One of the most challenging questions we ask as our parents get older is whether or not to put them into nursing homes. If you decide to do this, the next question is slightly easier: Which nursing home should you choose? Here are some simple questions that can help you find an answer that works.
1. What Can You Afford?
This can be a tricky question, and it’s even trickier if the answer is “not much.” But it’s where you have to start when you begin shopping for an elder community. As much as you might want something top-shelf for your parents, there’s no point in looking at anything you can’t afford.
When you run the numbers to determine costs for nursing homes, remember that help exists. Medicaid will pay for some assisted living costs in 30 different states if your parents qualify due to income or a particular condition, such as memory issues. Also, look at group benefits your parents might be eligible for, including veterans’ benefits, union assistance, and anything available in their state or community.
Once you know what price range you can manage, you can compare options that work for your family’s budget.
2. What Is the Staff Turnover Rate?
A data review by Ashvin Gandhi of UCLA found correlations between higher staff turnover in nursing homes and patient wellness and quality of life statistics, such as number of hospital visits and the need for physical restraints.
A facility with high turnover means the staff isn’t happy. If the team isn’t happy, they’re less likely to care about their jobs. High turnover also means staff have less experience and fewer opportunities for meaningful training.
When you ask about turnover, remember the average annual turnover rate in nursing homes is pretty high: 94% overall and higher among highly-qualified staff nationwide. If a nursing home you’re considering has a turnover rate of 80%, that might feel high, but it means the place is above average.
Average rates vary in different places, however. You can find a state-by-state breakdown and link to Gandhi’s data review here.
3. Can You See the Activities Schedule?
A good nursing home has a robust activities schedule available for all residents, and that schedule is available in printed calendars residents and families can evaluate. When you review a program, consider the following questions:
- Does the schedule include a wide variety of activities?
- How many of those activities would your parents enjoy?
- Are there activities at different times of the day?
- Does the schedule work with the times your parents are awake and active?
- How many different people lead the activities?
- Do they hire outside experts for some activities?
- Is the sales representative proud of the schedule, or do they seem shifty or apologetic?
- Does it look like the program rotates to offer variety?
- Is there an extra cost for activities? If so, how much is it?
- How frequently do the activities take residents outside into the world?
Not all of these considerations have a set right or wrong answer, but they’ll help you identify programs that work better for your situation.
4. What Are the Staffing Ratios?
Before asking this question, look up the legally required minimum staffing ratio for the kind of care your elder needs. This varies by jurisdiction but is easy enough to find with a quick online search for “minimum staffing ratio for nursing homes in (your location).”
When you have a nursing home’s staffing ratio, compare it to the legal minimum. It will tell you quickly whether the facility is just doing what’s required or is taking on extra expenses to ensure a positive community for its residents.
5. What Is Included in the Contract?
More than a few nursing homes advertise a low rate but charge for extra services, many of which you might reasonably expect to be part of care. Once you’ve agreed to that contract, you have few options apart from paying for what you need.
Reviewing the contract, you can see what the price tag represents and how much it will cost to get anything else. When you’ve narrowed your search to a few favorite facilities, this can be a powerful method for deciding between them.
Also, look at how long the contract guarantees your current pricing. Some will lock you in for several years, while others start you at a low rate for a few months, then escalate to something less affordable.
6. What Are the Levels of Care?
Most nursing homes offer various levels of care, ranging from high-level memory care down to something more like living in a college dorm. Asking about all levels of care provided can give you essential information about the facility.
Compare included services at different levels so you know what to expect with cost and care as your needs increase over time. This can help you budget and choose a facility your parents can stay in permanently, rather than having to move as their health declines.
Even something as simple as the names of levels of care can give you insights into a facility’s culture. Do they use marketing labels like Bronze, Silver, and Platinum? Are they technical and medical in their descriptions? Flowery and poetic?
7. What Do the Surveys Show?
In most jurisdictions, nursing homes are required to undergo inspections. Inspection results are available to the public, and you can look them up for each facility you’re considering.
Do that, and then ask to see the results while visiting each location. A reputable and honest facility will have their ratings posted publicly, someplace easy to see, and they will be justifiably proud of what they show.
If you don’t see the results, ask to see them. Not seeing results posted publicly is a mild red flag but not a deal-breaker. If the sales representative hesitates to show you, however, that could indicate a severe problem.
8. How Many Residents Receive Mood-Altering Medication?
Very few nursing homes use physical restraints anymore. They have instead moved on to “chemical restraints.” That’s using drugs to calm down aggressive patients or other people who pose a danger to themselves and others if left free to move on their own.
How many residents receive antipsychotics, sedatives, and similar medications can tell you some fundamental things about the facility. It shows how potentially dangerous the other residents might be and could indicate a staff that relies too much on drugs and too little on proactive care.
That said, bear in mind the sort of facility you’re looking at because as needs grow, so does the necessity for medication, especially in memory care.
9. Can Nursing Homes Provide [X, Y, Z] Care?
This one is simple, but you might be surprised by how often it goes unasked. If your parents need a certain kind of care, make sure the facility offers it and that the price you’re quoted includes receiving that care frequently enough to do some good.
The same goes for anything your parents want but don’t need. If they like TV, find out how much the cable package costs. Do they like to swim? Ask if the facility has a pool or a transportation program to the local aquatic center. If they’re green thumbs, find out if the staff will help with keeping a beloved collection of plants thriving.
Ask for what you want and need, and find out how much extra it might cost.
10. Who Do I Go to If I Have a Problem?
A facility’s process for dealing with problems and complaints is a strong indicator of its priorities.
The sales representative should explain in detail who you go to, what you do, and how the process works if you need to bring something to someone’s attention. This explanation should include which government agencies you can approach if you’re unsatisfied with the facility’s response.
If the representative claims the facility never has any problems or says they don’t have a set policy, opting for another nursing home is usually best. Every facility receives some complaints, whether they’re about serious issues or minor ones.
11. How Are You Prepared for Disasters?
Nursing homes, prisons, and hospitals are the most vulnerable locations during a natural catastrophe. They have a lot of people in one place, and those people are not very mobile. Every facility should have a solid plan for the common catastrophes in your area, and every staff member should know it backward and forward.
Don’t listen just to the plan’s details when you ask about this. Watch the representative for signs of how well they know that part of their job. Ask when they receive training, updates, or practice on the plan.
This question is critical if your parents need an electrical device for their health and wellbeing. If that’s the case, you should ask what the facility does when the power goes out.
12. How Do You Satisfy Cultural Food Preferences?
You should ask this question even if your elder has no cultural or food preferences.
Watch how the representative reacts to the question. It will show you how flexible the facility’s meals are, how much they’re willing to personalize the experience, and how sensitive they are to the needs of other cultures. It can also help you spot racists by how they react to the needs of other cultures.
Final Thought: Who You Ask Matters
When getting recommendations for a nursing home, who you ask is just as important as what you ask.
The answer you get from a sales representative won’t be the same answer you get from somebody who just lost a lawsuit against the same facility. Brokers get paid per placement, so their incentives aren’t aligned with customers’ needs. Most government employees are forbidden by policy to make clear recommendations of any kind.
Who can you ask for the truth? The nurses and physical therapists in your town work with the senior population. They know who keeps coming in from neglect and abuse injuries, and many make house calls, so they see the state of elder care facilities day-to-day. If you know one of these professionals, their advice can be worth its weight in gold. If you don’t, find a friend who does.
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John Manigold is a New York-based journalist who has written in-depth about elder care issues.