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Guide to Choosing a Nursing Home (Part IV)

Health Care Financing Administration (HCFA) has published a booklet entitled "How to Choose a Nursing Home."

Table of Contents

Visiting a Nursing Home

Talk to Residents and Staff

It is very important for you or a family member to visit a nursing home before becoming a resident. A visit provides you an opportunity to talk not only with people who work at the facility, but more importantly, with the people who live and receive care at the nursing home and their families.

Ask residents what they like about the home and what they do when they need something to be different. Ask them what they like about the staff. Ask visitors or volunteers the same questions. If you see no volunteers, ask why none work in the home.

Take advantage of this opportunity. You can gain valuable insight into the quality of life in the facility.

When and How Often Should You Visit a Home?

Ideally, you should visit a nursing home more than once and during different times of the day. One visit should be during late morning or midday so you can observe whether people are out of bed, and, if possible, whether the noon meal is being served. You should also plan to visit during the afternoon to observe activities as well as during and after the evening meal and evening hours.

The first time you visit a nursing home, make an appointment to see the administrator or admissions director so that you can fully explain the purpose of your visit. Mention that you would like to watch the daily routine at the nursing home, including staff preparing and serving a meal in the dining room and to residents in their own rooms, and observe as many different resident activities as possible, including therapy sessions.

Most nursing homes will gladly arrange for a guided tour of the facility, and they should be able to direct you to the posted Residents' Bill of Rights. You may ask for a copy of the statement, which you can then review carefully at home. You may also ask to see the posted results of the nursing home's most recent Medicare and/or Medicaid survey of the facility and the resulting plan of correction, if there were problems.

The administrator or admissions director can also arrange for you to speak with any of the staff, including the nursing home social worker. In fact, when you visit a nursing home, you should carefully observe staff members at work. Once again, the interactions among staff and between staff and residents should be warm, but professional. You should also note the physical condition of the nursing home.

Is the building clean, free from overwhelming odors, and well-maintained?

Evaluate the quality of the care and concern for residents you see. For example, do nursing assistants speak slowly and clearly so the resident can hear and see them? How does the staff react when a resident's behavior is inappropriate? How does the staff respond to residents with Alzheimer's disease or residents who seem to have some impairments in expressing themselves? Overall, does the staff show an active interest in and affection for individual residents? In addition, ask residents if there is enough staff to meet their needs.

Form Your Own Impressions

Although a formal tour is useful, it is important that you talk to residents and observe conditions in the nursing home by yourself, without facility staff assisting you. Make an unscheduled visit.

Ask residents their opinion of the nursing home, and if they will show you around the facility. In either case, be observant. Notice whether the residents are dressed neatly and appropriately for the time of day. Ask how often residents get a full bath or shower. Do they appear to be contented and enjoying the activities, and do residents interact with one another?

Remember, although some residents may prefer to watch rather than participate in activities at the nursing home, if most residents are passive, it may be a sign that the home has no activity program or that residents are kept on medications.

Are residents eager to discuss their feelings about the nursing home with you, or do they appear apathetic about their surroundings? Ask residents whether the facility has a resident council a committee of residents that helps advise the facility about resident concerns, needs, wants, likes, and dislikes. The law does not require nursing homes to have such councils.

And, if possible, meet with members of the family council at the nursing home. Family councils, which are similar to resident councils, are composed of family members of the facility's residents. Even if the nursing home does not have a family council, ask to speak with family members of residents of the facility. Also note whether visiting hours are generous and set for the convenience of residents and visitors.

In making these kinds of observations, trust your instincts and perceptions. Be certain to bring a note pad and pen with you to make notes about your impressions soon after you leave the facility. Impressions become blurred with time.

Medical Services

Medical and nursing care are crucial to you or your relative's welfare as a resident of the nursing home. Therefore, you need to spend extra time to ensure your needs will be met in this important area. In most cases, you can choose your own physician, even for emergency care.

Nursing homes also have their own physician. You should understand how often the physician visits the facility and reviews medical records of the residents. Does the physician and nursing staff meet with residents and their families to develop plans for treatment? On average, how many residents is each nurse aide or direct care nurse assigned to care for? Are licensed nurses on duty around the clock? If not, is there 24-hour access by telephone? In addition, will the confidentiality of your medical records be assured? The importance of understanding the answers to these questions in part depends on the needs of the individual resident. Still, you need to know the answers in case you need medical treatment.


The law strictly limits circumstances under which facilities can physically restrain residents in beds or chairs. Residents can never be restrained simply for the convenience of staff. All physical or chemical (medication) restraints must be ordered by a physician. Many nursing homes are making progress in finding other, safe ways to care for residents without restraining them. If you see residents with restraints, you should carefully question the staff about the nursing home's philosophy on the use of restraints. Ask what kind of activities and rehabilitation are used to keep residents restraint free.

When a medication is used, facility staff must check the resident to make sure there are no adverse side-effects. When a physical restraint is used, the resident should be monitored frequently to see that all is well, and to take care of any physical needs such as toileting.

Remember that federal law states that nursing home residents have the right to be free from any restraints administered for purposes of discipline or convenience, and not required to treat medical conditions.

In addition, the law says you will have the right to be free from any type of abuse-verbal, sexual, physical, and mental. That includes corporal punishment and involuntary seclusion.

Food Services

The preparation and serving of meals is one of the most important services provided to nursing home residents each day. On your visit to the nursing homes, take the time to watch servers in action. Ask to sample the food. Are hot foods served hot?

Ask the dietitian at the facility for a list of menus for the month, and ask how special diets are handled. Among the questions you should get answers to from both the dietitian and residents are:

    • How much time is allowed for eating each meal?
    • Is food delivered to residents who are unable or unwilling to eat in the dining room?
    • Are snacks available?
    • Are those residents in need of special equipment or assistance at meal time provided with such equipment or assistance?

As you watch residents eat their meal, note whether they seem to be enjoying the food. Talk to residents about the quality and variety of their meals.

Fire Safety

Although nursing home fires causing multiple deaths do not occur often, fire safety is very important. It is often difficult to evacuate residents quickly enough should a major fire erupt. Therefore, review the facility's fire safety training program. Do all staff know what to do? Are residents provided a supervised place in which to smoke?

Follow-Up Observations

When deciding on which nursing home to enter, one visit is not enough. Ideally, you should plan on a second and, if time permits, a third visit to a facility after reviewing your written notes from the initial visit. Once again, you should make unannounced visits to the nursing home.

On your follow-up visit, go back at a different time of the day, preferably during the evening and/or weekend. There are usually fewer staff on duty at that time, and the visit will give you an indication of the types of evening or weekend activities, if any, that are available for the residents. These visits will also give you a way to compare the level of attention that staff give to residents and whether the attitude of staff is the same during the night and day and during weekdays and weekends.

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