Whether a loved one needs temporary care after an illness or injury, or more permanent care, moving a loved one to a nursing home is a difficult decision. Although you might not be able to meet the physical and/or medical needs of a loved one, it’s natural to feel reluctant to take this step. Of course, you want your loved one to feel happy, safe and well-cared for. If you are ready to choose a nursing home, realize this is a process. Before deciding, conduct online research and visit several facilities in your area in person.
Also, it’s important to realize there are safety risks for patients in nursing homes that can cause serious patient harm or even death. Therefore, I strongly suggest you read last week’s blog post for information on what kinds of health risks patients face in nursing homes and consider these risks when it’s time to choose a nursing home.
Before we go further, I want to clear up any potential confusion. Nursing homes are sometimes referred to as skilled nursing facilities. Of the 15,000+ skilled nursing facilities in the US, 90% are also certified as nursing homes. Although this article refers to choosing a nursing home, the information applies to any skilled nursing facility.
Make a list of potential homes.
First, get personal recommendations. Ask friends, neighbors and relatives if they, or people they know, have stayed in a skilled nursing facility in the past year or so. Find out what places they recommend and what places they think you should avoid. If you get a list of options from a case manager, try to find people who stayed in these facilities. Consider posting on social media to quickly and easily expand your reach.
Where can you find information online to help you choose a nursing home?
The first thing you should do is make a list of facilities that are conveniently located. Let’s be honest – long drives and/or difficult parking discourage visitors, an important part of your loved one’s life. Ask medical providers, friends and families for recommendations. Conversely, ask others which facilities in your area to avoid.
Once you have a list of possible facilities, conduct online research, as suggested below:
Medicare’s Nursing Home Compare.
The best place to start your online research is Medicare’s Nursing Home Compare site. The Centers for Medicare & Medicaid Services (CMS) uses a 5-star rating system to help the public evaluate nursing homes. The website includes an overall rating for a facility, and separate scores based on health inspections, staffing and quality measures.
But it’s critical that you realize that high CMS ratings do not translate into a promise of patient safety and high quality care. For example, according to a Kaiser Health News article, 40% of nursing homes with 5-star ratings have been cited for a lapse in infection control. Not surprisingly, the Kirkland, WA Life Care Center nursing home with a high number of COVID-19 patient deaths falls into that category.
And, there’s one more thing important to understand when reviewing the information in the Medicare website. Although Medicare has tough safety standards, they do not uniformly enforce their standards. As you might expect, some inspectors are tougher than others. And sadly, some states do not conduct their onsite investigations in a timely manner after serious complaints have been filed. In fact, the 2017 HHS report found that almost 1/4 of the states did not meet Medicare’s performance threshold for timely investigations.
Check out the Medicare list of homes to avoid.
The Centers for Medicare & Medicaid Services (CMS) keeps a list Special Focus Facilities (SFF) – nursing homes with a history of serious quality issues. These facilities have:
- More problems than other nursing homes (about 2x average).
- More serious problems than most others (including patient harm or injury).
- A pattern of serious problems that has persisted over at least 3 years.
Find the February 2020 list of SFF homes here. Additionally, this report list includes a list of nursing homes they consider candidates for SFF classification.
U.S. News and World Report.
The U.S. News and World Report has a website that provides reports on over 15,000 nursing homes in the US. Information on each nursing home includes an overall score, as well as ratings on staffing and other quality measures.
Read Yelp reviews.
Although I would never suggest you choose a nursing home based only on Yelp reviews, it is a good place to get information. Recent research found that nursing homes with positive Yelp reviews and high ratings with Medicare’s Nursing Home Compare had hospital readmission rates 2% lower than facilities with low ratings on both sites. Hospital readmission rates are an important measure of the quality of care provided and the quality of patients’ lives. And, although a 2% reduction is small, the researchers found it statistically significant. However, it’s important to note that researchers did not distinguish between necessary rehospitalizations versus those that could have been avoided.
Additionally, the Yelp reviews may contain comments that illustrate people’s perceptions of nursing homes that are not reported elsewhere. For example, Yelp reviews may provide insight into the quality of the building and equipment, staff attitudes and behaviors, their ability to manage pain and potential communication issues.
Do a little detective work yourself.
First, perform a “deep dive” of prospective nursing home websites. And to find out about past complaints, type in the name of the facility with the search terms “complaint”, “quality of care” or “medication errors”.
Tour prospective facilities.
After you’ve narrowed your list, it’s important to visit your top choices in person. Your visit should focus on quality of care provided and the interactions between staff and residents. If possible, it’s great if you can “pop in” for an impromptu tour of the facility (likely with an employee). This will help you get a feel of what life is like there for residents, avoiding prearranged tours that might not portray reality.
As you walk around the nursing home, try to get a sense of:
- How well cared for the residents seem.
- How the staff treats and cares for the patients.
- The demeanor of the staff (are they smiling or scowling?).
- The cleanliness and ambience of the facility.
While touring a home, talk to as many residents as possible. Ask them if they are happy and what they like about living there.
What factors should you consider when you’re ready to choose a nursing home?
There are so many factors to consider when choosing a facility. Of course, you want a home that meets as many of your loved one’s needs as possible, while keeping them safe and comfortable. Consider the following recommendations when you research online, visit nursing homes and speak with others regarding their own experience and recommendations:
Certification and experience.
First and foremost, check the Medicare’s Nursing Home Compare website to make sure any facility you consider is licensed and certified by CMS. And find out how long has the facility been certified.
Also, find out how long the nursing home has been in operation and if/when it’s changed management. And ask about the experience, tenure and turnover of the top leadership.
Quality of care concerns.
Clearly, the quality of care provided should be of utmost concern. Use the Medicare site and/or the US News site to learn about inspection results and quality of care measures. Make note of the percentage of residents who:
- Go to the emergency department and/or are hospitalized
- Report moderate to severe pain
- Experience one or more major falls
- Develop a urinary tract infection or bed sores
- Lose control of bowel and/or bladder
- Have a catheter inserted and left in their bladder
- Are physically restrained
- Have lost the ability to move independently
- Have lost too much weight
- Show signs of depression and/or anxiety
Infection control measures.
Everyone needs to take infection control measures seriously. Consider the terrible COVID-19 outbreak at the Life Care Center in Kirkland, WA. Sadly, about 57% of patients there were hospitalized for COVID-19 infections, leading to the death of at least 29 patients. The virus spread as staff members worked while sick. Additionally, a lack of personal protective equipment and failure to follow infection control procedures fueled the spread.
Importantly, Medicare requires that all nursing homes that accept Medicaid and Medicare payments have a written plan to prevent and control infections. These infection programs must teach workers on how to avoid getting and spreading disease, including hand washing and disinfecting equipment. Additionally, they program must detail when and how employees must use protective equipment (gowns, masks and gloves). Lastly, each program must describe how to manage a contagious resident. But, as you can imagine, some homes do a better job than others.
Therefore, infection control measures must be considered when choosing a nursing home. Look for infection control ratings on the Medicare Nursing Home Compare site.
And when you visit, ask these questions:
- What infection control measures do you have in place?
- How and when do you train new staff on these measures?
- How do you make sure all staff members follow the procedures?
- What steps do you take to ensure that sick workers do not come to work? Do you have paid sick time to discourage employees from coming to work sick?
- Do you have an adequate supply of personal protective equipment? How do you know it’s enough?
- Are gloves and sanitizer gel available in every room?
- Has the facility ever been cited for infection control failures? If so, what specifically was found? When? What changes did you make?
For more information, read Germs in Hospitals and Doctor Offices – Watch Out!
Consider the number of complaints filed against a particular facility. Clearly, the more complaints filed against a particular facility, the higher the risk of abuse or neglect. You can find this information both on the Medicare site and the US News site.
Location, location, location.
Like in real estate, location matters. Try to find a place that is convenient for you and others to visit your loved one. Not only do residents enjoy regular visits from friends and family, visits can boost their emotional wellbeing. Moreover, visitors can address any quality of care issues they notice during visits. Finally, the staff may provide better care if they know a family is involved and watching for potential problems.
Find out what types of medical care is available to residents. Ask about the qualifications and hours of the doctors, nurses and other staff. And find out how often, and under what circumstances, residents see doctors and nurses. Ask about what kinds of medical testing and services residents can receive at the nursing home, instead of traveling to a doctor or hospital.
Furthermore, if your loved one has specific medical needs, such as Alzheimer’s, ask how they will address his/her needs and how they will keep your loved one healthy and safe. Finally, ask how they handle residents who get sicker. Under what circumstances, if any, would your loved one need to go to a different facility?
- How are employees selected?
- How are employees screened for drug use, criminal records, and other potential problems?
- What is the turnover rate for skilled employees?
- How long is the average tenure of staff (RNs, LPNs, and CNAs)
- What is the ratio of staff to residents during each shift?
- Do they struggle to find qualified employees?
- Do they use a staffing agency? If so, what percent of their employees are from staffing agencies?
What’s the cost?
Stays at nursing homes are expensive, so don’t be shy about asking about costs. Ask about the baseline expense, and what that includes. Ask what services they provide and how much each service costs. Find out about Medicare coverage. Generally, Medicare may cover the costs of short-term nursing homes in certain situations. Typically, Medicare would pay for up to 100 days if a doctor referred the patient after a hospital discharge. After that period, personal funds or other insurance (such as long-term care insurance or veteran’s benefits) must pay the costs.
In addition to the base pay, find out about the cost difference between a single room or one with a roommate. And, ask about the expected cost of “extra” items, including prescription drugs. Lastly, ask if there are any measures you can take to reduce the bill, such as doing your loved one’s laundry yourself.
How do they develop care plans?
The nursing home’s doctor must evaluate every resident to develop a care plan, detailing medical care, medication, dietary concerns and any other pertinent care-related items. Talk to the nursing home administrator or nursing staff (not just the marketing person) about how they create care plans and how often they update each resident’s plan. Additionally, ask how they address changes in health and any family concerns.
Daily living needs.
If your loved one will need help with daily living activities, such as bathing, eating, dressing and toileting, find out how and when they provide help. Also ask if about fees for this additional help.
The fun stuff.
Many nursing homes have programs to help keep residents socialized, active and happy. Ask to see a daily or weekly schedule of group activities to ensure your loved one will find suitable activities. Many facilities offer a variety of options, including art classes, movies, games, exercising, dancing, singing, lectures, and more. If your loved one enjoys books, find out if there is a library with large print and audio books. If relevant, ask about religious services. Finally, ask if (and when) they take residents to community events, such as concerts and museums.
And don’t forget to ask about visitation rules. Are visitors welcome any time, or are restrictions in place?
The living spaces.
Look at the room options to get an idea of the size and amenities of the rooms and bathrooms. Look for safety devices, such as grab bars in the shower and near the toilet and conveniently located emergency call buttons. If your loved one needs a bed rail, ask if they can provide one. Find out if they allow personal objects, including small furniture, artwork and plants. As appropriate, ask if residents can have a pet. And look for outdoor space available to residents.
Additionally, ask if your loved one will share a room or have a single. Find out how do they determine where to put each resident. And ask what happens if roommates cannot get along.
Unfortunately, these homes are not known for fine cuisine, but some are better than others. Frequent repetition of the same meal can take any pleasure out of eating, so, ask to see a month calendar of dinner selections to see how often a particular meal is repeated. And if your loved one has special dietary restrictions, such as kosher, vegetarian or vegan, or dairy intolerance, ask how they will accommodate these special needs.
Since dining with others provides important social connections, it’s great if residents eat together in a communal room. Ask where residents generally eat each meal. For communal meals, how do they decide who sits where? Does the seating plan rotate? And, if communal meals are the norm, what happens when a resident is too ill to make it to the dining room?
If possible when touring, ask residents what they think of the food, and try to get a look or taste.
Ask about the availability and cost of transportation to medical appointments, errands and religious services.
The admissions process.
Every nursing home has their own rules regarding the admissions process. Find out what financial information they will need and how long the process normally takes. Don’t sign any contracts without taking the time to carefully review them – asking for copies early in the process can save time and hassle down the road.
Once you’ve narrowed your list, ask each facility for names and contact information for relatives of current residents. Ask them about the quality of care provided, any concerns they have had, and how staff deals with any concerns or complaints raised by the resident or family members. Ask them what they consider the best and worst things about the nursing home. And ask about the quality of the food.
Some nursing homes use surveys to measure the opinions of residents and families. Ask each nursing home if they conduct this type of survey, and if so, ask for a copy of the results.
When possible, take your time to choose a facility.
Hopefully your research will lead you to the best possible facility for your loved one’s needs. But it turns out that people frequently make poor decisions. The 2018 MedPAC report states that almost 84% of Medicare patients who go to a skilled nursing facility after a hospital stay could have selected a higher-rated facility within a 15-mile radius.
So, don’t let feeling overwhelmed and stressed lead you to a less than optimal choice. Take the time needed to conduct appropriate research.
One final thought on medication safety.
Medication errors are common in nursing homes and other long-term care facilities. Fortunately, there are steps you can take to reduce the risk of medication errors and subsequent harm. Read my blog posts:
- Medication Errors in Long-Term Care Facilities – One Patient’s Cautionary Tale.
- Reduce Your Risk of Medication Errors
- How to Avoid Medication Errors in the Hospital and at Home.
- How Can Hospitals Reduce Medication Errors?
- Are Antibiotics Helpful or Harmful? What You Need to Know.
- Doctors Prescribe Too Many Medications.
- Are Medications Safe?
NOTE: I updated this post on 5-15-20.