how to Select a Nursing Home

It’s critical to begin the search for a suitable nursing home well in advance (i.e. a year or two) of seeking admission to the facility. Why so early? There are several key reasons:

• Finding the right nursing home takes time. You’ll need to pull together detailed information for your loved one’s finances, including all savings, medical and personal needs, advanced directives and medications to complete most applications. Less information is generally required to simply add your loved one to a waiting list.
• You’ll want to visit each home you’re seriously considering once or preferably twice.
• Nursing homes often have long waiting periods of several months to a year for available accommodations.
• You won’t be under the stress of a short deadline letting you evaluate what you hear and observe in a calm state of mind.
• If you’re faced with an unexpected emergency requiring nursing home care, you’ll want to be able to quickly notify medical personnel of your preferences.
• Planning ahead can make the transition of moving into a nursing home much easier.

Begin by talking with your loved one (if you can) and caregivers about what services will be needed. Take time to consider what services are “must have” versus “nice to have.” Think about the following:

• Typical nursing home rates for a shared room currently range from $300 - $350/day. What financial resources does your loved one have to cover the cost of a nursing home? Do they have Medicare Parts A (hospitalization and similar care), B (medically necessary services) and D (drugs)? Will they need to apply for financial assistance such as Medicaid? If you plan to apply for Medicaid, has your loved one transferred substantial assets within the past five years? If so, this should be carefully researched as it may cause your loved one to be denied benefits. If you feel your loved one will need assistance, be sure to review information on the Medicare and Medicaid programs.
• What are your loved one’s specific medical needs (e.g. do they require a catheter, do they need oxygen, are they diabetic, etc.)?
• What are their personal needs (e.g. are they hard of hearing, unable to perform a number of their activities of daily living – dressing, bathing, hygiene, grooming, eating, taking medications, etc.)?
• Do they exhibit any behaviors as a result of their illness that must be managed (e.g. wandering, aggressiveness, mood swings, repetitive actions, etc.)?
• What type of socialization are they able to engage in and enjoy?
• How mobile are they?
• What distance can you manage? Your caregiving role will shift to become your loved one’s advocate while they’re in the nursing home. This role cannot be emphasized enough, so you’ll need to consider your ability to visit often to ensure your loved one is getting proper care. You’ll also want to consider what trusted friends and family will be visiting to help you by routinely checking in on your loved one.

Now that you have an idea of needed services, try to get a list of possible homes to investigate. Ask your loved one’s physician, friends and members of your caregiver group (if you have one) who have used homes for their opinions.

First-hand experience can be very helpful. Also call the nursing home ombudsman at local elder care organizations for your area. Try to get specific information about the type of care received by residents of the facility, for how long, and what they liked or disliked like about the services received. However, remember that your needs may differ. Someone may be very positive about a home that won’t match your loved one’s needs.

Before scheduling a visit to the nursing homes you are interested in, call the admissions office for each one to conduct a quick survey to see if they meet your basic needs. Ask about vacancy availability, if they keep a waiting list and how it’s managed, if they have short-term beds, admission requirements, levels of care provided (e.g. a dementia unit if you need one, hospice services, etc.), and participation in government-funded financial assistance options.

Asking about short-term beds is important for several reasons:

• Emergency situations: Your loved one may need rehabilitation after an injury or medical situation. Also, if your loved one’s stay turns into a long-term care situation, it’s much easier to work with a home to transfer them to a long term care unit than to a new facility.
• Your loved one’s need for long-term care may occur suddenly and no long-term beds may be available at any of your preferred homes at that time. If they have a short-term bed available, they may accept your loved one in anticipation of a long-term bed soon becoming available.

If a nursing home accepts Medicare and Medicaid insurance, they must meet federal participation requirements to be certified. Surveys are conducted periodically to determine if a home complies or does not comply with these requirements. Enforcement actions may also be recommended to rectify certain areas of non-compliance.

You should acquaint yourself with the types of information gathered on surveys as it may prompt you to ask certain questions when you visit a nursing home. You can then compare their responses to the averages for other homes. The Centers for Medicare and Medicare Services (CMS) provides a wealth of information on survey results.

Look for the latest “Nursing Home Data Compendium” discussing how surveys are conducted and a second section providing summary data by state. Here you can find information on, for example, how many residents received anti-psychotic drugs, or had bed sores, weight loss or other undesirable outcomes for comparison with data from your nursing home interviews. Be sure to check the “Special Focus Facility Background Info and List” for those homes with serious quality issues.

Though not something that will help you narrow your choices, if you’re interested you can also find information on the nursing home certification process from CMS.

Once you’ve identified your top choices for your loved one, it’s time to visit each home. After you visit a few homes, the details of each will start to blur. Be sure to take a checklist with you to ensure you cover all your questions, and take notes of all responses. Record the nursing home name, date, time, and who you meet with. Also take a small camera but be sure to ask where it’s permissible to take pictures. During you visit, get copies of literature, activity schedules, menus, price sheets per service (e.g. room, laundry, phone, television) and other pertinent material.

In addition to the generally available checklists [PDF], here are some additional questions that may be useful for your visits:

Facility:

• Do you like the appearance of the building and its surroundings?
• Is the decor attractive and home-like?
• Do any areas smell or look unclean?
• Is the floor plan easy to follow?
• How many residents does it have overall? How many are in a unit?
• What is the profile of the resident population? Age range? Male/female ratio?
• How many current residents have needs similar to your loved one?
• How can the home meet your loved one’s specific care needs (e.g. specialized unit, staff, etc.)?
• What is the facility’s admissions process? What days and time of day can new residents be admitted?
• Is the building centrally heated/cooled (a few older homes only allow resident supplied window air conditioning units in certain rooms)? Is the temperature appropriate?
• Do doorways, hallways and rooms accommodate wheelchairs and walkers?
• Are elevators available?
• Are handrails available?
• Is there a TV in each room in a good viewing location?
• Are shelves easy to reach?
• Are carpets secured and floors made of a non-skid material?
• Is there good natural and artificial lighting?
• Is there a safe outside walking area?
• What is your policy on personal belongings?
• Is there an emergency plan (e.g. major power outage, fire/evacuation, etc.)? What is it? Are backup generators in place?

Fees:

• What is the daily cost for your loved one’s type of care?
• Are there different costs for various levels or categories of services?
• How often has the cost increased over the past five years? Is an increase expected next year? What is included/excluded in the daily cost?
• Is the fee structure easy to understand?
• What are the billing, payment, and credit policies?
• Are the billing and accounting procedures understandable?
• Does the nursing home reveal what services are covered in the quoted fee and what services are extra?

Staff:

• Is there a written plan of care for each resident?
• How are care changes decided and implemented? Are you involved in the decision process? How long is it before they go into effect?
• How is care coordinated among for your loved one? Are electronic medical records used?
• Is the staff employed directly or are they from agencies?
• What is the staff-to-resident ratio?
• Is staff available to provide 24-hour assistance with activities of daily living, if needed?
• Does the facility employ a nutritionist? How often will they review my loved one’s dietary needs?
• Is there at least one full-time therapeutic/activities person assigned to a unit?
• Is there a designated social worker?
• If special training is needed to care for your loved one (e.g. dementia) how is the staff trained? By what organization? Is training refreshed periodically? How often? How many of the staff members are trained (e.g. all who come in contact with residents including maintenance etc. or just Certified Nursing Assistants (CNAs), nursing staff)?
• Does the facility follow the Alzheimer’s Association suggested guidelines (for dementia only)?
• Is there a Director of Nursing available 24 hours a day, seven days a week?
• Who do you speak with if you are dissatisfied with a service for your loved one? When is that person available?
• How frequently does a physician visit your loved one? If there is a medical need, how long will it take for a physician to be on site?
• What is the procedure for responding to a medical emergency?
• Does the facility have someone who can help me file for Medicaid insurance (if necessary)?

Dealing with Residents:

• How are new residents acclimated to the facility?
• How does the facility deal with wanderers?
• How does the facility deal with those who get agitated, are unsteady or can’t sleep?
• What percentage (or how many) of the residents are on psychoactive medications?
• What percentage (or how many) of the residents have or have had bedsores? How are they treated?
• How many residents were sent to the hospital in past year?
• How are drugs provided? Can you use your own pharmacy? What pharmacy does the facility use?
• How are medications handled? Is there a medication management system?
• How are residents in semi-private rooms paired? How are roommate issues handled?
• Are laundry services available? Is there a cost?
• How are lost belongings (including missing in-house laundry items) handled?
• Request a tour of the bathing areas.

Food and Meals:

• Is the food prepared on site?
• Request a tour of the kitchen area.
• Ask to taste the food.
• How many meals are served?
• What time are meals served?
• How are special dietary needs handled?
• How are the resident’s food choices made? How does the facility handle situations where the resident cannot make their own choices? How are the meals served?
• Does the dining area enable wheelchairs to fit under the table so residents can easily reach their meal?
• Are snacks and drinks readily available on the unit throughout the day? Can visitors enjoy these snacks with your loved one?
• Is there a safe outside walking area?

Daily Activities:

• How often are activities held? How many hours of activities are there per day?
• Are there separate activities for each type of unit (e.g. dementia unit versus medical only)?
• Are there activities suitable for your loved one if they are sight impaired, hearing challenged, immobile, etc.?
• Can you take your loved one out of the facility for periods of time for meals, etc.?
• How does the facility deal with residents who cannot make their own activity choices?
• Are residents escorted outside if they want it?
• Are there religious services available? What type? When?

Visitors and Family:

• What are the visiting hours?
• Are there common rooms available for visiting? Are visits allowed in patient rooms?
• Are there family support groups?
• When is the initial care planning session? How will I be notified?

Once you’ve make your top selections (three is a good number), you’ll want to get your loved one on the waiting list for the facility, if they keep one.

Wait times can be several months to a year for highly regarded nursing homes. Get confirmations in writing in case any confusion occurs in the future. If a bed is available before your loved one is ready to move, most facilities will just keep you on the top of the list but move to the next person.

Once your loved one enters a nursing home, you’ll become their advocate for the services they receive. Get to know the staff taking care of your loved one, particularly the CNAs providing personal care and assistance. Immediately raise any concerns you have about your loved one’s care and keep a daily log of these concerns.

If you are a Power of Attorney you are entitled to view your loved one’s medical and other records at any time. Certified nursing homes are required to have a Care Plan Assessment for your loved one a few weeks after their admission and then periodically afterward. These meetings bring together your loved one’s “care team” to review with you the services they’re receiving. It’s important that you attend these meetings, bringing your written list of concerns (if any) and also compliments for good service. Be vocal about your concerns, and get a commitment for how and when they’ll be addressed.

Visit your loved one as frequently as possible, taking time to enjoy whatever activities you can share with them. Be sure to introduce your loved one to other residents, their families and other staff members so they’ll become known to others who can interact with them when you’re not there.