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Introduction and Objectives: Hospitalization for respiratory events is common in nursing home residents (NHR). Pneumonia in NHR has different features, is more severe, and appears in more dependent patients. Aspiration pneumonia is usually misdiagnosed as infective pneumonia. Hospital-at-Home (HaH) has emerged as an alternative to conventional hospitalization. We decided to study respiratory admissions in NHR and the safety of our HaH program. Methods: Retrospective study of all consecutively hospitalized NHR with a respiratory crisis, discharged from 2016 to 2017. Univariate analysis was used for differences between aspiration and infection, multivariate analysis to check for prognostic factors. Results: 301 episodes were included in the study. Patients (mean age 86.4 years) showed numerous comorbidities (hypertension 80.7%, dementia 70.8% and chronic heart failure 41.5%), high degree of dependence (Barthel Index 12.7, Katz 5.3), and poor prognosis (high-risk PROFUND 91.7% and high-risk PALIAR 76.7%). Severity was high by Pneumonia Severity Index (97% groups ≥ 4) and CURB65 (89.4% ≥ 2) indexes. Antibiotics were used in 288 episodes, 67 covering MDR bacteria. Aspiration was associated with dementia and dysphagia, scored higher on CURB65, and showed worse prognosis: In-hospital mortality 27.5% versus 15.1% and 1-year survival 20.8% versus 38.6%. 55 episodes (18.3%) were treated in HaH, with the lower mortality than conventional hospitalization. After multivariate analysis, HaH and chronic oxygen therapy showed protective role, whereas CURB65, altered mental status (both as referral symptom or physical finding), leukocytosis and acidemia proved deleterious. Conclusions: NHR hospitalized for respiratory events are highly complex, comorbid, and dependent. Aspiration carries worse prognosis than infection. HaH care leads to better outcomes, whereas altered mental status, acidemia, leukocytosis, and CURB65 confer worse prognosis.