As you grow older, you may begin to explore the potential for your need to move into a nursing home in the future. Although these facilities may all seem great and reliable from the outside looking in, not all are equal. It would be best if you did your due diligence to determine whether the nursing homes on your list of considerations can provide an acceptable standard of care in your remaining years.
Researching nursing homes is a tall order, especially when you don’t quite know what you’re looking for. Fortunately, the guide below summarizes the most significant factors to keep in mind throughout your search. Read on for a step-by-step guide to picking the best nursing home for you, along with specific risk factors to watch out for and quality measures to compare between facilities.
Determine Your Goals for Seeking Out a Nursing Home
Nursing homes offer a vast diversity of care options that can cater to various parts of your life and wellbeing. For example, you may find some institutions that are specially designed to treat religious individuals. They might offer regular church service and encourage social connections based on similar faiths and more.
Other specialized areas that you might consider when choosing your nursing facility include (Source: National Institute on Aging; National Institute on Aging):
- Physical therapy
- Mental health care and support
- Rehabilitation services
By definition, you can expect any nursing home you choose to provide continuous medical care, as they are also officially known as “skilled nursing facilities.”
Some homes are considered long-term facilities and do not offer advanced skilled nursing support. They do, however, provide nursing, CNA, and ancillary support services
Additional essential services include 24-hour supervision and the provision of three daily meals as well. This is how nursing homes operate at their core. So, you’ll need to ask for specialized care to verify whether it’s the right nursing home for you.
Speak to the Staff at the Nursing Homes You’re Considering
As you look through the services offered by the nursing homes in your area, you may find a few that pique your interest over most other alternatives.
Note these facilities on your phone or a notepad for later reference. (You can write down as many as you prefer. However, it’s easiest to jot down the top five, their contact information, and their critical distinguishing characteristics to keep things organized.)
After you’ve collected the top five (or however many you choose), it’s time to start making some calls. This research step is crucial, as it is relatively easy for any institution to make their business look good online or on paper. Instead of taking their advertising at face value, dig a little deeper and politely request more information from the staff.
Ask the following questions upon contacting the nursing home staff (Medicare.gov):
- Is your nursing home Medicare or Medicaid certified? A “yes” answer means that they’ve passed a state-mandated, random inspection that allows the facility to earn compensation via the Medicare and Medicaid programs.
Note: All nursing homes are subject to this evaluation, including state-operated facilities, non-state-operated facilities, and non- or state-operated dual participating facilities. (Source: Centers for Medicare & Medicaid Services)
2. Do your nursing home and administrator currently hold a state license? The nursing home administrator is essentially at the head of all care operations in the facility. Their job is to plan and supervise all care standards and techniques within the nursing home. With this immense responsibility, you want to be sure that they comply with state regulations.
3. Do you offer specialized services? Some patients, such as those living with dementia or similar cognitive conditions, require more hands-on assistance in day-to-day life. If this is not the case for you, you may desire rehabilitative services like speech, physical, or occupational therapy. Ask about their supplemental care options to determine if you can live there happily.
Note: You’ll always want to ask whether they charge extra for these services. While the facility may include some of these specialized services in your daily care, others like beauty services are likely to cost more.
4. Do you enforce resident policies? If so, will I receive a hard copy of the rules? Many nursing homes and other types of care facilities enforce rules for both the staff and residents to protect everyone’s safety and wellbeing. However, it’s hard to follow such regulations without a definitive guide. Make sure you know the home’s expectations before making a decision.
Talk to Your Friends and Family
Your friends and family know you better than anyone else. As much as you might love the nursing homes you’ve added to your list, it’s best to get a second opinion on whether your selected options will work best for you. Plus, having a loved one listen in on your exchanges with the nursing home staff will ensure that you don’t fall for any misleading information.
Another advantage of talking to your friends and family before finalizing your nursing home choice is that they can give you personal suggestions. There may be someone in your life who has supported a family member in their transition into assisted living and nursing home.
If so, reach out to them and ask about the things they looked for or what seemed like red flags. If you have friends in a nursing home already, ask about their experience. What are some of the core services they receive and the activities they participate in each day? Are there specific things about their facility that they would change?
Finally, check if you have anyone in your life who has knowledge or training in the medical field. If so, feel free to pick their brain about the health services you should be looking for. Perhaps even invite them to tour with you and help identify any advantageous or potentially hazardous conditions at the institution.
Don’t be afraid to include others in your decision-making process – you’re not in this alone.
Know What Red Flags to Look For
Just like any healthcare facility – or any other business, at that – nursing homes have unique red flags that you must keep an eye out for. Catching these signs early will ensure that you don’t fall into subpar care or end up paying far too much for the available services. To identify any potentially disadvantageous living conditions at the nursing home, you’ll need to visit in person.
When you arrive, request a tour or walkthrough, and keep an eye out for the following red flags (Source: U.S. News, Health):
- Noisiness: Remember to focus on both the nursing home’s appearance and soundscape. According to the American Health Care Association’s spokesman, Greg Crist, you must pay attention to how chaotic and loud the nursing home is. It will not be suitable for someone who’s easily stressed or with mental health conditions without reasonable silence.
- Staff etiquette: How do the staff treat the residents? Respectfully observe a few interactions between the nursing home caregivers and the elders living at the facility. Are the staff disrespectful, aloof, or otherwise impersonal? If so, this detachment and lack of friendliness may show in their medical care standards, too.
- This concern extends to the residents as well. You don’t want to live in a facility where everyone is at each other’s throats all the time. Make sure that the residents are all polite, considerate, and perhaps even friendly toward one another. This way, you know you’ll feel welcome upon moving in.
- Administrator involvement: Is the nursing home’s administrator present? If so, see if you can get an opportunity to speak with them. They should be happy to receive and answer your questions and will hopefully provide you with detailed insight on facility operations, care and conduct standards, and more.
- Residents’ agency: You may need to chat with both the residents and staff to get a well-rounded perspective on this factor. Specifically, you should focus on how much an individual resident can exercise choice in day-to-day matters. Can they choose their recreational activities? Do they have several meal choices throughout the day? If not, it could be indicative of a deeper problem. Do you know what staff member’s roles are in the nursing home?
- Visiting hours: This is simple but important. You should confirm that the facility is close to your family and that there will be ample opportunity to spend time with them. You should also be able to leave the facility whenever you like (of course, with reasonable curfews in place).
- Staff and facility values: At some point, all nursing home residents must face the inevitable. However, just because the staff understands that some individuals are nearer to passing than others doesn’t mean they can treat the passing with indignity. Make sure that the staff’s valuations and prioritization of health and foreseeable end-of-life align with your own.
Research the Area Where the Nursing Home is Located
Just as you would with any living space, care facility, or otherwise, you must research the surrounding neighborhood during your in-person visit. Even though the nursing home itself may seem to meet your needs perfectly, the location could still be a deal-breaker.
For instance, you might find that the nursing home upholds high-quality care standards and maintains excellent cleanliness and dedicated attention to their residents. However, if the physical location is marked by social unrest, such as high crime rates or rising socioeconomic tensions, you may want to set your sights elsewhere.
This is perhaps one of the most difficult calls to make when looking for a nursing home. After all, the city or neighborhood’s conditions are not the nursing home’s fault. Such matters are entirely out of their control. However, even when you find a place that seems right for you, you must remember that your safety and wellbeing extend far beyond the walls of the facility.
Imagine you wanted to go for a walk with your family during visiting hours, or simply wanted to sit outside for a while and enjoy the sunshine. You shouldn’t have to worry about your safety when enjoying such simple life pleasures (and neither should your family). Research the area before finalizing your choice to make sure you’re going to the safest possible place in this new chapter of your life.
Arrange a “Surprise” Visit to the Nursing Home
Visiting the nursing facility that’s captured your interest is a must. However, it would be best if you didn’t make all your visits known ahead of time.
When you call ahead for your first tour, you give the management and staff enough time to potentially put on a façade and present their facility in the best light, even if it’s not representative of their regular operations.
Such advanced notification is acceptable when you’re first getting to know a nursing home. However, it is best to schedule any subsequent visits according to your availability alone. For example, some of the best times to see a nursing home in person are during mealtime and at night.
Here are a few things to look out for at these hours:
- Mealtime: How well-kept is the dining area? Look around and note the cleanliness of the eating and lounging areas. It would also be helpful to get a glimpse of the available food. Is there a wide variety of options for breakfast, lunch, or dinner? This could be a good indicator of residents’ agency, mentioned earlier, and the staff’s awareness of diet-related health concerns.
- Nighttime: Going to a nursing home at night is one of the quickest ways to detect any issues with understaffing*. When you get to the facility in the evening, notice how many staff are present compared to your first, presumably daytime visit. If there are only a handful of caregivers (if any), you might want to choose another location.
Understaffed nursing homes pose a direct threat to their residents’ health and wellbeing. Lucky for most patients, understaffing is not as common a problem as one might think. Nursing homes undergo inspections from state and federal programs to protect against this problem.
Lack of Assistance for Immobile Residents
Immobility or mobility challenges are among some of the most common ailments that nursing home residents live with. Studies show that approximately 90% of long-term care facility residents struggle with limitations to their mobility, which places them at increased risk of suffering from (Source: U.S. National Library of Medicine):
- Ulcers
- Incontinence
- Gradual declines in health and quality of life
These individuals typically require more assistance from their caregivers than others, especially in daily tasks like getting into or out of bed and visiting the restroom. Although there are advantages to living in a 24/7 care facility, assisted living can also present significant dangers if there are too few staff to meet the residents’ needs.
Residents who need help with the daily movements mentioned previously are significantly less likely to receive the care they need without adequate staffing. Further, those who need to be periodically turned over in their beds to prevent muscle atrophy and bedsores are at an increased risk of developing infections and other health complications without the necessary help.
Inability to Distribute Essential Care and Medications
One of nursing homes’ core functions is to provide residents with essential medications and regular medical care as often as they are needed. However, if there are not enough staff to pay attention to all residents in the facility, then there is no possible way to expect these responsibilities to be fulfilled.
Although not all residents will require such care, those that do must have dependable assistance to lead fulfilling lives. Reports concerning the health of nursing home residents in the United States show that (Source: Nursing Home Abuse Center):
- 7% of residents live with mild cognitive impairment
- 1% have minimal cognitive impairment, but not so extensive that it interferes with daily activities
- 15% of nursing home residents have substantial cognitive impairment that is so extensive that it affects several aspects of daily living
Some of the most common illnesses that cause these impairments include dementia, Alzheimer’s, and various physical limitations such as eye and joint problems. Without adequate access to required medication via the caregiver’s distribution, nursing home residents face the tremendous risk of a lowered quality of life and perhaps the worsening of their current health conditions.
Patient Abuse in Understaffed, Overworked Nursing Homes
Abuse can be a dangerous threat one might face in an understaffed nursing home. Fortuanately, it is not a common occurrence in long-term care nursing homes.
Understaffing and poor (or a lack of) training are the leading causes of elder abuse in nursing homes, followed by neglect and a lack of personalization in care techniques. Most facilities operate with ratios of 1:15. Some can even reach up to 1:30.
When there are too few staff on the payroll, those tasked with upholding facility operations are subjected to immense stress, in addition to the burdens of their personal lives. These pressures may lead to pent-up frustrations, which will inevitably come out in their interactions with the patients in their care.
The ratios also depend on the level of care required by the patients in the facility. If you are taking care of more acute (sick) residents, staffing ratios should be lower. If you have more long-term residents, you can extend the nurse to patient ratio to a more significant number.
Many states such as Connecticut have protections in place for their residents thru state and federal surveys. Other states have less oversite which may lead to problems for patients. The majority of nursing homes are safe places for patients to stay and abusive homes are not the norm.
Get Details on the Nursing Home Staffing
In direct relation to the potential issues discussed above, you’ll need to research the state of caregiver employment at your chosen facility.
One of your core questions should be, “How many staff do you employ per X number of residents?”
You may want to get more information. For example, a poor ratio could be less hazardous if most residents are non-disabled. However, in a nursing home specializing in caring for the cognitively impaired, this is a severe issue.
Secondly, you may want to ask about the average staff turnover rate. Like any business, high turnover rates may indicate structural problems in the workplace and with management.
Past studies have revealed alarmingly high turnover rates in nursing aids, specifically, with annual averages reaching 100%, even 400% in some institutions. (Source: The Gerontological Society of America)
Researchers say that turnover rates should never exceed 50%. Any facilities that pass this rate may be considered “problematic,” specifically in terms of their company longevity and service effectiveness.
Since the Covid-19 pandemic, the turnover ratio in most nursing homes has increased. Turnover is most likely due to the increased stress of providing care to residents while protecting themselves and residents with personal protective wear.
Hopefully, this turnover related to Covid-19 will decrease with time, and staff learning better ways of handling the pandemic’s stressors.
Ask the nursing home about how many of their staff come and go per year and use this to determine whether that institution would be right for you. Don’t judge the facility based on short-term turnover rates.
Risks of High Turnover
It would help to know precisely why a high turnover rate is a major red flag as you search for a potential nursing home. Firstly, studies show that this problem is the direct cause of unsustainably high operation costs, stretching a nursing home to its limits, taking resources away from resident care.
Estimates show that turnover cost per employee can reach $1,885-2,100 per employee. The high price can put a sizable dent in the institution’s funds, especially at turnover rates as high as those mentioned previously. Still, finances are not the only concern related to the rapid loss of employees.
Investigations into the relationship between turnover and resident health have exposed some ugly truths as well.
In comparisons between nursing homes with high and low caregiver turnover, residents struggled with the following ailments significantly more frequently and intensely in the former (Source: Mather Institute):
- Pressure ulcers
- Note: Excessively high turnover rates for licensed nurses (for which the national average is 47%) correlated positively with a doubled risk of pressure ulcers in nursing home residents.
- General pain related to health and fitness issues
- Urinary tract infections (UTIs)
Check Telehealth Availability
Not all nursing homes have implemented telehealth into their core services. Those that have, though, are leaders in quality and convenience concerning residents’ healthcare.
Researchers consider telehealth to be a highly valuable untapped opportunity for these care facilities, as they allow on-demand communication with experts that may not be readily available on-site. (Source: National Library of Medicine)
Telehealth is essentially the opportunity to receive clinical healthcare remotely, often for the following care types (Source: University of Pittsburgh, School of Nursing):
- Dermatology
- Psychiatry
- Neurology
- General practice
- Geriatrics
Nursing homes that implement telehealth-friendly technology have a more significant service advantage than their counterparts. Through this technological advancement, they can lower the frequency of hospital transports, provide vital consultations with healthcare specialists, and increase the efficiency of care. Here is another post regarding telehealth in nursing homes.
Many experts consider telehealth to be a must-have in your prospective nursing home. (Source: mHealth Intelligence)
One group in Connecticut, InHouse Care LLC, provides Advanced Practice Nurse Practitioners (APRN’s) to Nursing Homes and Assisted Living Facilities. They offer in-facility medical coverage as well as a Telehealth component for patients in the nursing home.
Compare the Quality of All Nursing Homes You’ve Considered.
Now that you’ve done your due diligence in thoroughly researching the nursing homes that have caught your eye, it’s time to nail down your decision. To do so, you need to know the exact qualities to compare between each available facility. These quality measures, according to long-term and short-term care, are as follows (Source: Centers for Medicare and Medicaid Services):
| Long-Term Care | Short-Term Care |
| Sum of hospitalizations per 1,000 long-term residents Sum of residents who visited outpatient emergency departments per 1,000 residents Fraction of residents who received antipsychotic, antianxiety, hypnotic, etc. medication or who present for various mental health issues (e.g., depression) Percentage of residents with declining physical health (i.e., incontinence, UTIs, pressure ulcers, loss of mobility, excessive weight loss) Number of residents who experience fall-related injuries Total distribution of flu shots during flu season Total residents who had to be physically restrained | Fraction of residents who were readmitted to the care facility after discharge Percentage of residents that have visited outpatient emergency departments The proportion of residents whose health conditions improved over their stay (e.g., gained mobility independence) Fraction of residents who received necessary medical care (e.g., flu shots, antipsychotic medication, pneumonia vaccinations) Percentage of patients whose pressure ulcers either worsened or appeared during their stay Amount of patients who incurred fall-related injuries Consideration of patient health issues in individual care plans Total Medicare spending per resident |
Assessing the details related to these quality measures is, admittedly, quite a challenging task. Although you can ask the nursing home staff and management for background information on these factors, it is best to do some research yourself.
Plus, this aspect of choosing your nursing home would be much easier with someone to discuss your findings with, so don’t be afraid to ask a friend for help.
We do not recommend using the Medicare star rating system as a significant determinate in picking a nursing home. This system is set up so that nursing homes can focus on a few measures Medicare finds important and get a good star rating.
While other homes may spend more time focused on patient care measures that are crucial yet not measures by Medicare. It doesn’t mean that one is better than the other.
Certain “tags” in the facility should carry more weight in your decision-making. If the facility is in “immediate jeopardy,” see how long it took the nursing home to correct the issue. Did they fix the problem once it was identified? Was it a problem that they knew about and ignored?
Sometimes issues get identified during surveys of the facility. The owners or management may not have known them. How did they handle the case once addressed?
In Conclusion
Choosing a nursing home is incredibly challenging. Because of the vast amount of background research you must do to ensure your choice is the right one, it’s best to get started far in advance of your need for assisted living. The most important things to do when choosing your prospective nursing home include:
- Determine your specific requirements for a nursing home
- Speak to the staff at the facility
- Talk to friends and family
- Know the red flags
- Research the surrounding neighborhood
- Arrange a follow-up, unscheduled visit
- Research the nursing home’s staffing details
- Check for telehealth availability
- Compare quality measures between facilities
Selecting the ideal nursing home for you or a loved one is a monumental effort, yet the outcome is worth every bit of work. You are (or your loved one is) entrusting their very life to the staff at the nursing homes you’re considering. By following this guide, you can ensure that your or your loved one’s quality of life is not compromised but enhanced by future caregivers.
