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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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. 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."

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