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 my recent 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.
How to Choose a Nursing Home
This is a big decision that will impact the health and happiness of your loved one. Take the time to choose a nursing home carefully by following the suggested steps below.
Make a list of potential facilities.
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 Care Compare site.
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 2024 list of SFF homes here. Additionally, this report list includes a list of nursing homes they consider candidates for SFF classification.
Get information from your local agency on aging.
A great source of information to help you choose a nursing home is your local area agency on aging, which is a public or nonprofit resource. Additionally, your local long-term care ombudsman, who helps residents resolve problems with their nursing home, should have valuable insights that will also help you choose a nursing home.
Use the US government’s Eldercare Locator website or call 1-800-677-1116 to find your area agency on aging and ombudsman. You can also find your local ombudsman through the advocacy group National Consumer Voice for Quality Long-Term Care.
Check out 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.
Who owns the nursing home?
Generally, nonprofit nursing homes provide better care because they can reinvest revenue back into the home. For profit homes must pay some of their revenue to owners and investors, leaving less for patient care and other overhead expenses.
However, there are some very good for-profit homes and some badly run nonprofits.
Unfortunately, most nursing homes in the US are for-profit, leaving you without a non-profit option.
According to KFF Health News, the more local and present the owner, the more likely the home will be well run. In many cases, the owners live out of state and hide behind corporate shell companies. Think twice if a nursing home can’t (or won’t) give you a clear answer when you ask about ownership.
Finally, ask if the home’s ownership has changed in the past year or so or if a sale is pending. Generally, owners of stable, well-run nursing homes are not trying to sell them.
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”, and/or “medication errors”.
Tour prospective facilities.
If possible, it’s great if you can “pop in” for an impromptu tour of the facility (likely with an employee). Popping in 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 – are residents engaged with others and in activities, or parked in wheelchairs in the hall?
- How the staff treats and cares for the patients – does staff know residents by name?
- 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 and family members as possible. Ask them:
- Are they happy?
- What do they like about living there?
- How is the food?
- Do the same staff members provide care, or is there a frequent change of staff?
- How long do they have to wait for help bathing or getting out of bed?
- Do they get their medications, physical therapy, and meals on time?
- Do aides come quickly if they turn on their call light? (Delays are strong signs of understaffing.)
Additionally, Medicare requires homes to allow residents and families to form councils to address common issues. If the nursing home has a council, ask to speak to its president or an officer.
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. Finally, ask if home is currently up for sale.
Quality of care concerns.
- 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.
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 how to avoid getting and spreading disease, including hand washing and disinfecting equipment.
Additionally, a nursing home’s program must detail when and how employees need protective equipment (gowns, masks and gloves). Lastly, each program must describe how to manage a contagious resident. Clearly, some homes do a better job than others.
Alarmingly, in an August 2024 report, the US Department of Health and Human Services’ Office of Inspector General estimates that about 25% of for-profit nursing homes in the US are likely not complying with federal regulations regarding infection control staff. Unsurprisingly, the report indicates that this failure increases the health and safety risks for residents and staff members.
Therefore, you must consider infection control measures when choosing a nursing home. Look for infection control ratings on the Medicare Care Compare site.
And when you visit, ask these questions:
- What infection control measures are in place?
- How and when are staff trained on these measures?
- How do you ensure all staff members follow the procedures?
- What steps are taken to ensure that sick workers don’t 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 were made?
For more information, read Germs in Hospitals and Doctor Offices – Watch Out!
Complaints filed.
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.
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.
Medical considerations.
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?
Emergency planning.
Ask about their plans for handling emergencies, including weather-related emergencies, fire, and disease outbreaks like COVID-19. Ask how they handle power outages – do they have generators that can power all medical equipment, elevators, A/C and heat, and lighting? Each facility should have a written plan – if they don’t, be concerned. Ask to see the plan and consider how well prepared they seem.
Staffing.
Staffing ratios.
How much staffing is enough? Unsurprisingly, the quality of care can suffer if there are not enough staff members to pay attention to residents.
Unfortunately, there no straightforward answer on the best levels for nursing home staffing. However, the level of staff needed depends on how frail and sick a nursing home’s residents are.
Nursing homes employ registered nurses (RNs), licensed practical nurses (LPNs) – also referred to as licensed vocational nurses (LVNs) – and nurse aides (CNAs). Importantly, RNs are the most skilled and manage patient care. LPNs/LVNs provide care for wounds and catheters and handle basic medical tasks. Finally, nurse aides help residents eat, dress, and get to the bathroom.
Importantly, experts cannot agree on the ideal ratios for staffing. Frustratingly, a study by the US government published in 2023 found quality improved with higher staffing but didn’t recommend a particular level.
Turnover rates.
How high is the turnover rate for nursing staff and for the leadership? Ask how long the home’s administrator has worked at this facility – ideally it should be at least a year. You should also ask about the tenure of the director of nursing. Finally, ask about the turnover rate for nursing staff.
Certainly, high turnover rates can indicate trouble.
How can you learn about staffing at prospective nursing homes?
You can find information on staffing levels, including administration turnover, on the Medicare site and/or the US News site. However, realize the information posted may be out-of-date.
Additionally, you should ask the following questions regarding their staff:
- 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? (Importantly, temp workers are less likely to know the residents’ needs and likes. A home that relies heavily on temporary staff most likely has trouble recruiting and keeping employees.)
What’s the cost?
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 concerns expressed by the family.
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 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.
Finally, see if there is outdoor space where residents and visitors can congregate.
Food concerns.
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 while touring, ask residents what they think of the food, and try to get a look or taste.
Transportation availability?
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.
Get references.
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 deal with any concerns or complaints raised by the resident or family members.
Additionally, ask them what they consider the best and worst things about the nursing home. And don’t forget to 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.
It can feel impossible to choose a nursing home. But hopefully your research will lead you to the best possible facility for your loved one’s needs. However, 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 to conduct appropriate research to help you choose the best possible nursing home for your loved one’s needs.
One final thought on medication safety.
No matter which nursing home you choose, realize 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 these posts:
- One Patient’s Tale of Medication Errors in Long-Term Care.
- Reduce Your Risk of Medication Errors.
- Medication Errors in Hospitals – How Can You Protect Yourself?
- Are Antibiotics Helpful or Harmful? What You Need to Know.
- Are Medications Safe?
NOTE: I updated this post on 8-26-24.