Molly, 36, didn’t want to move her mom into skilled nursing. Who would?

But Stephanie, her mother—who was only in her 60s, though you wouldn’t know it if you sat with her over Goldfish crackers and a chat—started falling. Such was the slow unfolding of her confusion following a series of minute explosions in the brain, adding, it seemed, decades to her age. Her falls got more and more frequent. One night, she rolled out of bed.

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At the time, Stephanie was living in a senior apartment. She had lived there for years. Her building contained a handsome lobby with plush chairs and side tables, real wooden antiques that were stacked with copies of the current USA Today. The friendly folks at the front desk handed out parcels of mail and recorded dinner preferences.

Stephanie mostly used a wheelchair and took the lift to the second floor, then rolled down the hallway to her apartment. But this wasn’t skilled nursing and certainly not a nursing home by any stretch of the imagination.

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In the progression of elder-care housing that begins in older adulthood and leads through end-of-life services, senior apartments are a gentle downward slope. You retain your freedom of movement. You have your own room.

At some point, though, you require 24-hour care. You need someone to remind you to use your walker and to chase you down if you forget or go blithely sprinting down the hallway for reasons not even you could say. You need people to make sure you get your meds. It’s for your own good. It really is.

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Anyway, we’ll get back to Stephanie and Molly later. We promised secrets.

Daily Life at the Skilled Nursing Facility

Terrance is a 40-something long-time nursing home volunteer who explained his desire for anonymity by citing the Health Insurance Portability and Accountability Act of 1996 (HIPAA). People don’t tend to open up about nursing homes and what goes on there, Terrance says, and HIPAA’s strict privacy edicts are not entirely to blame.

Why the secrecy? Is it because life under skilled nursing is horrible, full of elder abuse and Nurse Ratched-types and downtrodden residents who have given their entire selves over to suffering and bad pudding? Or is it because we don’t want to look, knowing that the local nursing home is a scrying pool that shows our own probable futures?

It’s pretty firmly the latter, to hear Terrance tell it.

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“I’ve been to a bunch of nursing homes, good ones and bad ones,” Terrance says. “And I’ve seen the saddest people in the nicest places and the happiest people in places with, like, wheelchairs blocking the halls and bad smells.”

Joy in an overcrowded, stinking hallway. Misery at the medical Four Seasons. In one crucial way, maybe the only way that matters, life in a skilled nursing residence is just like life anywhere: Wherever you end up, you bring yourself with you.

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In other ways, though, nursing homes are far from equal. Setting aside the issue of nursing home abuse, a subject for a different and much sadder document, there are lots of things you’d never know if you don’t spend time behind the walls of a skilled nursing facility.

You may no longer be solely responsible for your loved one’s care, but the love remains. So does some measure of the care.

Here are the nursing home secrets you should know when you’re weighing the spirit-buckling decision of whether to pursue a bed at a skilled nursing center for a parent, sibling, or maybe even yourself:

1. Funky smells are not necessarily a sign of poor management.

“I think I’ve smelled pee at every place that I’ve volunteered,” Terrance says. “A little bit of that just goes with the territory. After a while, everyone gets used to it I think.”

Skilled nursing facilities care for older adults at every stage of ability. Inevitably, some residents will lose control of their bodily functions. This is a medical fact. This is one of the things that frightens us about aging—that we will lose control. And we will. Why the indignity, then? Why the fear?

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Of course, there are odors, and then there are odors. Maryglenn Boals, a one-time nursing home administrator in Arizona, spoke to the AARP Bulletin in 2012.

“Urine can penetrate into floor wax, and if someone is having a lot of accidents on the floor, a room can get a very [intense] smell if they’re not stripping and rewaxing the floors regularly,” Boals said.

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So when you take your tour, don’t let a little whiff get you down. If you feel like you need to invest in a gas mask before moving day, though, strike the place off the list.

2. You don’t want staff working too hard.

Say you’re looking for a skilled nursing residence for your dad and you tour two facilities, back to back. In the first, staff are bustling about, clearly engaged in their duties, zipping wordlessly from one task to the next. In the second, the pace is slower. Half the time, the nurses on duty are simply chatting with the residents. They sit down at the communal table, not apparently engaged in anything we’d usually call “work.”

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Which home would you choose for your father?

In a culture that sanctifies labor for its own sake, it’s easy to be tempted by the beehive-like atmosphere of the first nursing home. Actually, though, signing that contract would be a mistake, says Jasmine, a former certified nursing assistant at a large Midwestern elder-care facility.

“Everyone [where I worked] was just waiting for another job,” says Jasmine, who also comments under the condition of anonymity. “They worked us so hard. I worked doubles for a week. I couldn’t wait to get out of there.”

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When the staff is overworked, they’re more likely to miss signs of distress or illness in the residents they serve. They’re less likely to take the time to forge real human connections. And these deficits make life worse for residents.

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“Find a place that has its staffing right, that’s what I’d say,” says Jasmine.

3. Nursing home staff help care for your loved one, but they don’t take over the job entirely.

“I knew someone who did her mom’s laundry even though there was laundry service at the place,” Terrence says. “She’d take it away every week and do the laundry and bring it back. I never got that.”

Adult children who move their parents into skilled nursing facilities often find themselves racked by shame. The idea is that you’re throwing your loved one away, that you’re burying them, that you’re putting them behind bars because you don’t love them enough to care for them yourself.

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Hogwash, says Jasmine. The truth is, after your loved one moves into skilled nursing, you’ll still be a big part of their care plan. It’s just that you won’t be alone in the effort anymore.

“We loved it when family would visit [the residents],” Jasmine says. “Not just because it’s nice, but lots of times family would see stuff that we would miss.”

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The keyword here is advocate. You may no longer be solely responsible for your loved one’s care, but the love remains. So does some measure of the care. You might even get some say in what that level of care looks like, an unimaginable gift for those locked into full-time family caregiving.

How the Story Goes

So there was Stephanie, tottering on that precipice, and there was Molly, all alone with this terrible decision, ultimately signing over her mother’s monthly insurance check in the office of a long, palatial building. In exchange for the check, Stephanie got a room, complete with a roommate who smiled at everyone but didn’t say much, and 24/7 care, and all the therapies her progression could want: physical, emotional, chemical.

(Music therapy they saved for hospice care, for which you only qualify if your doctor gives your life a six-month expiration date. Sometimes residents of Stephanie’s new home got jealous of the services their neighbors received through hospice, which were admittedly pretty nice. No one explained the situation honestly to the aggrieved; this was arguably the best course of action.)

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Was Molly ashamed to move her mother into that place, even though she knew it was the safest, healthiest option? Of course she was.

But it was the right move. If her mother were seriously injured in a fall back in her senior apartment, Molly never would have forgiven herself.

There comes a time when we all need care from a particular type of community, the sort that doesn’t flinch at the smell of urine and is willing to help you undress. Skilled nursing facilities are today’s version of that community, which seems sad, unless you’re sitting in the sunny dayroom one Sunday, listening to the warbling group song of the afternoon Methodist service.

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Molly didn’t want us to quote her directly. Her sense of guilt never did entirely lift, she suggests, though it has lost its teeth over time.

Anyway, she has help with her mom now. And her mother is embedded in her community, such as it is. We should all be so lucky.