Choosing the right nursing home is challenging. Here are questions you need to ask.
Choosing the right nursing home is challenging. And COVID-19 has added another dimension when making long-term care decisions. Although we now have vaccines and know the most effective preventative measures, the pandemic left a mark in terms of staffing, supplies, visitation and infection control policies.
Chances are good you’ll someday have to find nursing homes for yourself or for a loved one. Of adults turning age 65 now, nearly 70% will develop a need for some kind of long-term care services and support, according to the Department of Health and Human Services. And at some point, about 35% will receive in-facility care at a nursing home.
Obviously, you can’t just rely on facility tours or promotional brochures to make this crucial decision. “You have to go look at the place,” says Alice Bonner, senior advisor for aging at the Institute for Healthcare Improvement and chair of Moving Forward: Nursing Home Quality Coalition. “Going and sitting in the lobby is not (enough). You need to go to the units, walk around and see: How do the residents appear? Do they seem like they’re interacting? How do staff (members) interact with residents? It’s those very basic, human qualities that really determine quality of life for any of us who are living in that environment.”
First, get your ducks in a row. You can locate possible facilities and find inspection data by searching the U.S. News Best Nursing Homesrankings. You can also check general quality-related and specific COVID-19 data reported by nursing homes on the federal Centers for Medicare & Medicaid Services website. Data includes vaccination rates for the facility’s staff and residents, as well as the number of confirmed COVID-19 cases and deaths.
Make Sure You’re Comfortable With the Home’s Location
Before you visit, consider whether the location is realistic. Lengthy drives, not to mention flights, will affect visits and add barriers to relationships with friends and family members, including spouses still living at home. Sometimes, it’s a choice between top-ranked but distant facilities versus more accessible locations for loved ones to visit regularly and monitor care, says Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care.
“It’s a really tough situation for families to try to figure out: How can they get a good nursing home?” says Amanda Lambert, a geriatric care manager and consultant who heads Lambert Care Management in Salt Lake City, Utah. “You can read all the reports and you have to hope you’re getting the right information. What do you do, realistically, when you’ve kind of covered all your bases? The most important thing is to visit.”
Although facilities are easing pandemic-related visitor restrictions, you should still schedule nursing home tours in advance. Knowing what questions to ask a nursing home is important. When you’re ready to visit a nursing home in person, turn to administrators, staff members, activity directors and residents for answers to these pivotal questions.
Questions to Ask Administrators and Nursing Directors
— How are you protecting residents from COVID-19?
— Are staff members and residents fully vaccinated with boosters against the virus?
— Do residents have private rooms and bathrooms?
— What is the number of COVID cases that would trigger a lockdown?
— What are your current visitor policies or restrictions?
— What are the staffing ratios?
— What is your staff turnover rate?
— Which standard and higher-level services do you offer?
— Is your staff trained and experienced in managing this specific, complex health issue?
— What do nursing home surveys show?
— How do you prevent pressure sores in this facility?
— How does your facility avoid infections in general?
— Who can I speak to about payment and financial issues?
— What if I run out of money?
— Do you provide special care for people with dementia?
— How do you promote diversity so all residents feel comfortable?
— What about mood-alerting medications?
— How are you prepared for disasters?
— Who do I go to if I have a problem with my family member’s care?
How are you protecting residents from COVID-19?
Most nursing homes have made COVID-19 vaccinations — including boosters — available in-house for residents and staff. Also, ask about infection-control procedures such as sanitation measures, social distancing, mask use among staff members and quarantine protocols in the event of possible COVID-19 exposures. Finally, ask if staff members have enough personal protective equipment including masks, gowns, gloves and face shields.
Are staff members and residents fully vaccinated with boosters against the virus?
As of late March 2022, nursing home staff members have been required to be vaccinated against COVID-19 (with exemptions for specific medical and religious reasons), with all states in compliance. However, some nursing homes may still be lagging, putting residents at risk.
“Vaccination is prevention,” says Anne Montgomery, director of the Center for Eldercare Improvement at Altarum, a nonprofit health care research and consulting organization headquartered in Ann Arbor, Michigan. “Where we can make that happen, it’s incredibly important to this very vulnerable population.”
Do residents have private rooms and bathrooms?
In terms of infection prevention, private roomsand private bathrooms are much safer than rooms in which there are two or more residents, Montgomery notes. “And that’s what people want anyway,” she says. “They do want privacy, if you ask them. In their 80s and 90s, they would prefer not to have roommates that they’re never seen.”
What is the number of COVID cases that would trigger a lockdown?
Although lockdowns are no longer routine, that potentially could change if current or future virus variants spread widely and cause major outbreaks with severe illness. While lockdowns reduced exposure opportunities, they also left family members out in terms of making in-person visits.
During the height of the pandemic, Lambert notes, some family members removed residents from nursing homes, frustrated at not being able to assess firsthand whether they looked dehydrated or malnourished, were in pain, experiencing depression or if symptoms of dementia had worsened. It could also help to ask about the facility’s past experience with lockdowns.
What are your current visitor policies or restrictions?
As the pandemic eased, so did nursing homes’ visitor restrictions, fortunately allowing residents and loved ones to reconnect in person. However, some facilities may still limit the number of visitors in the building at a time, and may require visitors to wear masks or answer brief screening questions.
What are the staffing ratios?
Bolster your question with research: You can see state-by-state staffing data for individual facilities, including average hours for registered nurses, licensed practical and certified nursing assistants, via the website of the nonprofit Long Term Care Community Coalition. Also ask about staffing ratios at night and on weekends.
A resident’s acuity level refers to how complex their medical care is, how much assistance they need with activities of daily living and how much clinical expertise and caregiver resources their care requires. The minimum threshold for adequate staffing is 4.1 hours of care per day for low-acuity residents, Montgomery says. An essential question is: “Does the home have that staffing or not?”
What is your staff turnover rate?
Stable staffing is a good sign. In addition, consistent assignment — when the same caregivers are assigned to the same residents on a daily basis — is “critically important,” Grant says. That way, staff members really get to know residents, anticipate their needs and can recognize and address problems early.
Which standard and higher-level services do you offer?
Besides room, board and routine caregiving, ask about basic services included in monthly rates. If you’re undergoing rehab to recover from a hip fracture, you’ll need a higher level of care than some nursing homes can offer. A strong rehabilitation staff including physical therapists is essential in such cases.
Is your staff trained and experienced in managing this specific, complex health issue?
Residents may have a variety of clinical and health-related conditions to address, Bonner notes. “People who have certain complex health issues may do better overall in terms of their quality of life at a nursing home that has a really skilled staff that knows how to manage these things,” she says.
With medical conditions like chronic obstructive pulmonary disease, or COPD, for example, residents may require respiratory therapy and need help managing supplemental oxygen.
What do nursing home surveys show?
On an about-yearly basis, nursing facilities undergo inspections on behalf of the CMS. Survey data, reports and ratings are available to the public. Annual survey reports should be posted in each facility — and if you don’t see that, ask. Good nursing homes should have lower-than-average deficiencies, particularly in the categories of mistreatment, actual harm or immediate jeopardy. Otherwise, you should probably look elsewhere for long-term care.
You can check nursing home ratings including deficiencies by using the Nursing Home Compare tool on Medicare.gov. The most serious deficiencies are “immediate jeopardy,” which could be life-threatening, Montgomery explains. “If a nursing home gets that kind of citation or deficiency, it’s a much higher fine that they pay, and it’s a much more serious type of deficiency,” she says. “You would want to know: Are there immediate-jeopardy citations which this nursing home has had?”
How do you prevent pressure sores in this facility?
If your family member has mobility issues, in addition to inquiring about care protocols, ask about on-site equipment, such as special mattresses that can relieve pressure points. In general, residents should spend time out of bed daily when possible. Those who must spend all or most of their time in bed should be assisted in moving from side to side or with gentle limb movements to avoid immobility complications such as pressure sores and muscle deterioration.
That basically speaks to staffing, Montgomery says. “The adequacy of staffing is super-important,” she emphasizes. “The more needs you have for support with activities of daily living, the more important it becomes to have adequate staff.”
How does your facility avoid infections in general?
In 2016, the CMS mandated that nursing homes must improve their systems to prevent infections and detect outbreaks. However, infections like MRSA remain a problem.
“Infection control was a huge problem even before COVID,” Lambert notes. Ask about infection-control practices for employees, like yearly flu shots.
Who can I speak to about payment and financial issues?
“There is usually a business office and a person who’s in charge of the billing and payment related to new residents who come into the nursing home,” Bonner notes. The administrator should also have this type of information at hand and be able to discuss it with you.
What if I run out of money?
Involuntary nursing home evictions have been reported across the country. Ask about resident safeguards and make sure contact information is clearly posted for your state’s long-term care ombudsman’s office. Long-term care ombudsmen, who exist in every state, are advocates for residents of nursing homes and other long-term care facilities. (You may also want to speak to an outside expert on financing long-term care.)
Do you provide special care for people with dementia?
Memory care means much more than just a locked unit to prevent residents from wandering. Caregivers should have special training in dementia care, and the awareness and sensitivity to best address these needs.
How do you promote diversity so all residents feel comfortable?
One approach is to ask what kind of diversity training staff members receive, Grant says. Without that, for instance, some LGBTQ seniors may find themselves withdrawing socially when they become nursing home residents, making isolation a risk.
What about mood-altering medication?
Most facilities no longer use physical restraints. But so-called chemical restraint is another issue: when residents receive antipsychotic, anti-anxiety or antidepressant medications as a means to control their dementia or related behaviors. According to Grant, antipsychotic medication should only be used as a last resort, if at all — and only with consent, for a limited time period and with residents closely monitored for side effects.
How are you prepared for disasters?
In the event of hurricanes, fire, flooding or other disasters, nursing homes must have a disaster plan in place. Follow-up questions Lambert suggests include: “Is there a designated shelter in case of a natural disaster? How are immobile residents evacuated?”
Who do I go to if I have a problem with my family member’s care?
This is a really important question, Lambert says. “I don’t want to be passed along to two or three people,” she says. “I want one person to contact.”
There may be specific contact points for different areas, she adds, such as the director of nursing for related questions. However, “I want to know that I can pop into the executive director’s office anytime, ask any question and make any kind of complaint,” she emphasizes. “I want to know that person is available. Because sometimes, you have to go up to that level.”
Questions to Ask Dietitians
— How do you prevent residents from becoming dehydrated?
— What kind of food do you serve?
— How do you satisfy cultural and individual food preferences?
— Do you accommodate special diets?
— Can residents eat when they want?
How do you keep residents from becoming dehydrated?
Older adults are the most likely to become dehydrated. Lack of thirst, health conditions and medications all contribute to a higher risk of dehydration — as does dementia.
“If a (resident) has cognitive impairment, the only reliable way to keep someone hydrated is to have a care staff member come in on a regular basis during the day and remind them to drink,” Lambert says.
What kind of food do you serve?
Residents rely entirely on nursing homes to meet their nutritional needs. Healthy, tasty food improves everyone’s quality of life. Recent financial challenges may have affected food budgets in some facilities, Bonner notes. Make sure residents have access to more interesting food alternatives, not just basics like peanut butter and jelly sandwiches.
How do you satisfy cultural and individual food preferences?
People in nursing homes still want to enjoy meals that evoke family traditions and tastes they’ve developed over their lives.
Do you accommodate special diets?
Residents come in with their own dietary preferences and restrictions. Some also may have medical orders for soft or puréed diets, for example.
Can residents eat when they want?
Some people prefer to eat outside of routine schedules. For these residents, Grant says, it’s worth asking, “What if I like to get up late and I want to eat my breakfast at 10?”
Questions to Ask Residents
— Are you happy here?
— Are the caregivers kind to you?
— Do you have freedom of choice?
— How often does someone come to your room to help you get up?
After the formal tour, explain that you’d like a chance to speak with several residents. Drop in at the activities room or a lounge, introduce yourself, say you’re considering a move there and ask what living in the facility is like for them, Grant suggests.
Are you happy here?
“Do you enjoy living here?” “What do you like best about living here?” and “If you could change one thing, what would that be?” are positive ways to frame your questions and make residents more likely to respond.
Are the caregivers kind to you?
Ask specific questions along these lines, Lambert suggests: “Do you like the caregivers? What do you like about them? What do you like least about them?”
Do you have freedom of choice?
Does the facility offer resident-centered care? Are you able to get up when you want? Do you go to bed at the time you want?
How often does someone come to your room to help you get up?
It’s not just about having residents sitting in a wheelchair, Lambert says. Caregivers helping residents who are able to get up and walk around, for instance to activities or meals, is good for them.
“One of the biggest problems in nursing homes is leaving people in bed too long,” she says. When people don’t use their muscles, they lose stability and balance.
Questions to Ask Activity Directors
— What about activities? How do you keep residents engaged?
— Are there any activities on weekends?
— Does the facility have a resident or family council?
— Is reliable transportation available?
— Can residents easily spend time outdoors?
What about activities? How do you keep residents engaged?
Ask to see monthly activity calendars. Offerings should be varied and appealing.
Are there any activities on weekends?
Residents need stimulation seven days a week. Check activity postings for weekends, as well, Bonner suggests. In some cases, Saturday or Sunday offerings may be limited to watching a movie or puzzle time, not necessarily with an activities staff member present. “You may really have to drill down on some of these things,” she says.
Does the facility have a resident or family council?
These self-determined groups can provide a strong voice for quality care. “The resident council is the folks who actually live there,” Montgomery says. “They’re engaged residents who are trying to make the home as good as it can be. I would want to go and talk to the resident council for sure. ‘OK, what’s it like here? I’m sure everything isn’t perfect, but is it basically a good place to live?’”
Is reliable transportation available?
Many nursing homes have vans or specially equipped vehicles for transporting residents to medical appointments when necessary. However, transportation for other activities may not be readily accessible. “I’d want to know if there was transportation that would be available so that I could use it to go into the community,” Montgomery says. “I want to be able to enjoy events.”
With the pandemic beginning to recede, she says, there’s no reason a resident couldn’t go out to dinner, to church, to shop, to see family or friends or even go to the theater, with assistance. “Obviously, you can’t do that on a whim, but is that a feature? I would want to know that.”
Can residents easily spend time outdoors?
Attractive courtyards are sometimes the first thing visitors notice. But how often can residents, particularly those with mobility issues, actually go outdoors? Does staff encourage and help them to do so?
Questions for Outside Sources
By speaking with outside professionals and community sources with knowledge of local nursing home facilities, you can find additional, valuable perspectives. “Word of mouth is so important,” Bonner says. Friends, neighbors and other community members can share their feedback. “And talk to your primary care provider: a physician, nurse practitioner or physician assistant,” she suggests, as well as others with the office staff, like a care manager, or an affiliated social worker. You could ask:
— What do you think of this nursing home?
— What have your experiences been?
— Do you know someone who lives there?
— Can you give me any background information?
Organizations such as Area Agencies on Aging or community senior centers may also have information to offer.
Make sure that the most important voice — that of the would-be resident — is heard. Don’t make assumptions about what matters most to the family member who’ll actually be moving in, Bonner advises. They may value a nursing home with good food, enriching activities, a homelike environment and opportunities to interact with peers as much, if not more, than living in a facility that might be closer for visitors but with less to offer in terms of quality of life.
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Update 10/18/22: This story was previously published at an earlier date and has been updated with new information.