Aging is a part of life, and for many Americans, the need for specialized health care increases as we get older. Many people choose to live in a skilled nursing facility when they have reached the age at which having additional care is necessary. For many older residents, their medical needs require they live in a skilled nursing facility. Frequently, older Americans are transferred to skilled nursing facilities following illnesses or injuries that make it unsafe to be on their own.
Choosing a nursing home can be a daunting process. With over 700 registered facilities in the state of Pennsylvania all vying for business, finding the one that is “the best” for you or your loved one is difficult. A great deal of information is available about nursing homes and the programs they offer. Many facilities will boast they are “the best” in one area or another, and most have nicely designed pamphlets and brochures with glossy pictures that cast their facility in the most idyllic manner. Nursing homes are intended to provide high levels of care, and most do just that. Sometimes things don’t go quite right, whether it is through accidental negligence or intentional abuse, and you or your loved one need to understand your rights and what to look for if you suspect a problem.
This page is intended to help you find important information about nursing homes before admitting yourself or your beloved family member in Pennsylvania, and provides information about getting help when negligence, abuse or neglect occurs. You will find information about what to look for when seeing a facility for the first time, the types of questions that are important to ask facility members, and links to government websites responsible for regulating and licensing skilled nursing home facilities in Pennsylvania. You will also find information about the types of incidents common at nursing homes and how to ensure your rights are protected.
Section 1: Care Facilities
Nursing homes come in a broad range of types, offering various amenities and services, and it can be difficult to tell one from another. When you are seeking a facility for yourself or a loved one, you don’t want to waste time looking at facilities that do not offer the services and skills you need. Not all facilities will accept Medicare and Medicaid for payment, and less than half are not-for-profit. All care facilities are regulated by state and federal laws that set minimum standards of care.
The National Caregivers Library breaks down the major types of care facilities into five main groups ranging from homes intended for self-sufficient older adults to skilled care facilities operated by, or even within, a hospital. Select the type of facility you are interested in to see where these types of facilities are located in Pennsylvania.
These facilities offer the least in terms of care. Residents of these facilities do not need assistance eating and dressing, handling bodily functions or taking medications. The facilities vary greatly from one to another. Some are single-family dwellings, apartments, condominiums or townhouses. Others are high-rise buildings. Some are mobile home parks, also. The services provided can be minimal and simplistic, intended to reduce or remove the daily upkeep of property and provide a safe place to live. Other facilities offer much, much more, including daily activities, exercise classes designed for older residents, travel and trips and an unimaginably diverse array of possibilities. These facilities will generally offer the lowest level of medical interaction. Some will have nurses or doctors on staff, but it is important to remember that these homes are intended for older residents that need very little or no care.
Assisted living facilities offer additional care over independent living facilities. Generally, these facilities are intended for residents that do not need a lot of care, but are not entirely independent. Typical facilities of this type offer private sleeping areas for residents, such as small apartments, that are equipped with emergency alerts in the event a resident needs immediate medical care. Assisted living facilities will typically provide recreational opportunities for residents, housekeeping services, and many other benefits intended to reduce the burden placed on older residents. These facilities may have medically-trained staff and 24 hour care available.
These facilities are differentiated from assisted living facilities in a few, important ways. Often referred to as board and care homes, these facilities are intended for residents that need more help and assistance and a moderate level of care. Residential care facilities are licensed by the state and have requirements in place requiring minimal on-site staff 24 hours a day. Many of these facilities have shared living spaces, often with small apartments or studios that lack kitchens. Some are dormitory style. Typically, they are designed to accommodate residents with mobility issues and are fully wheelchair accessible.
Offering a mixture of skilled care and independent living, these types of facilities are often the most difficult to get admitted to and have the highest cost. Typically, these types of facilities ensure that skilled nurses and doctors are on site to provide emergency and nonemergency care as needed. These facilities are the best option for individuals and couples seeking a good quality of life with plenty of activities who require medical assistance on a semi-regular to frequent basis and are seeking a long-term housing solution.
Nursing homes are intended for residents who are seriously ill and require regular care. Residents of nursing homes often are unable to care for themselves and require assistance with basic daily tasks such as washing and bathing, using the toilet, and taking medication. Many facilities require a physicians recommendation to be admitted. Levels of care can vary from an intermediate level to 24 hour care for bed ridden patients. Residents of a nursing home will be under the constant supervision of medical staff. These facilities can be long-term, but many are intended as a rehabilitation step for older residents that have experienced a medical setback for which they must have regular care before getting healthy enough to return to independent living or another type of care facility. Nursing homes are the most heavily regulated type of housing for older residents. State and federal laws regulate these facilities carefully to ensure minimum staffing levels, high quality care and safe, healthy facilities.
Most often, when a care facility is in the news for a violation, it is a skilled nursing facility. This is in part a result of the end-of-life care typical of nursing homes and the extensive regulation that ensures these facilities provide high quality health care. Much of the information you will find on this page pertains to nursing homes primarily, but should be considered when examining other types of older adult housing.
Many facilities will offer a hybridized blend of two or more of the types of skilled care housing above. It is important to know as much about the immediate and current needs of the person who will be going into housing to ensure the facility you look into will meet the level of care the resident will require.
Numerous federal, state and local laws require care facilities to treat residents with respect and avoid causing harm. This is often referred to as “owing a duty of care” and applies to both residents and their family members. The following list has been established to inform you of your rights as a resident of a care facility.
- Residents are to be informed of their personal medical conditions.
- Residents need to be informed of any charges or services they undergo.
- Residents need to receive, in writing, the policies, resident rights and procedures of the facility they are in.
- Residents should be free of restraints unless medically ordered.
- Residents can manage their own finances.
- Residents can choose their own doctor and pharmacy.
- Residents records – personal and medical – will remain confidential.
- Residents will participate in their plan of care, and they will have the ability to refuse treatment.
- Residents privacy, respect, and dignity will be maintained.
- Residents can use their own clothing and possessions.
- Residents can voice their concerns without fear of retaliation from the facility.
- Residents will receive immediate visitor access from family members and reasonable access from others.
- Residents will not be discharged or transferred except for the following cases: medical reasons, permanent closing of the facility, the welfare of the resident or other residents, or nonpayment.
If you or a loved one reside in a care facility and believe any of your rights are not respected, you should contact an attorney today to discuss your options. There are narrowly-defined reasons a care facility might violate a residents rights, and if this has happened to you, contacting an attorney could help to prevent neglect and abuse.
Section 2: What to Look For, What to Ask, What to Avoid
Choosing a skilled care facility can be a difficult process. With many options that offer differing benefits, and a large range in costs, it can be difficult to know where to start.
Knowing a few questions to ask and what to issues to look for in advance to touring a facility can help simplify the decision and make the decision a smart one for yourself or your family.
It is of vital importance to understand what level of care you are seeking before looking for a skilled nursing facility. An individual who is able to live independently would not want to seek housing through a skilled nursing facility, nor would a disabled older individual want to move into a facility that expects residents to care for themselves.
Does the person seeking housing have difficulty moving, standing or walking? Are they able to take their medications correctly? Can they do their own laundry and cook meals safely? Can they bathe themselves and keep up on personal hygiene? Are they prone to falls or other types of accidents that might put them in a situation of extreme danger without assistance? Understanding the level of care required can help to eliminate some of the types of housing that are not appropriate for the level of care required.
Paying for skilled nursing care, particularly long-term care, can be expensive. Having a budget is a first step, but costs of nursing homes vary. Some accept Medicare and Medicaid, others do not. Some are not for profit organizations often run by churches, while others are for profit businesses. Medicare provides advice on paying for long-term skilled nursing care on their website.
It is important to remember that care is required to be equal, regardless of whether a resident pays through Medicare, Medicaid or private pay. Discriminating against a resident based on how the facility is paid is a violation of federal and state laws.
When shopping for a nursing home, many people look for facilities near where they live. This can be because residents want to stay near family and friends, because of familiarity with the location, and many other reasons. Click HERE for a map of nursing facilities in the state of Pennsylvania that can be ranked by users reviews and can be zoomed in to specific areas to see the housing available in a specific area.
The choice to admit to a skilled nursing facility should not be made only on the basis of cost or location. Quality of care should be the most important factor when choosing a care facility for you or your loved one. Not all are equal.
Pennsylvania reports that 696 nursing home facilities are registered with the state. ProPublica.org, using data submitted through Pennsylvania’s Medicare and Medicaid programs, has established a list of homes with information about violations reported to the state for each location, including the dollar amount of fines. This information can be useful for identifying facilities that have chronic issues, but it should be understood that in most cases, skilled facilities will correct an issue rather than allow fines to be applied. So, even though a facility has been issued a fine for one or more violations, it should not be viewed as a ‘bad’ facility based solely on that information.
Establish a list of questions to ask when talking to a representative of a skilled care facility when you are considering moving in or when you are concerned about your health and wellbeing as a resident, or concerned about a loved one who lives in a care facility.
One of the most important factors to consider when trying to determine the quality of a facility is the level of staffing employed. Multiple studies and investigations have revealed a direct link between understaffed facilities and increases in abuse, neglect, falls, avoidable illness and infection, shortened life and low quality of life. Multiple state and federal agencies are involved in verifying staffing levels are maintained at care facilities, and homes that do not meet requirements as established by the law are fined.
Some questions to think about asking should include:
- How many staff members per resident are on site each shift?
- How long do staff spend with residents each day?
- How often are new staff hired?
These questions will provide insight into how the nursing facility manages care for residents. Facilities with fewer staff and more residents are likely to provide less care. Nursing homes that experience lots of turnover often struggle to make residents feel comfortable. These questions can lead to discussions about the overall quality of management of a nursing home.
Much of the information administrators should share with you about staffing levels can be verified through the Pennsylvania Department of Health. Nursing facilities are inspected for compliance annually and the results of the inspection are available online. Additionally, when a facility is found to be in violation, they are issued a sanction, also available online through the Pennsylvania Department of Health website.
Staffing levels are one of the most critical factors to take into account when looking at a nursing facility. The majority of injuries and illnesses that impact nursing home residents can be avoided by having sufficient number of properly trained staff on site. Understaffed facilities experience higher rates of abuse and neglect, often unintentional, that lead to mental and physical health issues for residents. Falls and dropped residents are more common, as are accidental overdoses, infections and even financial abuse.
Pennsylvania has strict laws regulating how nursing homes are staffed, and facilities that fail to maintain a minimum staffing level are fined. Facilities are inspected without notice, even at night, and inspections can take several days. A complete list of the Pennsylvania laws regulating nursing homes is available HERE.
In 1987, the federal government passed the Nursing Home Reform Act. Among various regulations, the act created a minimum standard of sufficient staffing that requires at least one Registered Nurse eight hours a day, seven days a week, and a licensed nurse on evening and night shifts. The Affordable Care Act of 2010 created a five star rating system in which staffing levels are a factor, but did not attempt to require staffing level changes. Rather, the ACA focused on establishing standards of reporting to negotiate the complex world of nursing facility ownership, which had made it difficult for regulators to gather data and hold responsible parties accountable.
Some studies based on data submitted by skilled care facilities suggests that as many as 90 percent are understaffed, with the largest issues occurring on weekends. Rural care homes struggle the most, as it is difficult to find people who have the required skills and labor costs can make it impossible for a care facility to remain financially sound. A significant cause of understaffing is the cost associated with hiring and retaining highly-skilled caregivers. Facilities that are chronically understaffed often are the ones faced with frequent violations, sanctions and law suits. Whether intentional or not, understaffing leads to numerous problems for residents and employees, exacerbates an already difficult environment, and has been tied directly to increases in neglect, abuse, fraud and wrongful death.
Section 3: Signs of Abuse
Abuse can occur in a number of ways, and it is important to understand the differences and how abuse can be identified and prevented.
The National Center for Biotechnology Information-National Institutes of Health describes self neglect as situations where an at-risk adult is unable to both make and implement decisions regarding personal needs, health and safety. Self neglect can be a person who refuses to take prescribed medications, bathe themselves, eat and drink appropriately or can’t differentiate between safe and unsafe situations. Nursing homes can be held liable for failing to intervene in self neglect situations, as they owe a duty of care to ensure residents are healthy and safe. Self neglect is among the most common type of abuse, and is likely grossly under reported.
Negligence is a broad term that is used extensively in personal injury law. Typically, negligence is determined on the standard that a reasonable person would have known, or should have known, that a situation was likely to cause injury. In terms of negligence that occurs at nursing homes, negligent actions can include ignoring a residents request for assistance, unintentional errors with medication, failure to move sedentary residents, dropping residents who require assistance standing, sitting or laying down and a broad range of other failures. Negligence is usually unintentional.
In most negligence cases, the staff, treating doctor and the facility can be found negligent. The law recognizes that facility employers owe a duty of care to ensure the staff is properly trained, supervised and that staff who demonstrate negligence are prevented from continuing in their position. Treating physicians that misdiagnose or fail to notice illness and disease are committing an act of negligence and can be held responsible.
Neglect and Abuse
Abuse is the intentional act of harming an individual, whether they realize the harm is occurring or not. Similarly, neglect is the act of ignoring signs of a problem, either intentional or not. Elder abuse and neglect occurs in nursing home facilities frequently and in many ways. The most serious involve use of anti-psychotic drugs and/or physical restraints, acts of violence, intentional misuse of medications, and acts of fraud. Ignoring signs of malnutrition, dehydration, changes in mood or behavior and failing to move residents for extensive periods of time are ways neglect occurs.
The watchdog agency Nursing Home Abuse Justice reports that a study found 24.3 percent of nursing home residents experienced abuse in a nursing home. Both abuse and neglect are more common in nursing homes that are understaffed. Multiple studies have shown that neglect and abuse impact residents negatively, with at least one study finding that residents who are neglected and abused have a 300 percent increase in mortality. Confidential surveys of nursing home staff revealed 50 percent self-admit to having verbally or physically abused a resident. Resident-on-resident abuse is also common, with an estimated 22 percent of residents reporting physical or sexual abuse by another resident.
Skilled care facilities are responsible for preventing abuse, regardless of who the abuser is. All too often, neglect and abuse are not taken seriously enough, leading to worse problems, poor quality of life and untimely death. Pennsylvania law mandates that all employees and administrators of a skilled care facilities are mandated reporters. If you or a loved one has suffered abuse in a nursing home and staff did not report it, you should contact a personal injury attorney.
Elder financial abuse is a common form of abuse, and estimates suggest the problem is vast and underreported. The Pennsylvania Older Adult Protective Services Act (OAPSA), is a set of laws governing the care provided to elderly residents and is administered by the Pennsylvania Department of Aging, which believes that for every report of financial abuse, 23 cases go unreported. Financial abuse happens when a caregiver takes advantage of the diminished capacities or misplaced faith of residents and uses monies for personal gain. This can be a situation such as a caregiver who is provided $50 to buy groceries, spends $40, and pockets the rest. It also can be much more serious. Caregivers have been found guilty of elder financial fraud for pressuring residents to change wills, deeds and other financial documents to benefit caregivers, forging checks and using bank cards of residents for personal gain, and coercing residents to sell property to pay caregivers.
Family members are the most likely to commit elder financial abuse, averaging about 90% of all cases.
Quite often, the signs of abuse can be subtle until there is a serious problem. Some of the key signs are unexplained bruising, scratches and sore muscles, unexpected falls, broken bones, strains and other unexplained injuries. Pressure ulcers, signs of malnutrition and dehydration and a decline in personal hygiene are signs of a problem. Sudden changes in finances should be investigated and reported as soon as possible.
Section 4: The Duty of Care
Nursing homes are required to provide a level of care that provides a balance between independence and healthcare. The facilities and the staff must provide nutrition and hydration, safe housing, and prevent illness, injury and neglect. Known as a duty of care, courts have recognized that facilities and staff have failed their duty of care when avoidable and preventable illnesses and injuries occur.
Questions to ask administrators about care:
- How does your facility prevent pressure ulcers?
- How does your facility prevent falls?
- How does your facility avoid infections?
- How does your facility treat mental illness?
- What steps does the facility take to prevent neglect, abuse and fraud?
One of the most common ailments that impacts residents of nursing facilities who are not very mobile is pressure ulcers, also called bed sores. Bed sores are completely avoidable and are the result of a person sitting or laying in one position for too long. Failure to prevent bed sores often leads to other illnesses, and can lead to death. Bed sores are often a sign of neglect.
Symptoms of bed sores are often overlooked and are commonly under-reported. At the earliest stages of development, the afflicted individual may experience soreness, red skin and bruising, typically at pressure points. These include hips, buttocks and tailbone areas, shoulders, back, ankles and feet, and other extremities. Pressure ulcers can even occur on the head and face when a person is left lying in one position too often and for too long.
Pressure sores can be difficult to avoid with some residents who are immobilized or medically unable to sit or lay in alternating positions. It is imperative that nursing staff pay close attention to residents who are bed ridden or wheelchair bound, as they are the highest at-risk group. A skilled nursing facility should have a plan in place that includes training for staff to prevent bed sores.
In the later stages, bed sores can cause broken skin, boils and ulcers. Infections are common and can lead to sepsis, organ failure and death. Poor nutrition and dehydration impact bed sores negatively.
A nursing facility should have an infection prevention plan available that details expectations and controls to ensure staff are well-versed in infection prevention and accustomed to ensuring less-mobile residents are moved every two hours.
Infections are frequently caused by unsanitary conditions. Nursing home staff are responsible for ensuring a clean and sanitary place to live. Failure to do so is a form of abuse and neglect. Personal hygiene is essential to preventing infections, and nursing homes that are understaffed frequently encounter problems with infections resulting from neglect and negligence.
Falls are the leading cause of non-illness related death in Americans over the age of 65, accounting for 30,000 deaths in 2016 alone according to data collected by the United States Centers for Disease Control (CDC). More than 300,000 senior Americans were admitted to the hospital in 2016 as a result of a fall. Falls that result in broken bones are more common with older residents, particularly women who are more likely to suffer from osteoporosis. The CDC reports that 95 percent of hip and knee fractures in older adults are the result of falls.
In older adults, awkward gait and muscle weakness are the most common cause of falls, and residents of nursing homes are more likely to be afflicted with these conditions, leading to a large number of falls. Estimates are that between 50 and 75 percent of residents fall each year.
Several studies have highlighted the importance of training staff on ways to prevent falls, with a significant amount of data to back up that having a policy or plan that is facility-wide addressing fall prevention and communication between attending staff and medical professionals.
One of the most common factors in cases of neglect, abuse and fraud involving elder residents is diminished mental capacity. Capacity can be mildly afflicted, like when a person is forgetful, or severe, like when a resident does not know who they are or why they are where they are. These residents are the most vulnerable group to be taken advantage of and abused.
It is a good idea to ask administrators about programs intended to treat mental illness and declining function, such as with dementia. The staff-to-resident ratio should be no more than five residents per staff in a facility that treats dementia according to mental health experts. This ratio provides a minimum of attention and prevents some of the issues associated with loss of cognitive function. In a 2016 survey, the Henry J. Kaiser Foundation found that 45 percent of residents at nursing homes nation wide suffer from dementia. Another 32 percent had diagnosis of mental illness that included schizophrenia and mood disorders.
Since a 2012 initiative aimed at reducing the overuse of anti-psychotic medications in nursing homes, the Centers for Medicaid and Medicare Services (CMS) reports that rates of use have declined to an average of 15.7 percent of residents nationwide. The national average was 34.1 percent at the end of 2011. Anti-psychotic medications are sometimes used to chemically restrain an individual. Some nursing homes have been accused of elder abuse by deliberately sedating residents to avoid proper care. Pennsylvania ranked 27th in the nation for percentage of nursing home residents treated with anti-psychotic medication and equaled the national average in the CMS survey.
Nutrition, Hydration and Exercise
Because residents are reliant on the nursing facility to provide meals and nutrition, some good questions might include:
- Does your facility have a diverse menu?
- Are residents able to eat when and where they want?
- How are your meal plans organized?
- Do you accommodate special dietary needs?
- How are staff trained to deal with residents that won’t eat?
State and federal regulations require all nursing facilities to provide nutritionally balanced meals and must have a meal plan that is managed by nursing staff. Residents have the right to eat what they want, where they want and when they want, except when refusal to eat or drink becomes a danger to their health.
Like physical restraints, force feeding has become uncommon in nursing homes. Some residents, particularly those who suffer from memory deterioration, can present problems for staff by refusing to eat.
Today, most nursing homes have a policy that encourages Certified Nursing Assistants who must feed residents to use either a hand-to-mouth or a hand-to-hand method rather than a feeding tube. The hand-to-mouth method is as though feeding a child, while the hand-to-hand method involves the CNA holding the utensil while the resident holds the hand of the CNA. Research published in 2011 by NCBI found that residents who were force fed with tubes had no better outcome than residents who were fed in other manners.
Dehydration has been found to be a rampant problem in nursing homes, with some studies finding nearly 100 percent of residents suffering from dehydration. Many ailments can be caused by dehydration, and the condition exacerbates the symptoms of many illnesses and slows healing.
Early warning signs of dehydration include insatiable thirst, dry mouth, pale skin and can progress to labored breathing, faintness and dizziness, and loss of consciousness. Dehydration is thought to occur more easily in older people due to changes in the body, medications, and has been tied to tube feeding and infections.
Malnutrition and dehydration are often signs of neglect and abuse. The duty of care requires that nursing home staff ensure residents are properly eating and taking in fluids.
Regular exercise is an important component of nursing home care. Many residents of nursing homes are at risk of declining health as a result of a lack of exercise. A lack of mental stimulation has been linked to memory loss and dementia. Nursing home staffing levels will play a big role in the consistency and quality of physical and mental exercise available. Many facilities will have an exercise plan in place that details how staff intend to provide physical and mental stimulation for residents.
Rapid decline in physical condition or mental ability may be indicators of neglect and abuse and should be taken seriously.
Section 5: Who Can Help
Don’t hesitate to seek help if you suspect abuse or neglect happening to a family member in a nursing home. The most common signs of possible abuse and neglect in a skilled nursing home are changes in personal hygiene, mood and activity, bruising and broken bones, unexplained falls, lethargy from overuse of medications, weight loss, dehydration, and changes in behavior. Sudden changes in finances can indicate that elder abuse is occurring.
Medicare recommends speaking with supervisors, social workers, the Director of Nursing and the treating doctor about suspected abuse. If the facility is not helpful in resolving complaints, contacting state agencies might be necessary.
The Pennsylvania Department of Aging manages a 24-hour hotline to report suspected abuse. Callers may remain anonymous and are protected from discrimination, harassment, civil and criminal litigation. That number is 1-800-490-8505.
Resources for residents and family members are available through the local Area Agency of Aging.
If you or a loved one is subjected to abuse in a nursing home, a personal injury attorney can ensure the abuse stops, your rights are protected, and the responsible parties are held accountable. Your family does not have to suffer because of neglectful and abusive nursing care.