Must-Ask Questions When You’re Choosing a Nursing Home

Choosing the right nursing home is challenging. And COVID-19 has added another dimension when making long-term care decisions.

Chances are good you’ll someday face this decision for yourself or for a loved one. Of adults ages 65 and older, 70% will develop a severe need for long-term care services at some point, according to an April 2019 Urban Institute report.

Obviously, you can’t just rely on facility tours or promotional brochures to make this crucial decision. First, get your ducks in a row. You can locate possible facilities and find inspection data by searching the U.S. News Best Nursing Homes rankings. You can also check COVID-19 data reported by nursing homes on the Centers for Medicare and Medicaid website. Data includes vaccination rates for the facility’s staff and residents, and the number of confirmed COVID-19 cases and deaths.

[SEE: 11 Red Flags to Look for When Choosing a Nursing Home.]

Make Sure You’re Comfortable With the Home’s Location

Before you visit, consider whether the location is realistic. Lengthy drives, not to mention flights, will affect visits and add barriers to relationships with friends and family members, including spouses still living at home. Sometimes, it’s a choice between top-ranked but distant facilities versus more accessible locations for loved ones to visit regularly and monitor care, says Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care.

“It’s a really tough situation for families to try to figure out: How can they get a good nursing home?” says Amanda Lambert, a geriatric care manager and consultant who heads Lambert Care Management in Salt Lake City, Utah. “You can read all the reports and you have to hope you’re getting the right information. What do you do realistically when you’ve kind of covered all your bases? The most important thing is to visit.”

With pandemic restrictions still in place in many nursing home facilities, you’ll need to schedule nursing home tours in advance. When you’re ready to visit a nursing home in person, turn to administrators, staff members, activity directors and residents for answers to these pivotal questions.

Questions to Ask Administrators and Nursing Directors

How are you protecting residents from COVID-19?
Many nursing homes are making COVID-19 vaccinations — including boosters — available in-house for residents and staff. Also, ask about infection-control procedures such as sanitation measures, social distancing, mask use among staff members and quarantine protocols in the event of possible COVID-19 exposures. Finally, ask if staff members have enough personal protective equipment including masks, gowns, gloves and face shields.

Do you have a vaccine mandate?
With nursing home residents so vulnerable to infection, you want to know whether or not all staff members are fully vaccinated against COVID-19, particularly as federal and state vaccination mandates are being put into place. If a facility’s staff members aren’t fully vaccinated and there’s no vaccine mandate, that’s a bright red flag.

“For me personally and for my clients, if there was a choice of another nursing home where there was a mandate, I would choose that one,” Lambert says. “It’s just too risky.”

What is the number of COVID cases that would trigger a lockdown?
Lockdowns can be a double-edged sword. While they reduce exposure opportunities, lockdowns leave family members out in terms of making in-person visits. During the height of the pandemic, Lambert notes, some family members removed residents from nursing homes, frustrated at not being able to assess firsthand whether they looked dehydrated or malnourished, were in pain or depressed or if dementia had worsened. It could also help to ask about the facility’s past experience with lockdowns.

What are your current visitor policies or restrictions?
As the pandemic eases, so are nursing homes’ visitor restrictions. Many now allow in-person visits for fully vaccinated family members, as well as outdoor and window visits to keep residents and loved ones connected.

What are the staffing ratios?
Bolster your question with research: You can see state-by-state staffing data for individual facilities, including average hours for registered nurses, licensed practical and certified nursing assistants, via the website of the nonprofit Long Term Care Community Coalition. Also ask about staffing ratios at nights and on weekends.

What is your staff turnover?
Stable staffing is a good sign. In addition, consistent assignment — when the same caregivers are assigned to the same residents on a daily basis — is “critically important,” Grant says. That way, staff members really get to know residents, anticipate their needs and can recognize and address problems early.

How long do nurses and aides spend with residents each day?
This is a critical component to getting the best care for your elderly or disabled loved one, says Mitzi McFatrich, immediate past executive director of Kansas Advocates for Better Care, a statewide nonprofit that works on long-term care and elder abuse issues.

Which standard and higher-level services do you offer?
Besides room, board and routine caregiving, ask about basic services included in monthly rates . If you’re undergoing rehab to recover from a hip fracture, you’ll need a higher level of care than some nursing homes can offer. With medical conditions like chronic obstructive pulmonary disease, or COPD, residents may need help managing supplemental oxygen.

What do nursing home surveys show?
On an about-yearly basis, nursing facilities undergo inspections on behalf of the CMS. Survey data, reports and ratings are available to the public. Annual survey reports should be posted in each facility — and if you don’t see that, ask. Good nursing homes should have lower-than-average deficiencies, McFatrich says, and none in the categories of mistreatment, actual harm or immediate jeopardy.

How do you prevent pressure sores in this facility?
“If someone is bed bound or not very mobile, they have to be moved every two hours in order to avoid development of pressure sores,” McFatrich says. In addition to care protocols, ask about on-site equipment, such as special mattresses that can relieve pressure points.

How does your facility avoid infections in general?
In 2016, the CMS mandated that nursing homes must improve their systems to prevent infections and detect outbreaks. However, infections like methicillin-resistant Staphylococcus aureus, or MRSA, remain a problem.

“Infection control was a huge problem even before COVID,” Lambert notes. Ask about infection-control practices for employees, like yearly flu shots.

What if I run out of money?
McFatrich suggests asking: “If I come in as a private-pay (resident) and I run out of resources, are you certified to accept Medicaid? Am I going to have to move because I can’t live here if Medicaid is the entity that’s going to reimburse for my care?”

Involuntary nursing home evictions have been reported across the country. Ask about resident safeguards and make sure contact information is clearly posted for your state’s long-term care ombudsman’s office. Long-term care ombudsmen, who exist in every state, are advocates for residents of nursing homes and other long-term care facilities. (You may also want to speak to an outside expert on financing long-term care.)

Do you provide special care for people with dementia?
Memory care means much more than just a locked unit to prevent residents from wandering. Staffing ratios should be no more than five residents per caregiver, including nurses and aides, around the clock, McFatrich says. Caregivers should have special training in dementia care, and the awareness and sensitivity to best address these needs.

[See: 9 Strategies to Reduce Falls for People With Dementia.]

How do you promote diversity so all residents feel comfortable?
One approach is to ask what kind of diversity training staff members receive, Grant says. Without that, for instance, some LGBT seniors may find themselves withdrawing socially when they become nursing home residents, making isolation a risk.

What about mood-altering medication?
Most facilities no longer use physical restraints. But so-called chemical restraint is another issue. McFatrich says she would ask, “How many of your residents currently receive antipsychotic, anti-anxiety or antidepressant medications as a means to control their dementia or related behaviors?”

This speaks to whether drugs meant to treat certain mental illnesses are instead being used inappropriately, she says. According to Grant, antipsychotic medication should only be used as a last resort, if at all — and only with consent, for a limited time period and with residents closely monitored for side effects.

How are you prepared for disasters?
In the event of hurricanes, fire, flooding or other disasters, nursing homes must have a plan in place. Follow-up questions Lambert suggests include: “Is there a designated shelter in case of a natural disaster? How are immobile residents evacuated?”

Who do I go to if I have a problem with my family member’s care?
This is a really important question, Lambert says. “I don’t want to be passed along to two or three people,” she says. “I want one person to contact.” There may be specific contact points for different areas, she adds, such as the director of nursing for related questions. However, “I want to know that I can pop into the executive director’s office anytime, ask any question and make any kind of complaint,” she emphasizes. “I want to know that person is available. Because sometimes, you have to go up to that level.”

Questions to Ask Dietitians

How do you keep residents from becoming dehydrated?
Older adults are the most likely to become dehydrated. Lack of thirst, health conditions and medications all contribute to higher risk of dehydration, as does dementia.

“If a (resident) has cognitive impairment, the only reliable way to keep someone hydrated is to have a care staff member come in on a regular basis during the day and remind them to drink,” Lambert says.

What kind of food do you serve?
Residents rely entirely on nursing homes to meet their nutritional needs. Healthy, tasty food improves everyone’s quality of life.

How do you satisfy cultural and individual food preferences?
People in nursing homes still want to enjoy meals that evoke family traditions and tastes they’ve developed over their lives.

Do you accommodate special diets?
Residents come in with their own dietary preferences and restrictions. Some also may have medical orders for soft or puréed diets, for example.

Can residents eat when they want?
Some people prefer to eat outside routine schedules. For these residents, Grant says, it’s worth asking “What if I like to get up late and I want to eat my breakfast at 10?”

[SEE: 24 Gift Ideas for Nursing Home Residents.]

Questions to Ask Residents

After the formal tour, explain that you’d like a chance to speak with several residents. Drop in at the activities room or a lounge, introduce yourself, say you’re considering a move there and ask what it’s like for them, Grant suggests.

Are you happy here?
“Do you enjoy living here?” “What do you like best about living here?” and “If you could change one thing, what would that be?” are positive ways to frame your questions and make residents more likely to respond.

Are the caregivers kind to you?
Ask specific questions along these lines, Lambert suggests: “Do you like the caregivers? What do you like about them? What do you like least about them?”

Do you have freedom of choice?
Does the facility offer resident-centered care? Are you able to get up when you want? Do you go to bed at the time you want?

When you ask for help, how long do you have to wait?
If you always have to wait beyond five minutes for help, you’re likely to try doing things on your own — which could set you up for falls, McFatrich says.

How often does someone come to your room help you get up?
It’s not just about having residents sitting in a wheelchair, Lambert says. Caregivers helping residents who are able to get up and walk around, for instance to activities or meals, is good for them.

“One of the biggest problems in nursing homes is leaving people in bed too long,” she says. When people don’t use their muscles, they lose stability and balance.

[See: Beyond Bingo: Innovative Activities at Today’s Nursing Homes.]

Questions to Ask Activity Directors

What about activities? How do you keep residents engaged?
Ask to see monthly activity calendars. Offerings should be varied and appealing.

Does the facility have a resident or family council?
These self-determined groups can provide a strong voice for quality care.

Is reliable transportation available?
“Sometimes nursing homes only provide transportation for certain medical appointments — and they don’t provide transportation for social (purposes),” McFatrich says. “Is there staff to help residents get to a granddaughter’s play?”

Can residents easily spend time outdoors?
Attractive courtyards are sometimes the first thing visitors notice. But how often can residents, particularly those with mobility issues, actually go outdoors? Does staff encourage and help them to do so?

More from U.S. News

Questions Doctors Wish Their Patients Would Ask

Where Does My Money Go When I Pay for a Nursing Home?

24 Gift Ideas for Nursing Home Residents

Must-Ask Questions When You’re Choosing a Nursing Home originally appeared on usnews.com

Update 10/22/21: This story was published previously at an earlier date and has been updated with new information.

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