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How to Choose a Nursing Home: The ‘Do’s’ of Due Diligence

Where to start - These pointers may help caregivers with the sometimes daunting task

The process of selecting a nursing home for a loved one can be both daunting and frustrating—and sometimes even contentious if many family members are involved. “Most families do this in a time of crisis,” says Toby S. Edelman of the Center for Medicare Advocacy, a nonprofit education and advocacy organization. “It’s very difficult to choose.”

But with diligent research and a hands-on approach to vetting the nursing home candidates, you can assure yourself and your loved one that you avoided questionable choices and did the best you could.

It may, of course, be both prudent and advisable to search out alternatives to a nursing home—most families do. Older Americans' shift to remaining in their own homes as they age is bolstered by an ever-widening array of options for receiving home- and community-based care.

If you decide to look into nursing homes, her are some pointers to help guide your search:

Know your rights. Hospitals seeking to discharge patients will recommend nursing homes, but often without leaving families enough time to investigate candidates, says Charlene Harrington, a professor of sociology and nursing at the University of California, San Francisco. “Most people don’t know that they can stand up to discharge planners and ask for more time,” Harrington says. “And they can also appeal the planners’ rulings.” (See the Family Caregiver Alliance’s Strategies for Working with Discharge Planners.)

Avoid easy answers. Many families begin their search online at Nursing Home Compare, which is operated by the Centers for Medicare & Medicaid Services (CMS). This government website lists every nursing home in the United States that receives funds from Medicaid or Medicare and provides basic data drawn from federal and state inspections. But critics of the site—including Consumer Reports magazine and Sen. Charles Grassley, R-Iowa—say that it provides inadequate information about nursing homes and is sometimes even misleading.

On the plus side, however, Nursing Home Compare can offer a good start in eliminating facilities that show serious deficiencies or worse, have an SFF tag—meaning that they have had chronic serious problems and are therefore on the Special Focus Facility watch list.

Look online for information about specific nursing homes. One starting point may be the Nursing Home Quality Monitor produced by Consumer Reports, which offers state-by-state listings of facilities to consider and to avoid. Two other potentially useful sites are, which features user-posted reviews of nursing homes and other care providers, and, which presents CMS data in easy-to-understand formats.

Visit, and visit again. The most important element of the selection process, according to the experts, is a personal visit—preferably more than one—to any nursing home you’re considering. “Ask yourself, ‘Does it feel like a home?’ ” advises Susan Reinhard, a senior vice president of AARP’s Public Policy Institute. “What would it feel like to live there? Is there any laughter? Are there any odors? Is it safe but not too sterile? Are there people visiting? Are children visiting? Is it integrated with the community?”

Make a comprehensive checklist. To add the most value to your in-person visits, it pays to make a checklist in advance. Medicare has a detailed Nursing Home Checklist, and AARP offers a Nursing Home Evaluation Checklist.

Many state agencies and nonprofit organizations offer sample checklists as well. The National Citizen’s Coalition for Nursing Home Reform, for example, includes an extensive checklist in its Consumer Guide to Choosing a Nursing Home. Some sample questions: Do resident rooms appear to reflect the individuality of their occupants? Does the facility provide transportation to community activities? Does the facility respect the resident’s wishes about their schedule (bedtime, baths, meals)?

Realize closest may not be best. Many families, Harrington says, default to the nursing home closest to where they live. While this makes frequent visits easier, it often isn’t the best choice.

Check references. Ask around to find individuals who have had loved ones in the nursing homes you’re considering. These people could, in fact, be your most important sources of reliable, firsthand information. If you come up completely empty, try to introduce yourself to others when you are making in-person visits to the homes on your list—even if it’s in a cafeteria or parking lot.

Consult the experts. State and local ombudsman programs and citizen advocacy organizations can help you assemble the information that you need for making an informed decision about nursing home care.

Under the Older Americans Act, every state is required to have an ombudsman program to “investigate and resolve complaints made by or on behalf of older individuals who are residents of long-term-care facilities.” The website of the National Long Term Care Ombudsman Resources Center includes an extensive directory of state, regional and local programs.

The National Citizen’s Coalition for Nursing Home Reform maintains a directory of citizen advocacy groups that work on quality-of-care issues. California Advocates for Nursing Home Reform, for example, maintains an online database of 1,300 nursing homes in the state. You can search by name, address, city or county and find details on services, staffing and violations.

Drill down into the data for Crestwood Manor in Vallejo and you can see raw reports like the one from October 2007, which led to an AA citation and a $100,000 fine for the home: “On 10/14/07, a wheelchair-bound resident who suffered from dementia and was on a pureed diet choked to death on a cinnamon roll while in the dining room during snack time. … A staff member described the resident as the facility’s ‘number one high risk for choking’ due to a history of stuffing food in his mouth and because he had no teeth. The facility was cited for lack of supervision and for neglecting to take necessary precautions.”

This level of detail is exactly what’s missing from Nursing Home Compare and most state websites. Nursing Home Compare, for example, includes no mention of Crestwood Manor’s AA state citation, which means that the home was the “direct proximate cause” of a patient’s death.

Get copies of inspection reports. A CMS official notes that any family has the right to ask any nursing home for copies of its state inspection reports. These reports, known as Form 2567s, by law must be “readily accessible” to residents and visitors. State inspectors conduct the surveys for CMS every 12 to 15 months. (See Form 2567: How to read this very important document from Consumer Reports.)

Put nursing first. A 2001 federal study found that 90 percent of nursing homes don’t have enough nurses and nursing assistants “to avoid harmful outcomes." And a nationwide survey published last year by the American Health Care Association found alarming vacancy rates for registered nurses (26.7 percent), licensed practical nurses (11.1 percent) and directors of nursing (4.4 percent), leading the organization to declare "a serious workforce shortage."

Experts say that things haven't gotten any better. That's why it's especially important to make sure that you learn all you can about a facility's nursing staff. According to the National Citizens' Coalition for Nursing Home Reform, it's "the single most important indicator of quality." Be sure to find out whether your state collects its own data on nursing staffs.

Before you sign on the dotted line, do a litigation search. You might need to enlist professional help for this, but it’s a relatively simple element of your due diligence process. Has the nursing home you’re considering been sued, and if so, why? (Negligence, discrimination, wrongful termination, etc.) Did the litigation conclude with a judgment or an out-of-court settlement?

While you’re at it, you might want to determine whether the nursing home’s medical director—who must be a medical doctor—or any other physician affiliated with the facility has been involved in medical malpractice litigation, and if so, how the litigation concluded.

In the end, of course, you may never locate the perfect nursing home. Experts say that once a decision is made, an individual moves into a nursing home and Medicare funds are expended, it’s all the more difficult to undo the decision and move the resident into another facility. Better a full-court press at the outset than remorse and very limited options later.

Peter Ross Range is a freelance writer based in Washington, D.C.

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