Safety First: Protecting Loved Ones in Nursing Homes

There are no current federal requirements for staffing ratios. Under a 2024 Centers for Medicare & Medicaid Services  rule, nursing homes were required to provide a minimum of 3.48 hours per day of direct care for each resident and have a nurse on duty 24/7. Both requirements were invalidated by a Texas federal judge earlier this year, ruling that CMS exceeded its authority beyond what Congress allows. 

Smetanka advises families to ask about staff-ratio levels, staff training, and protocols for coverage when employees call out sick. “Whether it’s day-to-day care or an emergency, safety starts with a well-staffed facility,” says Smetanka.​

Prevention of falls, one step at a time

​Falls are the leading cause of injury and injury-related death among adults age 65 and older, according to the Centers for Disease Control and Prevention.

At Grandvue Medical Care Facility in East Jordan, Michigan, falls are more than a statistic; they are a key focus for prevention efforts. With 113 beds for a population that includes individuals with dementia and physical limitations, the nursing facility has instituted several strategies to keep residents safe.​

Central to their approach is the “namaste room,” a quiet, sensory-friendly space staffed around the clock, where residents relax in recliners while enjoying hand massages, dim lighting, and soothing aromas. “If they’re relaxed and being watched directly by staff, they’re not falling, they’re not getting hurt in other ways,” says Shannan Butler, Grandvue’s director of nursing.​

Butler emphasizes that most falls occur inside residents’ rooms, which makes frequent staff monitoring critical. She explains that purposeful monitoring, when the staff regularly check on residents in their rooms, is an important safety element. During these rounds, staff ensure that essential items like call lights, water, phones or tablets are within reach so residents don’t try to get up on their own and risk a fall. Butler notes that staff are also trained to ask residents, “Is there anything else I can do for you before I leave?” to prevent situations where a resident might move unsafely after a staff member departs.​

Grandvue also partners with a lift manufacturer to improve safe transfers. Staff receive hands-on training and adopt practical measures like low beds, non-slip socks, and assistive devices to support stability and mobility. “One is never going to be 100 percent fall-free, but there are all kinds of little things that facilities can do to keep people safe,” explains Butler.​

Infection prevention matters​

Nursing homes are federally required to maintain infection prevention and emergency preparedness plans, a standard that included pandemic responses before the COVID-19 outbreak in 2020. By contrast, assisted living facilities are regulated at the state level, with rules that vary widely with no direct federal oversight.​

Smetanka stresses the importance of asking facilities how they coordinate with public health agencies and first responders, and how they plan to keep families informed during infection outbreaks, such as the flu, colds, pneumonia, and Clostridium difficile, a type of bacteria that causes severe diarrhea and stomach illness. “Infections spread quickly in nursing facilities, so there needs to be a robust plan in place,” says Smetanka.​

Following CDC guidance, facilities should enforce vaccination against influenza, COVID-19 and respiratory syncytial virus (RSV). “During these high-risk events, residents should stay in their rooms as much as possible, wear masks when outside, and maintain physical distance,” says Logan Jamieson, a post-acute care specialist at Relias. “Facilities should also post visible alerts to inform visitors of any active infection risks.”​

Medication watchouts

​Medication management remains one of the most critical and often overlooked safety issues in nursing homes. While electronic medical records (EMRs) are considered the industry standard, not every facility uses them, and fewer still integrate those systems with local pharmacies. The safest homes, Jamieson explains, rely on EMRs tied directly to pharmacy dispensing systems, which create automated checks to catch errors before they happen. In those facilities, a locked medication cart physically prevents staff from moving on with their “med pass” until a supervisor clears any flagged issues.​

Hill describes negotiating with nurses and administrators as sometimes very challenging to ensure her mom’s medications were given properly. Because her mom has Parkinson’s disease, her medication must be administered within a very narrow window, sometimes within 15 minutes of the scheduled time, to prevent severe anxiety, aggression and other disease-related symptoms. Early on, Hill discovered that facilities often did not meet these strict requirements, giving doses too early or too late. Each time, she had to work with doctors to create explicit instructions and communicate these repeatedly to facility staff.​

She also found that proactive solutions, like a continuous pump that consistently administers medication, were often rejected by facilities because staff did not want to handle the extra responsibility. This required Hill to persistently educate staff, provide manuals and insist on proper training and verification procedures to ensure her mom received medications safely.

Families evaluating nursing homes should ask about the systems in place to ensure safe and accurate medication administration, Jamieson advises. CMS conducts surveys through certified state auditors; facilities are required to make these reports available, but don't always make them readily accessible. The surveys document issues such as medication errors or IJ “immediate jeopardy” tags for unsafe practices. Families should ask detailed questions and review survey reports to determine whether a facility consistently keeps residents on their medications safely and on schedule.​

Communication flow

​“Transparent and ongoing communication between facilities, residents, and their families is essential for ensuring safety and trust,” says Smetanka. She adds that facilities that proactively share information about staffing, care planning, infection prevention, and emergency preparedness foster understanding and cooperation among families, while those that withhold information risk frustration and mistrust.​

Emergency response plans for fires, floods, or other disasters should clearly outline evacuation routes, designated safe zones, staff responsibilities, and communication procedures to keep families informed and coordinate with local emergency services.​

According to Smetanka, facilities that maintain consistent, clear communication tend to build stronger relationships with families. “The worst thing a facility can do is try to hide information,” she says. ​