Step 3, Part 1: Size Up a Nursing Home by Visiting

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

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Once the universe of nursing homes has been whittled down to a few possibilities, it's time for an in-person assessment. 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.

[See America's Best Nursing Homes and search for one near you.]

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." The Boston psychologist 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? Not only is it unpleasant—it suggests understaffing. The concern 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 infection that can be deadly in individuals whose health is already compromised. Helping residents get on a regular bathroom schedule is one of the main tools for managing incontinence, but adequate staffing is essentiasl. 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 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 haven't already absorbed the home's most recent inspection findings, reported on Form 2567, by finding it on your state website (not all states post it), ask to see it. The home is required to let you read it. Ask for previous reports as well. Nursing homes don't have to let you read reports other than the latest one, so it is a good sign if a home opens them up to you. Comparing several consecutive surveys could reflect a facility's progress—or a slip in care. "If it's thick, that's already a warning," says Wells of the survey report, which covers about 180 individual health-related requirements. If the home's managers are too busy to help you understand the details—even if you made appointment in advance to do so—that, too, says something. The home could be short-staffed, reluctant to open up, or both.


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