Looking at Optimal Outcomes If We Need Nursing Home Care
None of us wants to think about spending time in a nursing home or skilled nursing facility—but humans are unpredictable, and the need can occur from complications of old age, progressive illness, or an accident. If you or someone you know is faced with choosing a healthcare or end-of-life decision, bookmark this page, it could save or prolong a life.
• • • • • • • • January 2026 • • • • • • • •
This is my subjective glossary for folks who may need long-term care someday. About 50% of elders need nursing home care at some point in their lives. Optimal nursing home care occurs in a high-quality facility in San Francisco (or close to home if you don’t live in SF), so family and friends can keep close tabs on your care. Knowing the vocabulary is part of getting what you want!
A Geriatric Opinion
Glossary: Regarding long-term care vocabulary, insurance companies use precise financial definitions; if you or your family uses these terms in a medical setting, be sure to understand the implications, given our broken health care system!
Skilled nursing facility (SNF): A licensed nursing home able to do post-acute (after hospital discharge) rehabilitation. There are different types of “rehab”. Being at an “SNF” specifically for rehab is different from living in one indefinitely. The facility may also be certified to do “Custodial” or long-term care.
Custodial or Long-Term Care (Nursing Home/NH care): The facility is “home” for those who need more nursing and less medical attention without daily “skilled rehab.” While there is periodic attention from a rehab professional, care is overseen by licensed nurses. A doctor or equivalent must visit every 30-45 days.
Medical insurance does not pay for “custodial” patients—except for MediCal or long-term care insurance.
A Skilled Nursing Facility (SNF) is not the same as a custodial or long-term care facility (Nursing Home/NH), though the terms are often used interchangeably. Some facilities (like Laguna Honda or SF Jewish Home) are dual-certified to offer both services. The key difference is the type of care provided: NH/long-term care facilities (unlike SNFs) focus on the ongoing patient need for assistance with “Activities of Daily living.” NH care gets lower reimbursement from Medi-Cal, and is not covered by Medicare—although some bills—doctor and pharmacy—will still be paid by Medicare (part B). Medicare and insurance do not pay for the facility, which can be 8-18,000 dollars a month.
“Acute (Hospital) Rehab” is done in an acute hospital, is paid by insurance (if approved), and requires the patient to be strong enough to need AND tolerate a very intensive, short-term program with at least 3 hours of therapy per day. Acute hospital rehab provides 24/7 physician oversight.
Acute “SNF” rehab is less intensive, with one to two hours of therapy per day. It occurs in either a freestanding “SNF” or an SNF on a hospital campus. “SNF rehab” is funded by Medicare, MediCal, or private insurance for patients who have been discharged from the acute hospital after at least a 3-day stay. Frequent physician visits are not required. A facility that advertises itself as a “skilled nursing facility” or “rehab facility” should have rehabilitation professionals (Occupational, Physical and Speech Therapy) and “rehab gyms” on site. However, some SNFs bring in contract staff who are there only for limited hours and have minimal facilities/equipment, such as a gym & exercise machines. Best to ask and get someone to inspect the facility.
Licensed Nurses: are Registered Nurse (RN) or Licensed Vocational Nurse (LVN-- LPN in other states). Only RNs are trained to perform the skilled clinical assessment a medically fragile patient needs; LVNs are not. LVNs are generally trained to administer medications and take vital signs, but must report any problems to an RN. Objective studies show that an adequate quantity of RN staffing and generous “licensed” staffing (RNs and LVNs) lowers the death rate in SNFs or NHs.
Who do you see in the hallways when you visit? Look at their name tags.
Bedside care in SNFs/Nursing Homes and the “line of command”: Bedside care is generally done by unlicensed staff. Staff includes Certified Nursing Assistants (CNAs), who are better trained than various types of “aides” or “assistants”. Unlicensed staff cannot give meds or do complicated treatment and must report any “change in condition” to licensed staff. RNs and LVNs, in turn, should assess the patient, report any “change in condition” to the primary care provider (physician or equivalent), and arrange for treatment. If the patient cannot reliably report to a family member or whoever is the emergency contact, significant other, chosen family, i.e., the human(s) who is/are closest to the patient and have the capacity to advocate for the patient/understand what is going on if the patient has diminished capacity, staff must call them to report “Change of Condition,” such as falls, skin injuries, decreased responsiveness or sleepiness, signs of an infection, or concerning behaviors.
If you (visitor or patient) notice a problem, do not rely on overworked, unlicensed staff to report it to someone higher up: ask to speak to an RN or LVN. If the problem does not occur on the “day shift,” report it again directly to the “Charge Nurse” for the day shift. If, for an urgent issue, you have no luck finding an RN or LVN who will take responsibility, and the problem seems urgent, call the “Nursing Supervisor on Duty” for the facility: one is available, if not in person, by phone, 24 hours a day. Keep at it, if necessary. You have the right to insist on speaking to a doctor, and (sometimes faster) to insist on transfer to an emergency room. In understaffed nursing homes, training is poor (because that takes workers away from the bedside), overwork is exhausting, supervision by licensed staff is poor (too few RNs/LVNs or poorly trained), and the doc is nowhere to be found. Nursing home staff can only act on a “Change in Condition” that they actually notice! This problem is all going to get worse with the exclusion of immigrant workers, who often come from cultures that care about the elderly.
Understaffing and Poor training are the Capitalist way: payroll is the most significant expense in ALL long-term care. Low-quality SNFs/nursing homes are understaffed. They skimp on licensed staff, rely far more on LVNs than RNs to supervise (unlicensed) Certified Nursing Assistants (CNAs) and less-skilled assistants. On bad days, staff “puts out the biggest fires.” Sleepy or quiet patients are not served. Turnover is high (fragile patients, of course, do best with staff who know them).
When calculating “hours per patient day (HPPD)” for staff, there are “industry guidelines” on how to lie about these ratios. Understaffing and Undertraining keep the budget trim and the care bad! The saved revenue gets vacuumed elsewhere & disappeared.
Residents’ Legal Rights in a Nursing Home or SNF: The Omnibus Budget Reconciliation Act of 1987 (OBRA’ 87) established a foundational principle that residents receive care that allows them to “attain and maintain their highest practicable physical, mental, and psycho-social well-being.” This principle has been translated into regulations at both the federal and state levels. However, in California, inspectors/regulators are underfunded and overworked—worse than in most states, except for the deep South. Our governor and state elected reps listen to a lot of “industry” lobbies —profit over people! California actually has better staffing regulations than other states, but enforcement can be weak.
An assertive “significant other” who visits frequently and alerts nursing home staff — in writing if necessary — is your best bet for a good experience in a nursing home. For significant issues, be sure to talk to the “Charge Nurse” on the day shift (7-3), even if the problem occurs at another time. You also have the right to communicate with the “Director of Nursing” or the doctor. Don’t be put off by: “they are on break” or “they aren’t here today.” There is always a doctor on duty for the nursing home. See the CANHR link below for information on patient rights.
Laguna Honda Hospital and Rehab Center (LHH) is a rare public City and County SNF. Has 780 beds; 120 are currently closed indefinitely by the feds. LHH is fully operational and recertified, admitting new patients. (LHH is defined in the original San Francisco Charter as an entirely separate public facility from the public county hospital. Per the original City and County charter, it is open to San Francisco residents over 16 who need nursing facility care.) LHH is one of the few “SNF” facilities in San Francisco, not on a primary hospital campus, that offers both “Acute Hospital” and acute “SNF” rehab. Laguna Honda has an 11-bed “Acute” hospital. It also has 769 “SNF” and “custodial (NH)” beds. As of Nov 2025, about 557 of the 649 available SNF/NH beds were filled. So almost 100 empty beds remain to be filled.
San Francisco Health Network (SFHN): Essentially, an SF government-run health maintenance organization for San Franciscans who use public clinics and our county hospital. Founded in 2014. LHH has been arbitrarily defined as “part of SFHN.” “SFHN” patients have priority for LHH’s beds despite LHH’s separate mission and funding. 80% of LHH’s funding comes, when admissions are normal, from insurance — not from San Francisco’s general fund. Under “SFHN” management, LHH patients, staffing, and management were neglected for years-until LHH was decertified by regulators in 2022, with new admissions stopped until mid 2024. The local excuse was that SFHN managers “did not understand” how to run a nursing home(!) Hopefully this has (at great expense) been fixed, but vigilance is a good idea! Some problems are continuing to occur, but they are more isolated.
Activities of Daily Living (“ADLs”): Dependence on assistance for at least two of these is required for insurance to pay for a SNF or nursing home (legally defined as “medical” facilities). “ADLS” = bathing and hygiene, dressing, eating, toileting or incontinence care, and mobility (moving around, such as transferring, walking, or using a bed). “Instrumental” ADLs (“IADLs”) are for more complex activities, BUT assistance with IADLs can occur in a non-medical (residential) facility: using the phone, cooking, shopping, ordering food, paying bills, etc. “Wayfinding” (not getting lost) affects functional independence and can be classified as an activity of daily living (ADL) or an instrumental activity of daily living (IADL).
Hospice: BEWARE the “H” word-originally defined as a philosophy of appropriate and sensitive care at the end of life, a hospice “contract” has become a way of saving money for insurance companies who pay a flat monthly rate for all “Hospice Team” services. Beware of being asked to sign a “Hospice Contract” (saying you could die in 6 months) just to get nursing services when you are really NOT ready to die/ not “end of life.” A “Hospice Team” can supervise your care at home, as well as in an SNF, nursing home, or a residential care/assisted living facility. You sign a statement choosing hospice care instead of other Medicare-covered treatments for your terminal illness and related conditions.
Hospice care is managed by an RN who does not visit daily and focuses on “comfort” with narcotics and sedatives. Even when pain is not well-controlled, you are discouraged from going to the emergency room. A doctor is usually only peripherally involved, mainly with signing paperwork to get the hospice team paid by insurance. At home, hospice provides a few hours (or less) of daily home care — often by an unlicensed aide. So, if you do not have family or paid help at home to care for you 24/7, you must get your hospice team to move you to a facility. Otherwise, you could lie there by yourself for many hours a day. You will “break” the hospice contract if you go to the emergency room. Some hospice providers are better than others—close attention to the limits of hospice care is important!
Palliative Care: Insurance definition: Hospice lite. Saves money. Insurance pays for a team to come to your home, or a “palliative care” consultant comes to your bedside and advises your facility caregivers. The hope is you will stay out (or get out) of the acute hospital or rehab facility and cost your insurance less. Some palliative care consultants (MDs or Nurse Practitioners) are ethical and conscientious. However, many consultants are financially dependent on the facility and do not listen to the nuanced needs and wishes of the patient and loved ones. This failure can be due to a lack of time. If or when you are asked to make a decision regarding “withholding or withdrawal” of life-prolonging medical care, assertively refuse to budge until you get a consultant or hospitalist who actually TAKES SOME TIME. They should interview and observe the patient and the people who love them. They should be readily available to answer questions. Laguna Honda Hospital has a palliative care ward.
Assisted Living/Residential Care/Memory Care: The décor in the lobby is usually great, but these are, by legal definition, non-medical care facilities. They may increase their charges to you if more care is needed. Some are covered by government assistance; most are not. They are for-profit. The facility often does not increase the number of trained or licensed staff, even when they charge for “more care.” Commonly, although the facility charges more because the patients’ care needs have increased, there is no increase in poorly trained and poorly supervised staff (no profit in that)! Your doctor will not go there. Some facilities have a “Hospice Waiver” that allows end-of-life care by a visiting Hospice team. There are some good and adequately staffed “residential” and “memory care” facilities in San Francisco, but beware. Many of these facilities, despite being very expensive, will not say that a patient is too ill for them to handle, and it is up to the family to call 911 or arrange a nursing home transfer.
Comfort Care: Means different things to different professionals and caregivers. It depends on who is at the bedside and who is writing the medical and nursing orders. Often, “comfort care,” in practice, becomes medical abandonment. It may not bring either comfort or better care! Beware of what you ask for-when you use the term “Comfort Care” in our current system. You should agree that, if your oxygen falls off tonight, death is ok. A common problem is that a hospitalist or palliative care consultant comes to the bedside unannounced and takes direction from a patient who lacks situational awareness. Loved ones are not included in the dialogue. Orders are written for “comfort care” or “discharge to hospice care,” and staff may inform loved ones that it is a “done deal.”
Home Care Organizations (HCOs): These organizations are NOT licensed “Home Health Agencies” like VNA (Visiting Nurses Association); they are for-profit organizations that promise to send in the help you need at home while getting access to your credit card. “HCOs” intentionally blur the lines separating them from licensed Hospice or Home Health Agencies. There is no physical office you can visit—but HCO “marketers” are very nice on the phone. HCOs are for-profit organizations with a pretty website; they send in unlicensed, and often untrained, caregivers who may or may not show up, but are very good at charging your credit card. This, along with “high end” “Assisted Living,” is the latest way to separate vulnerable elderly from their money. Do your research and beware!
Resources to research SNF/NH, any kind of Long Term Care (LTC)-or defending your rights with home care or any kind of LTC facility:
1. Long Term Care Ombudsman: a State and National Funded agency that is supposed to represent the patient—and will send a trained person into an SNF/NH or Residential Facility to support the patient and/or investigate—every county has this, anyone may call or email for help. However, if there is a health emergency, it’s best to call 911 (or insist that the facility staff do so in front of you) and get the patient out of the facility to the emergency room before they get any sicker! In San Francisco the Ombudsman is available here.
2. California Advocates on Nursing Home Reform: Has resource pages “How to,” “frequently asked questions” on EVERY aspect of things that concern the elderly and disabled: your rights, current rules for MediCal Eligibility, how to research SNF/NH and different types of residential care facilities, how to report bad care to the state. They have a lawyer-referral service if you think you may need one: either for the best way to protect your estate while “spending down” to MediCal for long-term care, or to deal with harm from a violation of the right to safe care from either home health, NH/SNF, or assisted living, available here.
3. Long Term Care Community Coalition: Excellent webinars (recorded); links to data pages assist with research on nursing homes and residential care facilities; explains how to interpret the information that the government provides (Medicare.gov long term care pages). This is a national organization, so drill down to the California info. A recent useful webinar: Navigating Medicare Advantage.
4. Adult Protective Services (APS): The place to call for an adult who is not able to get enough help at home and is running into trouble—but not so sick that they need a 911 call. You or the person must admit the APS worker into the home. (You can call anonymously, but that will limit the help you can give.) Example: falls and refusing to get medical attention, going up and down their stairs by sitting on their bottom, accumulating garbage and take-out containers that they are too weak to dispose of, missing medical appointments because they are “too sick to go to the doctor.” APS can be the best way to get services at home for someone who is low-income, alone, and cannot work the system.
5. Free or low-cost legal services for the elderly or disabled are available in every county. These services could help with complicated “Medi-Cal” eligibility rules, defending your rights, or malpractice. They are freestanding organizations offering free walk-in or by-appointment services, run by local law schools and staffed by lawyers who donate their services. Unfortunately, lately, these legal organizations serving low-income folks have been impacted by the great need to help immigrants. Also see CANHR lawyer referral services. For possible long-term care neglect or abuse cases, most lawyers work “on contingency”—i.e., you do not pay until after a case is successful and the money is paid.
Teresa Palmer M.D. | Family Medicine/Geriatrics San Francisco.
January 2026
