilled nursing and still another wing that provides rehabilitation such as physical therapy, occupational therapy, and speech therapy.

Many facilities now add the term rehabilitation to the name, e.g. ABC Nursing and Rehabilitation Center. That name does have a more appealing ring to it doesn’t it? However, most of the general public still refers to these facilities as, nursing homes.

When a person (referred to as resident after admission) is admitted to a nursing facility, a medical doctor (M.D.) or doctor of osteopathy (D.O.) must provide a set of orders for the nursing staff to implement in caring for the resident. This is called skilled care because it has to be administered by licensed staff. This is what distinguishes a nursing facility from custodial homes and assisted living facilities. Each facility is licensed by its home state as a nursing facility, assisted living, group home, custodial home, etc.
The doctor’s orders will typically consist of any medications and/or treatments that the nursing and/or therapists are to administer. There will be other orders that the physician may choose to include in the plan of care including diet and any activity restrictions. These orders are to be strictly followed by the facility staff and can be changed only by the resident’s attending physician if the medication or treatment plan is no longer needed or it needs to be altered in some way. If you feel that the treatment plan is not working well, talk to your physician and discuss your concerns with him or her. It is your right to ask questions and voice your concerns about your care or the care of your loved one.


Most of these facilities are for-profit organizations owned by a corporation with multiple facilities and in many cases, across several states. Some facilities are not-for-profit that may be part of a church or synagogue. Then there are some that may be owned and operate by a local family who lives in the community where the facility is located.

Each facility is run by a staff composed of an administrator, a director of nursing, several licensed nurses, certified nurse aides, a social worker, an activities director, a kitchen staff, a housekeeping staff and maintenance personnel. The number of staff and more importantly, the integrity of the staff are what make the difference in the care provided. I will go into what to look for in choosing a nursing home a little bit later.

All nursing facilities must be licensed by their respective state licensing organization in order to provide nursing care and the license must be displayed in the facility where the public can see it. Most are also certified to provide care under Medicare and Medicaid guidelines and reimbursement. This makes a big difference in how you will pay for the care provided to you or your loved one.

Also posted for everyone to see will be the rights of the elderly and the phone number of an ombudsman who is available to intercede for you or your loved one. There should also be a notice of where and how to file complaints against a nursing facility. This will be contact information of a state agency and you can file your complaint anonymously. Having been a nursing home administrator, I always appreciated any complaints that were directed to me so that I could correct the situation. If the administration cannot correct the situation, you should then contact the state agency and lodge the complaint. Your complaint will be documented by the state agency and investigated.

The timing of the investigation will depend on the severity of the complaint. If the complaint is of a nature that can wait until the annual survey of that facility is conducted, the state surveyors may choose to conduct their investigation at that time. If the complaint has life threatening implications, the investigation will be conducted as soon as feasibly possible.

Unfortunately, nursing homes have been in the news because of allegations of elder abuse and/or neglect by the hired help. Any abuse of the elderly should be reported to the facility administrator and must be reported to the proper authorities for investigation including the state's regulatory agency and to law enforcement. If all else fails, you may need to contact a private legal firm. Levin & Perconti have put together a comprehensive guide on everything to know about nursing home abuse, including signs of it, how to prevent it, statistics, and they offer a free consultation. Contacting a legal firm could ultimately save your loved one’s life.

It is perhaps little consolation that most caregivers in these facilities are very caring individuals and sometimes they are the ones to report the abuse by a co-worker. But I know that abuse of one elderly resident is one too many.

Each facility must undergo an annual survey by their state’s surveying agency. Each state has its own and they are each under different state departments so I can’t name each and every one. If the organization participates in Medicare and Medicaid, they are held to higher standards through state and federal guidelines and regulations. Most nursing facilities participate in Medicare and Medicaid for financial survival. But not everyone admitted to a nursing home can benefit from Medicare and Medicaid.

How to Pay for Nursing Home Care

There are two ways in which nursing home placement and care will be funded. This is dependent on the funds that the resident has at his/her disposal at the time of admission and whether the resident is being admitted from home or from a hospital.

Private Funds for Nursing Home Care

A person may be admitted to a nursing home from their own home or from a hospital. Moving to a nursing home can be very difficult for the elderly person and their loved ones, especially is the elderly person does not have the capacity to make their own health care decisions. But there are resources available to the elderly person and their family. Social workers in the hospital are very helpful in arranging the transport to a nursing home. If the elderly person is still at home, there are resources on the internet that you can access. A very helpful resource is the website Senior Wellness.

If the elderly person or their medical power of attorney (MPOA) has not made application for Medicaid assistance or does not qualify for Medicaid, the placement will be made on a private pay basis. That means that the person/MPOA will be paying for care out of personal funds. The monthly charges will vary greatly from state to state and city to city. The national daily average rate for nursing home care in 2011 according to MetLife is $239. That over $87,000 a year. At that rate, it doesn't take long to deplete one's modest savings. But there are ways you can safeguard your savings and an elder care attorney may be able to help you with that. A quick internet search will provide you with attorneys in your area that specialize in elder care and asset protection.

Medicaid Pays for Nursing Home Care

Medicaid pays for custodial care for people who qualify financially and there is no time limit if you qualify. Not all nursing homes are licensed and certified by Medicaid, so in order for Medicaid to pay for your nursing home care, you would need to be a resident of a Medicaid licensed and certified facility.

Medicaid is a federally funded program that is administered by each state. Each state has its own method of administering the program so it is difficult to give you the rules and criteria of your state. If you think you qualify for Medicaid, you should contact your state's Medicaid office for information on whether you qualify and how to apply.

If you feel that you or your loved one needs a higher level of care, you may need to look into skilled nursing facilities.

After reading what I've given you here, you may decide that Nursing Homes are not quite what you were looking for. If not, go to my Home Page for more options for elder care.