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How to Pick the Right Nursing Home

Author: Daniel Jackson

Your mom, dad or another close relative needs a nursing home. Finding the right facility, with a constant level of skilled care, is a serious undertaking. Bad nursing homes neglect, steal from and even abuse residents. Good ones help them live happy, dignified lives despite being in poor health and may even help them improve enough to move to assisted living or return home. Here are some tips on how to pick the right place.

Check the Ratings

A good place to begin narrowing your nursing home options is with the feds – specifically, Medicare's Nursing Home Compare feature. The Centers for Medicare and Medicaid Services (CMS), part of the U.S. Department of Health and Human Services, rates nursing homes based on comprehensive annual health inspections, 18 measures of residents' quality of life and staffing levels. The ratings are updated about once a year or whenever someone files a complaint against a nursing home with the state regulatory agency.

CMS gives each nursing home a rating from one to five stars. Avoid facilities with one or two stars, which indicate serious problems with residents' care; look for ones with four or five stars. Then, review the detailed ratings for each facility. A home might have five stars overall, but just two stars for quality measures (which reflects treatment of specific conditions). You can also use the nursing home search tool from ProPublica, an independent non-profit organization that conducts investigative journalism in the public interest, to search CMS reports on nursing home deficiencies. The site will help you uncover specific problems cited during nursing home inspections.

Once you have a preliminary list, call each facility to find out if it has beds available and to ask how much it charges for care, making sure to get detailed figures based on your loved one's actual needs. If there is no availability or the cost does not fit your budget, there's no use researching that home further. (For related reading, see Top 5 Strategies To Pay For Elder Care.)

Flaws in the Ratings

Ratings can give you a general idea of which facilities might be best and which to avoid, but they aren't perfect. The New York Times in August 2014 reported on how nursing homes were able to game the star rating system, since they actually supplied the data for staff levels and quality measures; only the annual health inspection ratings were based on independent observations. This means a facility could have a five-star rating, despite numerous complaints and even lawsuits over the quality of care. In January 2015, CMS introduced improvements to the two self-reported measures.

Nursing homes can game the independent health inspections, too. Although visits are supposed to be unannounced, Most of the time, a nursing home knows roughly when that state is coming in to conduct their audit and inspection, says Ryan McEniff, owner of Minute Women Home Care, a private home health care company in Lexington, Mass. For the days or weeks leading up to the state walking in unannounced, the nursing home staff is focused on making sure they are free of deficiencies. This is good and bad, McEniff says. Since they know they are going to be scrutinized, the staff is on their best behavior and not on their normal everyday routine, which can lead to a higher-than-deserved rating. On the other hand, if the inspection still garners a low rating, it suggests a nursing home's problems are so bad that it can't fix or hide them even if it tries, he says. (For related reading, see Alternatives To Nursing Homes.)

Digging Deeper

Families for Better Care, a Tallahassee, Fla.-based non-profit advocacy group, says your next step should be to contact your local long-term care ombudsman. Under this government-mandated program, ombudsmen regularly visit and advocate on behalf of nursing home residents. Ask your ombudsman for complaint data on the nursing homes on your list. You can even talk to the specific person who has visited each facility.

Other possible s of recommendations include doctors, elder law attorneys, elder advocacy groups, members of religious organizations or clubs you or your loved one belongs to, friends and coworkers. Make sure their recommendations are based on recent experience, as nursing home conditions can change.

Hospital discharge planners, on the other hand, may or may not be good s, given their interest sometimes in just moving patients out of the hospital, says Eric Carlson, directing attorney at Justice in Aging, a national organization that fights senior poverty.

Get Referrals

If the whole process of finding a reputable nursing home seems like more than you can manage, consider a placement service. These services can recommend facilities, take you on tours and help you negotiate a contract. We review the care and violation histories of the communities we refer to, every single time, before we do a tour, as the violation histories can change dramatically in a short period of time, says Haley Gray, owner of CarePatrol of the Triangle, in North Carolina. We know the individual facilities, and we review their care and violation histories regularly. We also follow up with our clients after they have been placed, so we know what the personalities of the individual communities are, she says.

A reputable service only deals with licensed facilities in good standing. Some of them, such as CarePatrol, don't charge the client anything. But Justice in Aging's Carlson issues a word of caution about that: "The free services often derive their income from fees paid by the nursing homes," he says. That could color their recommendations, or influence the selection of homes they offer you.

Because of this potential conflict of interest, you should research the placement service's reputation and independently verify any information the placement service gives you. Make your own, unannounced visits to the facilities you're considering. Also keep in mind that there may be excellent facilities available that the placement service will not refer you to because they are not contracted with that facility and therefore won't earn any commission for sending you there.

Pay a Call

Just as you would never buy a house sight unseen, you should never put yourself or a loved one in a nursing home without visiting at least once and interviewing the staff.

Watch for the following red flags, which indicate negligent or abusive care at a facility:

  • Lack of staff. One way common way facilities cut costs is by minimizing the number of employees, says Brian Lee, executive director of Families for Better Care.
  • Lack of respect for residents' privacy. Do staff knock and wait for a response before entering residents' rooms?
  • Uncleanliness. Are the floors dirty or sticky? Do you see dead bugs or rodent droppings? Does the nursing home smell like chemicals or human waste? Do the residents look clean and well-groomed?
  • Poor maintenance. Is furniture in disrepair? Do you see anything that looks shoddy or broken?
  • Lack of activities. Ask for a copy of the facility's activities calendar and ask questions to get an idea of whether scheduled activities have actually taken place.
  • No resident or family council. These groups meet independently to and regularly to discuss concerns about the nursing home and opportunities to improve quality of life for residents.

(For further reading, see Things Nursing Homes Are Not Allowed To Do.)

Ask Questions

During your visit, ask about the staff-to-patient ratio and how that ratio changes throughout the day and over the weekend. Ask about – and try to observe – how long it takes staff to respond to patients' requests for assistance. Visit during meal time to see if the food is appetizing and observe how staff interacts with patients of varying needs. Drop by unannounced, and, if you make more than one visit, try going at different times of day. In a good, secure facility, you probably won't get far, but it can be significant to see how long it takes a stranger's presence to register. And a place should be ready to give you a tour any time; the more impromptu, the more of a real-life perspective you'll get.

Ask how many hours of physical and occupational therapy residents receive daily, and ask staff how long they've worked there Also consider staff morale; if the workers seem unhappy to be there, that could indicate an underlying problem with the nursing home. Also ask staff what they'd like to see improved about the home.

The Right Match

A nursing home might check all your boxes, but at the end of the day, what makes a a place excellent on paper doesn't necessarily make it the right match for the person who's going to be living there.

A huge amount of the customer satisfaction with a community will boil down to individual preferences and tastes and the distinct personality of the community, CarePatrol's Haley Gray says. For instance, we see some communities are better for extroverts, or introverts. We think that it's important to be sensitive to LGBT issues, and religious issues, and to be careful of placement based on those needs as well.

The better nursing homes are more likely to incorporate principles of resident-centered care, which places higher priority on resident preferences, Justice in Aging's Eric Carlson says. For example, it would be a good sign if the nursing home would be flexible enough to make breakfast available even if the resident were to wake up relatively late. On the other hand, it would be a red flag if the nursing home insisted on regimented wake-up times or seemed largely unfamiliar with the concept of resident preferences.

The Bottom Line

After narrowing down your options using ratings and your local long-term care ombudsman, visit the homes with a strong sense of what you want. Don't be swayed by a beautiful lobby or a flawless official tour; visit unannounced and ask staff about the things that matter to you. Due to the stress of moving from one facility to another and the potentially life-threatening consequences of choosing a poorly managed facility, it's important to do the research thoroughly and pick the right nursing home the first time.

A nursing home receives thousands of dollars monthly for each resident through private payment, long-term care insurance, Medicaid and/or Medicare, and is required by the federal Nursing Home Reform Law to provide individualized care, Carlson says. It's entirely fair to expect a high level of services, given the significant expense of nursing home care.

For more information, see A Quick Guide to Medicaid and Nursing Home Rules and 5 Ways to Protect Pensions from Nursing Homes

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