Finding the right nursing home, step by step

4. Following up: Making sure you picked the right nursing home

You can't stop paying attention after a loved one has moved in. Vigilance is the price of good care.

You hope and pray the chosen nursing home is a good one. But the hard truth is that the first few weeks are bound to be difficult. And getting through them without trauma is no guarantee that the months and years ahead will be uneventful. You'll need to keep all of your powers of observation and diplomacy intact in order to monitor your loved one's care and be sure it remains as skilled and compassionate as possible. Here is time-tested advice from experts:

Expect an adjustment period. Moving someone you care for into a nursing home will be tense and painful. "It was the worst day of my life because it was the beginning of the end," Barbara Gortych says of moving her mother from assisted living into a nursing home in Florida. At every turn, she says, she asked herself: "Am I doing the right thing?" It is simply inevitable that family members as well as the newly admitted resident will experience some difficulty in the transition. Still, says Cheryl Phillips, chief medical officer and geriatrician for California-based On Lok Inc., a provider of long-term care and services for the elderly: "If after the first month or so your mom still seems absolutely miserable, it may be time to talk [and ask yourself], 'Do we need to look for a different facility?' "

During the first few weeks, watch for dramatic changes in the health, disposition or appearance of your loved one. While illness and accidents are facts of life in a nursing home, says Janet Wells, director of public policy for the advocacy group National Citizens’ Coalition for Nursing Home Reform, "someone who is relatively active shouldn't experience a steep decline." A rapid change may be because of inadequate care or neglect or abuse. Is your mother losing weight? She may have an undetected medical condition, or she may not be getting enough calories. Malnutrition is a significant concern in nursing homes. Tremors can hamper the ability to feed one's self and medications can cause appetite loss — or worse.

Broaden your focus over the long term. If your sharp and active mom becomes dull and lethargic, suspect drugs. An ongoing concern in nursing homes, says Wells, is "the use of medications to keep people quiet so they're not a bother and don't require staff." Besides lessening mental acuity, anything that discourages residents from getting out of bed and being active can instigate pressure sores and muscle atrophy, she says. She points to January's news that pharmaceutical company Eli Lily & Co. agreed to a $1.42 billion settlement with the federal government for marketing Zyprexa, an antipsychotic, as a drug for dementia. Zyprexa is not approved for such use. In addition, says Wells, it is one of the drugs that nursing homes sometimes give patients without dementia to make them easier to manage.

Check for special skills. You want the staff not only to be alert for health changes but to be able to manage them before they become major concerns. If your mother develops a painful bedsore, or pressure ulcer, is she treated by staff members specially trained in wound care? The federal Centers for Disease Control and Prevention reported in February that only 33 to 40 percent of nursing home residents with significant pressure ulcers received such care in 2004.

Be firm, but don't yell. Feeling guilty about having to admit a loved one to a nursing home or distraught and helpless as a family member's health declines, some families take out their emotions on nurses and aides — the very people charged with the resident's care. During her decades in the industry, Phillips, the California-based chief medical officer, has watched families explode at staff, shouting and making finger-wagging threats to sue. Bluster and anger never work, she says; "care for your loved one never becomes any better" because of such outbursts. The goal is to have these essential caregivers advocating on your dad's behalf — especially when you're not around.

One demand worth pressing, however, is that the same people care for your father regularly so that he gets to know them and vice versa. "A lot of nursing homes don't do that," says long-term care expert Charlene professor of the University of California, San Francisco, because staff schedules traditionally rotate. "[You may have to] argue with the nursing director to get a consistent staff assignment," she says, but "I think facilities will respond if families ask."

Win over the staff. Identify your dad's most consistent caregivers and ask them how you can make their jobs easier, Phillips suggests. Such efforts will reflect your respect for the people responsible for meeting the most basic and intimate daily needs of those unable to cope on their own. Get involved yourself if you can. Lighten an aide's load by coming at mealtimes to help your dad eat if he needs assistance, or take him outside to walk the grounds. Employees at the nursing home should respond. "I think the people who get the best care have somebody going as often as possible," says Harrington.

Share your inside knowledge. You can connect with staff by conveying information about personality quirks, special interests, or medical highlights. A father's history of depression or anxiety should prompt the question, "What were the things [done] at home that worked?" says Phillips. If classical music or e-mailing the grandkids lessened his symptoms, pass that along — and then bring in or mail the nursing home his favorite Bach and Mozart CDs, or arrange for a laptop so he can e-mail.

Ask staff about specific problems. Phillips cites one resident with dementia who became highly agitated when staff tried to get her to take a shower in the mornings. When her adult daughter found out, she explained that her mother's parents had been killed in a death camp during the Holocaust. "Strangers taking her to the shower had a very different meaning for her," says Phillips. So the routine was altered: The daughter brought her mother's bathrobe — a familiar, safe reminder of a bathroom routine — and was present several times when her mother showered; the schedule was moved from the morning to later in the day so her mother wasn't groggy and disoriented from just having awakened; and the same aide provided assistance, to avoid an unfamiliar face.

Be alert for nursing home shifts. Changes, not necessarily positive, can come suddenly and from unexpected directions. When her mother's small nursing home was sold to a large chain, says Janet Wells, "the quality of care went way down." Regularly chatting with staff and participating on the home's family council might help you catch wind of potential changes before they happen.

To see U.S. News' America's Best Nursing Homes rankings, go to usnews.com/nursinghomes.

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