From our founding partner, Jody Moore

I've spent more than 20 years representing families in elder abuse and neglect cases. I've also sat in the family chair — walking into a facility, trying to read a room, wondering if my loved one would get the care they need, and not knowing if what I was seeing was normal or a warning sign. Both sides of that experience taught me the same thing: neglect rarely announces itself. It shows up in small things that are easy to explain away, until enough of them pile up that you can't explain them away anymore.

If you have a parent, spouse, or loved one in a facility right now, or you're touring facilities and trying to figure out who to trust, here are six things I tell people to watch for. Not because any one of them proves abuse or neglect. But because together, or repeated, they're worth noticing and taking seriously.

1. Weight loss or dehydration that no one can quite explain

Staff will often tell you that weight loss or dehydration is a part of normal aging, or that your loved one "just hasn't had much of an appetite." Sometimes, that may be true. But sudden or ongoing weight loss, dry mouth, cracked lips, dark urine — these can be signs that someone isn't getting help eating or drinking, not that they've lost interest in food. A resident who needs assistance and isn't getting it can decline fast.

Sometimes, the report is that your loved one is "refusing" to eat. A refusal of a meal should trigger someone to ask what's going on. Is the person in pain? Is the food unappetizing or not meeting the resident's preferences? Is it difficult to chew? Are they depressed, lonely, or confused? Is medication upsetting their stomach? A "refusal" alone is not justification for weight loss or dehydration. Staff must look into the reasons why the person is refusing to eat, and document their efforts to encourage food and fluids.

If you are seeing these signs, you have the right to ask specifically: who is helping them at mealtimes, and how often are they actually finishing a meal? What is your loved one saying when they don't eat the meal? Have any medication issues or pain issues been addressed? Has the dietician or doctor been informed? Have labs been drawn? This will help you stay on top of the issue before it's too late.

2. Repeated urinary tract infections

Urinary Tract Infections (UTIs) are quite common in the elderly population, especially in people who are catheterized or in diapers. A single UTI may not be a cause for concern, but recurring UTIs could be a sign of a larger problem relating to hygiene. If someone is not toileted frequently enough, or if their diaper is not changed when soiled, or if a catheter is not kept clean or gets contaminated, the failure to provide timely hygiene care can lead to recurring infections. And in the elderly, a UTI can turn bad quickly. A very common sign of a UTI is sudden confusion, and sometimes agitation. If you see signs of poor hygiene, or behavior changes without an obvious cause, you might be dealing with a UTI, and it's important to act quickly.

If you see evidence of poor hygiene, it's time to advocate. Push the call button and ask for help. As a matter of health and dignity, your loved one deserves fresh clothes and a clean diaper, and to have their basic needs for cleanliness met. If you see a sudden change in behavior, ask staff to do a simple urinalysis. This will show whether there is an underlying infection that can be treated, before it's too late.

3. Bedsores

Bedsores, also known as pressure injuries, are a problem in the nursing home population. They can occur as the result of neglect, if your loved one is lying in bed or sitting in a chair all day and does not get repositioned. The fleshy part of our body — muscle and tissue — sits over the bony part of our body, and when that tissue is compressed for too long, it restricts blood flow. Without proper blood flow, the tissue can break down and open up into a wound.

Bedsores are easier to prevent than to heal. So it's important that staff take preventive measures to keep the skin from breaking down in the first place.

Sometimes staff either don't recognize the early sign of a bedsore, or they report something that sounds different than a bedsore, and families don't really understand what's actually happening. I have seen bedsores described as "skin tears," "scratching," "bruising," "rash," "scarring." All of these can be a sign of unrelieved pressure, and it's important to ask the question: does my loved one have a bedsore or a pressure injury? When was it first discovered? How bad is it (you can ask for size, stage, depth, whether it has an odor, etc.)? And, importantly, what is the treatment plan? A doctor and wound nurse must be part of the treatment team to ensure aggressive treatment and to promote healing.

4. A sudden change in mood, alertness, or personality

Confusion that wasn't there before. Agitation. Impulsiveness. Unusual drowsiness. Withdrawal. Staff will sometimes describe these as symptoms of dementia, or the normal aging process. That might be so. Dementia-related behaviors are vast and differ from resident to resident. But sudden changes can also mean a medication error, over-sedation, depression, or an untreated medical issue, like the UTIs described above or pain from a pressure sore. You know your person. If they seem like a different version of themselves, don't let anyone talk you out of that instinct. Ask questions.

5. The small signs — dirty clothes, soiled bedding, poor grooming

This is the one families feel guilty about noticing, because it seems petty next to bigger fears. It isn't. Unwashed clothing, a bed that hasn't been changed, hair that hasn't been brushed in days: these are often signs of understaffing, and understaffing is where neglect usually starts. It's rarely one bad day. It's a pattern.

Facilities must have enough staff to meet the basic custodial needs of the residents they serve. If they cannot keep up with personal hygiene and the cleanliness of the room, sheets, and clothing, chances are that's just the tip of the iceberg. Understaffing means late medications, missed assessments, failure to identify when someone's condition changes, poor shift-to-shift communication, and rote — sometimes false — charting.

The little things often lead to the discovery of the big things. So it's worth noticing and advocating early. Loved ones who have someone watching over them and talking to staff often get better care than those who don't have visitors, or whose visitors don't speak up.

6. Your loved one goes quiet, or seems anxious, around staff

This is the sign I tell people to trust the most, and the one that's hardest to catch because it only shows up in person. Watch how your loved one behaves when a caregiver walks in. Do they change the subject? Get tense? Stop talking altogether? Fear is information. People don't always have the words for what's happening to them, especially if they're confused or afraid of retaliation, but their body language will often tell you first.

I'm not pleased to report that we've had our share of assault cases over the years — resident-on-resident and staff-on-resident. It's more common than I would like to admit. Pay attention and follow your gut.

What to do if something feels off

Start a journal — dates, what you saw, what staff told you. Take photos if you feel it's appropriate. Ask direct questions and get answers in writing when you can. Ask for a team meeting. Reach out to the doctor. Request a copy of the care plan and compare it to what's actually happening. And if your gut is telling you something is wrong, don't wait for proof before you start asking questions. The paper trail matters later, but trusting yourself matters first.

I built my career on the belief that vulnerable adults, whether they're in a nursing home or assisted living, deserve to have their needs met with dignity and care. If you're seeing signs like these and aren't sure what your next step should be, we're here to talk it through with you — no obligation, just answers.