Finding the right nursing home, step by step

3. The visit: How to size up a nursing home

Ask the right questions, know the signs of good and bad care, use your senses. It's detective work.

Once you've whittled down the universe of nursing homes to a few possibilities, it's time you visit. No matter how diligent your research, data are only part of the story, and glossy brochures are an unknown mix of facts and marketing. "A lot of facilities say they offer Alzheimer's care, but it doesn't necessarily mean they have [the correct staffing and] skills to do so." says Cheryl Phillips, chief medical officer and geriatrician for California-based On Lok Inc., which provides long-term care and services for the elderly.

You'll need to plan your tour in advance. Bring the U.S. News checklist to jog your memory. And be ready to use all of your senses, from sight to smell, to build a profile of each home. If time allows, visit more than once, ideally at different times of day and on different days of the week. On Saturdays and Sundays, for example, nursing homes may operate with lighter staff, which could compromise residents' care. Mealtimes can be particularly revealing — the routine, the quality of the food, and the attention paid to residents who require help eating. As you look around, keep the following points in mind.

Fancy wallpaper is nice, but… Institutional white walls are hardly inspiring, and a drab environment can sour the soul in people already prone to depression. It's natural to equate a sunlit lobby and tasteful decor with high quality. But there are better ways to gauge a home's overall vibe. Look for a full parking lot when you arrive, says Susan Reinhard, senior vice president for public policy at AARP and a former professor of nursing. Throngs of visitors tell you families and friends are welcome. Do you hear the chatter of grandchildren? Laughter? Music? The nursing home Barbara Gortych chose for her mother "may not have been the fanciest, but the quality of care I liked very much." She recalls observing the facility before moving her mother in and finding the staff plentiful, efficient, and tender. And her impressions remained consistent; "My mother could give you a run for your money," she explains. "They never seemed to lose their sense of humor."

Do you smell urine? It not only is unpleasant, but it suggests understaffing and goes beyond keeping residents dry and comfortable. Incontinence is a major reason for moving someone to a nursing home, and urine-soaked pants or bedding can break down elderly skin. And while some residents may need a urinary catheter because of a temporary or continuing medical condition, catheterization should never be used to manage incontinence, says Phillips. Long-term use invites urinary tract infections that can be deadly in individuals whose health is already compromised. Helping residents get on a regular bathroom schedule — which requires adequate and efficient staffing — is a primary tool for managing incontinence. Pay a visit in the morning to see how the staff handles residents who are just waking up and may have not been to the bathroom all night. No urine odor but a strong antiseptic smell? It might be an attempt to cover poorly monitored incontinence.

Quiz administrators who know the numbers. Bring along printouts or notes of Best Nursing Homes data, and ask for explanations in a friendly, nonconfrontational manner, suggests Phillips. “If they’re a five-star facility, ask how they got there,” says Janet Wells, director of public policy for the National Citizens’ Coalition for Nursing Home Reform, a Washington, D.C.-based advocacy group. If the facility is down at two or three overall stars, or performance in a particular area such as medical quality measures seems questionable, ask the administrators how they got those marks and what they've done to improve. The medical quality measures and staffing sections are based on self-reported data, so a touch of skepticism is healthy.

If you've haven't already absorbed the home's inspection reports by finding them on your state Web site (not all states post them), ask an administrator to show them to you. Also ask for previous reports. Nursing homes don't have to let you read the Form 2567 survey reports other than the most recent one, so if a home has retained them and gives you access to them, that is a good sign. Comparing several consecutive surveys could reflect a facility's progress — or a slip in care. The observations of the survey team on the 2567 forms will draw a picture far more vivid than any guided tour ever could — a pile of soiled linens in the hallway, food left on a counter for hours. "If it's thick, that's already a warning," says Wells of the survey report, which covers about 180 individual health-related requirements. The details can also inspire more pointed questions for the director of nursing or an administrator, as the facility's plan for correcting the situation is also on the 2567 form. And if the home's managers are too busy to help you understand the details — even by appointment — that tells you something about the staffing level or openness. Or both.

Ask about the violations described on the 2567 form. If an inspection report states that nurses didn’t wash their hands as they went from one resident to another, ask why not and what has been done to address the findings. Infections are doubly worrisome in nursing homes: The elderly are more susceptible to disease, and the close quarters — and shared, hands-on care from nurses and aides — make for efficient transmission. Other red flags, says Wells, include untreated weight loss, which can lead to significant frailty; medication errors; untreated pressure sores, which can be painful and can send a resident along a bedbound trajectory; and use of physical restraints. While declining in popularity, "safety belts" that strap a resident into a wheelchair or bed, says Wells, may actually trigger harm if a person already prone to poor balance tries to get free and falls in the process.

As picky and obsessive as inspection findings may read, they often don't go far enough. A 2008 report by the Government Accountability Office concluded that the state surveyors frequently miss or understate the extent of serious care problems. Between 2002 and 2007, federal surveyors did follow-up inspections of nursing homes recently evaluated by their states. They found that 15 percent of the state surveyors had overlooked at least one problem carrying a risk of death or serious injury, such as untreated pressure sores or weight loss.

Discuss staffing with administrators. The National Citizens’ Coalition for Nursing Home Reform, which has a helpful explanation of the ways in which nursing homes are measured, suggests a ratio of at least 1 registered nurse, licensed practical nurse or certified vocational nurse, plus 1 certified nurse assistant for every 5 residents during the day, every 10 residents during the evening, and every 15 residents at night. A home's director of nursing should be able to give you these numbers, and the Best Nursing Homes page displays ratios of nurses to patients, although they are not broken down by time of day.

High staff turnover is a special challenge for nursing homes. "Three out of four staff leave every year," says Charlene Harrington, professor at the University of California, San Francisco, and an expert in long-term care. "That's a new staff person about every three months." Studies show that high turnover rates lead to generally poorer care. One study suggests that families should look for a turnover rate below 30 percent for registered nurses, below 50 percent for licensed practical nurses, and below 40 percent for nurse assistants. Until CMS begins providing turnover data, all you can do is ask a home for its  turnover rates. You could also chat up some of the nurses and aides about how often employees seem to come and go.

Even if turnover is low, scheduling can hamper care. "Does the facility tend to have the same caregivers day after day, or do they randomly assign ... or rotate staff?" asks Phillips. The more consistent the contact between your mother and her nurses and aides, the better they will understand her needs and be her intelligent advocates.

As part of selecting trustworthy staff, nursing homes are required to run a state background check before a hire, but some facilities are broadening their due diligence by also conducting a national background check. The more thorough, the better.

Not all nurses are the same. Some homes make frequent use of temporary or "agency" nurses; others do so only occasionally, and still others have a policy against using them at all. Ask. "If they're doing it regularly," says Wells, "it probably means they're desperately understaffed."

A first impression of an abundant nursing staff may be misleading. Some may be private duty nurses hired by families to supplement the care provided by the home. Ask an administrator or nursing director.

Tailor your questions to your loved one's needs. No one facility is best for everyone. Your 85-year-old father needs a shorter stay but a higher level and intensity of nursing if he is being discharged from a hospital after a bout of pneumonia than if he needs management of a chronic condition like diabetes or heart failure. If your mom recently had a stroke, ask about stroke rehabilitation and how she will be kept safe and mentally engaged. Don't settle for "we have lots of residents who’ve had a stroke and plenty of services for them." You want specifics, says Reinhard of AARP. First, find out from your mother's doctor how many rehab hours of stroke care are needed, say, of speech and occupational therapy. Using this as a baseline, you'll want the nursing home administrators to prove they've got a robust staff appropriately trained to provide the therapy your mom needs, she explains, not that their therapists come in for a few hours a week and serve a long list of residents.

A history of falls often leads families to consider a nursing home. If that is one of your concerns, ask how falls are prevented. "Do they just use lap belts?" says Phillips, who also specializes in geriatric medicine. Or, because nighttime trips to the john are a frequent cause of falls, "do they have exercise and balance programs, and creative ideas like [foot placement] maps on the floor" leading from the bed to the bathroom? A night light next to the bed may be helpful, she explains, or the family may need to goad staff to be proactive, checking on your mother every few hours at night to ask gently if she needs help going to the bathroom.

Observe — and talk to — the staff. Your loved one will spend more time with nurses and aides than with anyone else, so watch how they relate with residents and one another. When Michelle Becker visited a nursing home on the shortlist of possibilities for her grandmother, she saw a resident in a wheelchair laughing and joking with a nurse seated nearby. Becker, a registered nurse who works for an elder services company in Milwaukee but spent a few short stints working in nursing homes, wondered whether duties somewhere else were being shirked. She and her family ultimately chose that home, deciding that what counted was the evident caring and connectedness that Becker had observed. On a tour of a different nursing home, Becker was turned off when she saw call lights blinking outside several rooms, only to see the same lights still blinking when she swung back later. It suggested inefficiency, short-staffing, or plain lack of caring.

How staff members interact with each other is another tip-off. At yet another nursing home Becker visited, she was repelled by gossipy chitchat she overheard at a nursing station. "They were talking about how 'So-and-so didn't show up for work this morning — they were probably out partying,' " says Becker. And the cluster around the station made her wonder, again, whether residents' needs were being neglected. Becker hardly felt comfortable at the idea of her grandmother in the care of such staffers.

At some point during a visit, go right to the source. Ask several nurses and aides how many residents they have to care for on a daily basis and how heavy they feel their workload is. Harrington has seen the threshold at some facilities reach 12 or 15 residents per staff member: "That is really not enough."

Watch how they eat. Malnourishment is often a very real concern for elderly people and nursing homes alike. To gauge a home's commitment, visit at least once during mealtime. "Some homes give hardly any help," says Harrington. Enough aides should be available to help all residents who have trouble feeding themselves. "It takes at least 30 minutes," she explains, to help such a person eat safely and have enough time to chew slowly without choking. Keep an eye out for untouched trays being picked up from the cafeteria tables or from residents' rooms — a possible signal that staff isn't giving those folks the assistance they need. Fresh water should also be readily available in all parts of a home because dehydration plays into the challenge of keeping residents properly nourished. Sparking residents' appetite, too, must be taken seriously as they often take medications that can blunt their interest in eating. Phillips recalls how one nursing home piqued residents' urge: As the time neared, a bread maker would be plugged in at the nurse's station, and "the aroma of baking bread would stimulate their appetites."

See how they play. No matter what age, everyone needs recreation and playful stimulation. Walk into a nursing home and see wheelchairbound residents parked in a semicircle around the television? "That's kind of a bad sign," says Harrington. Checking the activity schedule or, better yet, speaking with an activities director, will give you a feel for the facility's level of creativity — even if funds are tight — and its commitment to residents' emotional and cognitive health. Excursions should be expected, says Harrington, to the local art museum, a park, or a ballgame. And because volunteer groups are typically just a few phone calls away, Harrington says a facility should be able to recruit outside help, say, someone to come in and teach an art class, kids from a nearby school to do skits, or amateur musicians to perform. Special events — like a barbecue to which families are invited or holiday-themed parties — should be regular occurrences.

Talk to residents and their families. These people will have some of the best insights about the level of care at a given nursing home. But a generic question like, "Are you happy here?" will get you a generic response. It's wise to tactfully inquire about the things that matter most to your loved one. If incontinence is a primary reason you're considering moving your mother into a nursing home, ask residents if they get timely help to make it to the bathroom. Wells suggests also posing similar questions to family members: "If your parent needs to go to the bathroom, do they get help? Have you ever visited to find your mother sitting in her own waste?" If your concern about your dad is that he's not particularly mobile, tailor the inquiry, says Wells: "If they have a pressure sore and need to get repositioned, does it happen?" Be sure to ask if the residents have the same nurses and aides caring for them most of the time. Being on the receiving end of a rotating staff schedule is unsettling, and the nurses and aides won't get to know your loved one's specific medical needs and personality quirks. Many facilities have resident or family councils that may be able to offer advice and comfort.

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