Personal and Health Care
All nursing homes certified by Medicare and Medicaid are required by federal law to make a comprehensive assessment of each new resident and develop a written plan of care for them. After that, the federal law requires them to reassess each resident at least once a year, or more frequently if a resident's condition changes significantly, and make appropriate changes in their plan of care. While other health care professionals may do the assessment and prepare the plan of care, each assessment and plan must be reviewed and approved in writing by a registered nurse (RN).
Each assessment evaluates level of function and social, emotional, mental and medical condition. The resultant plan of care should focus on maximizing independence and functioning at the highest level possible.
In addition to the following questions, ask the facility to specifically describe how it will meet your loved one's known care needs, e.g., incontinence, mental health, supervision or dementia. When asking your questions, remember to take into consideration the fact that your loved one may need more care in the future.
Personal Care Needs
How will the facility determine if it is the appropriate facility for my loved one's needs, or if another type of facility, e.g., assisted living, would be more appropriate?
How will the facility evaluate my loved one's needs? Who will do the assessment? What are his or her qualifications? How often are reassessments done?
How does the facility help residents maintain their ability to care for themselves, especially toileting, dressing, and eating?
How does the facility accommodate residents with changing needs - what if they need more physical assistance, become confused or incontinent?
For patients who develop confusion, how does the facility help determine whether it is due to problems with medications or because of the onset of Alzheimers or dementia?
How often does a staff member check on a resident's whereabouts and well-being?
If a residents behavior changes and becomes verbally or physically abusive, what steps will the facility take?
Health Care Needs
Nursing homes are medical facilities. As such, they manage the medical care for their residents, and provide most of it. The nursing home's physician will usually become your loved one's primary doctor. Consequently, it is important to evaluate the facility's capacity to manage a broad range of health care needs even if your loved one is relatively healthy now.
The Plan of Care
What professionals/staff are involved in the development and implementation of the plan?
How will my loved one, my family and I be involved?
What involvement does a confused resident have?
What if I don't agree with the plan of care?
Does the plan focus on maintaining independence?
Does it cover every aspect of a resident's life ... physical, psychological, social and medical?
How often does the staff consult the plan?
Providing the Required Care
How will the facility monitor my loved one's health?
Is each resident's weight routinely monitored?
Are there water pitchers and glasses on tables in the rooms? Does the staff encourage residents to drink liquids frequently?
Does the staff routinely check each resident thoroughly from head to toe to avoid the occurrence of bed sores?
If a resident doesn't feel well, how quickly and to what extent will they receive medical attention?
Does the staff respond quickly when residents push their call buttons?
What health care services are available at the facility: physical therapy? wound care? hospice care? social services? etc.?
Will the staff set up medical appointments for my loved one?
Under what circumstances does the facility call the family? ... the resident's current doctor?
Does the facility use physical or chemical restraints?
If yes, how many residents are in restraints?
When are restraints used?
What is the policy on the use of restraints?
Is the family involved in the decision to use restraints?
Who decides when to call 911? Are there written policies about how that decision is made?
What kind of emergencies are the staff expected to handle and how are they trained for them?
Are there any limitations on how the staff will handle your loved one's medications?
What safeguards are in place to ensure that your loved one gets the appropriate medications on time and in the correct dosage?
How are prescriptions filled? Must a resident use the facility pharmacy? What are the costs?
Who gives out medications?
If not a nurse, how are staff trained and supervised?
Who reviews medication procedures and how frequently?
Health Care Transportation
How does the facility handle non-emergency transportation to medical appointments? Are there any limitations?
Is the transportation wheelchair accessible?
What are the fees for using the facility's transportation?
Who is the facility's physician? What hospital is he or she affiliated with? How can they be reached?
How often does he or she visit with each resident?
Is a resident allowed to keep a personal physician not affiliated with the facility?
If so, how would the facility communicate with the physician about the resident's care?
For short-term recovery patients: Will the facility's physician consult with the resident's personal physician? Will the facility's physician keep the personal physician informed of the resident's progress?
Who is the Director of Nursing? How long has he or she been with the facility? How can they be reached?
How many registered nurses (RNs) are on duty during the day? at night? At least one RN should be on duty at all times, 24-hours-a-day, 7-days-a-week.
How many Certified Nursing Assistants (CNAs) are on duty during the day? at night? on weekends?
How many Aides are on duty during the day? at night? on weekends?
What is the training/certification of the people who care for residents? What are the trainer's qualifications?
Does the staff receive abuse prevention training?
Are background checks performed on all staff members? Who does it, how and when?
What is the staff-to-resident ratio? In general, facilities that offer care for Alzheimers or other forms of dementia should have a ratio of about 1-to-4. On the other hand, if most residents are lucid and need minimal assistance, the ratio could be much higher without endangering the safety of the residents. For example, a staff-to-resident ratio of 1-to-8 during the day and 1-to-15 at night are both appropriate for lucid patients needing minimal assistance.
Is the staff trained to deal with aggressive residents? Wanderers?
Is the staff visible?
How long are staff shifts?
How is staff members' morale? Observe their demeanor and their interactions with each other and with the residents.
Do staff members know residents' names? Do staff and residents greet each other in passing?
How does the staff respond to your questions? Trouble signs: Are they rushed, uncomfortable, angry?
If either the resident or staff members are not native English speakers, can they communicate effectively with each other?
What is the procedure for notifying families of any changes in routine or medical condition?
Ask to meet these staff members if they are not part of your official tour:
1. Manager of facility and/or on-site administrator
How long have they been with the facility?
How can they be reached?
2. Activity director
Full-time or part-time?
Are they creative and innovative?
Do they offer programs that would appeal to your senior?
What do they do to encourage shy seniors to participate in their activities?
3. Social workers
What are their hours?
What services do they offer residents and families?
How often do they come?
Are they from the community? If so, this might indicate that the facility welcomes observers and values outside interaction with its residents.
Are they screened?
Daily Life in the Facility
When looking at a facility's activities, consider your loved one's preferences and capabilities. Some people enjoy group activities such as bingo, word games, card games, crafts, etc., even discussions of current events. Others prefer to enjoy their activities privately ... they aren't generally "joiners," preferring instead to read or watch TV. With this in mind ...
Look at activity schedules. Are they varied? Are your loved one's interests reflected? Are activities planned with residents' involvement in mind? Are they designed to be fulfilling, that is, something residents look forward to ... or are they designed primarily to keep residents busy?
Who develops and supervises recreational activities? What is their background?
Is reading assistance available for residents who are visually impaired?
Do residents have any input into the activities offered?
Are residents involved in the community outside the facility? If so, how? What staff members are included?
Are there recreational facilities such as game rooms on site?
Does the facility offer opportunities to exercise? Are the exercise facilities pleasant to be in, and the equipment easily accessible and in good condition? Are there organized exercise programs, or are residents left to themselves to exercise if and when the whim strikes them?
Can residents take walks outside? Are there protected/enclosed walking areas for residents with dementia?
Are residents encouraged to be as independent as possible? Ask residents and staff, and make your own observations.
Are residents allowed to make choices about their daily routine? For example: when to go to bed or get up, when to bathe, or when to eat.
Does the facility own any pets that it keeps on the premises for the residents to interact with?
Can family pets come with visitors? if yes, what are the restrictions?
How does the facility meet the religious/spiritual needs of residents? Does it provide transportation to nearby churches and synagogues? Or, are worship programs conducted in the facility itself?
Is there a resident and/or family council? How often does it meet? Has the council taken any action recently?
What arrangements have been made for residents to see the following health care professionals? Are their services included in the basic fee or do they cost extra?
Ophthalmologist / Optometrist
Psychiatrist / Psychologist
Are the following services available? If yes, note whether they are included in the basic fee or cost extra:
Beauty parlor or barber
Transportation for non-medical appointments
-- Meals --
Before selecting a nursing home, join the residents for a meal, if possible. How does the food taste? Are residents offered a choice of foods at each meal? How often does the menu change? Or, do residents get bored with the “same old food all the time?”
At what times are meals served? Is the meal schedule flexible?
If your loved one has special dietary needs, how will they be accommodated?
Does a nutritionist or dietitian review meals and special diets? If yes, how often?
What happens if your loved one is late, misses a meal, or refuses a meal? Is the answer different if a resident is confused?
Can your loved one ask to have a tray delivered to their room? Is there an additional charge?
If a resident doesn't like a meal, what are the alternatives?
Is the dining area pleasant?
Is the food attractive and nutritious?
Is the food culturally familiar?
Does the staff help residents get to the dining room if needed?
Does the staff help residents eat if needed?
Are nutritious snacks available at any time? What kind?
If your senior is mentally alert, try to find a facility with similar residents. Living with residents suffering from Alzheimers or dementia will not offer a good quality of life for someone who is frail but mentally alert. Likewise, it can also be disturbing for a confused resident to be placed with primarily lucid residents.
Do other residents appear happy and relaxed?
Are they well-groomed? Are their clothes clean? Are they dressed appropriately for the time of day and room temperature?
Are they interacting with each other or just sitting around not doing much? Do they isolate themselves in their rooms? Or, are they parked in wheelchairs in front of the nurses' station at times other than just before meals?
Talk to residents about the facility:
What do they like best?
What do they like least?
What is daily life like at the facility?
Are most residents at the same level of mental function as your loved one? If not, are residents kept mainly with others at similar levels of mental function and cognitive awareness?
Does the facility accept residents who:
The Nursing Home Facility
Is there an emergency call button near each bed? Or, do residents wear pendant or wrist call buttons? If so, do the pendant or wrist call buttons work outside of their room?
How often are call buttons checked to see if they are working correctly?
Is the bedroom/living space big enough?
Is it well-lighted?
Does it have a window?
Is it clean and pleasant?
How often is it cleaned?
Can residents bring in personal belongings? furniture? a TV?
Is there a cable TV connection in each resident's room?
What measures are in place to prevent personal property from being stolen?
Is there a private bathroom? If yes, is there a call button in the bathroom?
Are there grab bars in the shower? next to the toilet?
Is the bathroom wheelchair-accessible?
Are the living quarters private or shared?
How many roommates would there be?
Is there a privacy curtain around each bed, or between beds?
Does each resident have a reading lamp, chair, nightstand, and his or her own dresser/closet with adequate storage?
How are roommate(s) selected? by matching their needs and personalities? or based only on which beds are available?
What's the policy if roommates have problems getting along with each other?
What if one roommate has habits or mannerisms that upset another roommate, e.g., staying up late at night, yelling, going through personal possessions of others, keeping a TV's sound too loud, etc.?
What does the facility do if problems such as those in the previous question arise?
What's the policy on choosing or switching roommates?
Can you and the senior meet the prospective roommate(s) in advance?
Are separate rooms available for private visits?
Is the facility in a safe area?
Is it convenient to:
Hospitals and other medical facilities?
Family and friends
Is the building's exterior well-maintained?
Is there a nice outdoor area? Are residents encouraged to use it? Is it accessible to wheelchairs, with plenty of benches and shade? TIP: Don't judge a facility based solely on its looks. However, a poorly-maintained facility may indicate a lack of adequate funds and potentially inadequate care of residents.
Is there is a smell of urine? A mild urine odor is normal for a nursing home. But, be especially leery if the smell is strong. And, be equally concerned if a powerful room deodorizer is being used to mask an unpleasant odor. That could mean the facility is trying to obscure an unclean area rather than clean it.
Is the temperature comfortable?
Is the noise level acceptable?
Do you see personal, home-like touches?
Is it well-lighted? Does it have good natural light?
Are the facility's doors locked? When? How does a resident or family member get into the home when doors are locked? Are exit doors alarmed?
Are there safety locks on the windows?
Would your loved one be able to get out in an emergency? What procedures are in place to assist residents who may need help evacuating the facility?
If it is a multi-story facility, what safety arrangements are in place to help people in wheelchairs evacuate the building?
Are the emergency exits clearly marked and accessible?
Are evacuation instructions posted that residents can read?
Does the nursing home hold fire drills?
Are stairway doors kept closed to prevent potential spread of fire?
Do halls and public bathrooms have grab bars?
Are there wheelchair ramps?
Are hallways, doorways, bathrooms and common areas wide enough to accommodate people in wheelchairs?
Is the floor covering made of a nonskid material?
Is the building generally clear of clutter?
What safety measures are in place to protect residents from wandering away? Do exit doors have alarms in case a wanderer tries to leave? Are exit doors unlocked from the inside? Locked doors prevent wanderers from leaving the building, but they also create a potential hazard.
Ask for paperwork showing that the facility has been inspected and meets federal and state codes for fires and other disasters.
State Health Inspections
Ask to see the latest State inspection report (federal law requires that the facilities have a copy easily accessible for anyone who wants to see it). If you have questions, ask a staff member to go over it with you.
Does the facility post a valid license?
Does the facility have a written description of a resident's rights and responsibilities?
The Legal Contract
A legal contract must be signed in order to be admitted into a nursing home. That contract obligates your loved one, and/or you as his or her representative, to potentially pay very large amounts of money for their care. Before signing it, we encourage you to review a copy of the contract with an attorney who specializes in elder law.
What is the facility's base monthly fee for your loved one?
What services are provided for that fee?
If your loved one is a short-term recovery patient covered by Medicare, what fees will they be expected to pay out-of-pocket?
What additional services are available, and what are their costs? Extras such as laundry and incontinence supplies can be costly.
Can any of the fees/charges be changed? Under what circumstances? Who will be notified? How much advance warning will be given?
If your loved one has to temporarily leave the facility in case of hospitalization, recovery in a skilled nursing facility, etc., how long will the nursing home hold his or her bed? What fees/charges would apply during your loved one's absence?
Other Legal Provisions
Answers to these questions will help you clarify a facility's ability to care for people with health and behavior conditions that are more difficult to manage. It will also help you determine if you have recourse if you are asked to leave.
What behaviors, conditions, or other circumstances are reasons for discharge?
Is there an internal appeal process? What is it?
How many days notice is given and to whom?
How does the facility assist you if they proceed with discharge?
What are the eviction procedures?
Does the facility offer a separate insurance policy that covers theft or damage to a resident's property, or is theft or damage to a resident's property covered under the facility's own insurance policy, or will a resident's property be uninsured (the latter situation is usually the case)?
What happens if there is a spill or accident that destroys property - your loved one's or the facility's? Who is responsible for cleaning/repairing, payment or replacement? TIP: Be wary of any clauses that exempt the facility from liability for injury or lost possessions. Once again, you may want to have an elderlaw attorney to review the contract.
Try these sources:
Hospital discharge planners
Nonprofit organizations specializing in your circumstances
Friends who have faced similar situations
Private geriatric care managers
Volunteers from the community
Final Notes and Comments
What I liked most about this nursing home:
What I liked least:
Nursing Home Checklist
Name of facility: _________________________________________________
Date(s) of visit:__________________________________________________
Contact _________________________________ Phone_________________
Is the nursing home Medicare-certified?______ Is it Medicaid-certified? ______
General rating on a scale of 1 (poor) to 5 (excellent)
Circle one: 1 - 2 - 3 - 4 - 5