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How to select a nursing home?

The selection of nursing home care for a loved one or friend is often a difficult task. To do the job right, one must be prepared for the time-consuming effort of gathering the many facts needed to help in the decision-making process. Finding the right facility is all-important to a loved one's well-being. The facility selected will be the person's home and community sometimes for the remainder of the person's life. However, through rehabilitative efforts, nearly one-half of the patients of a proficient nursing home can be discharged to live independently once again.

What Is a Nursing Home?

The term "nursing home" is a widely misused and misunderstood term. The term has been defined as anything from a rest home to an acute care hospital. This is confusing to anyone who needs to know the type of facility to select that will best meet their needs and what the appropriate level of care should be.

Nursing homes are primarily designed to meet the needs of persons convalescing from illness or to provide long-term nursing supervision for persons with chronic medical problems. A nursing home is not a hospital and does not provide the acute care provided in a hospital setting. The goal of nursing home care is to provide care and treatment to restore or maintain the patient's highest level of physical, mental, and social well-being. To help the reader better understand the various levels of care available, included below are definitions of nursing facilities:
  • A Skilled Nursing Facility (SNF) is a facility that is required to provide continuous (24-hour) nursing supervision by registered or licensed vocational nurses. Commonly referred to as "nursing homes" or "convalescent hospitals," these facilities normally care for the incapacitated person in need of long- or short-term care and assistance with many aspects of daily living (walking, bathing, dressing, eating). At a minimum, SNF's provide medical, nursing, dietary, pharmacy, and activity services.

  • An Intermediate Care Facility (ICF) is a facility that is required to provide 8 hours of nursing supervision per day. Because of their physical appearance, these facilities are often confused with the SNF's. Intermediate care, however, is less extensive than skilled nursing care and generally serves patients who are ambulatory and need less supervision and care. Licensed nurses are not always immediately available in an ICF. At a minimum, ICF's provide medical, intermittent nursing, dietary, pharmacy, and activity services.

  • A Skilled Nursing Facility for special disabilities is a facility that provides a "protective" or "security" environment to persons with mental disabilities. Many of these facilities will have "locked" or "security" areas where patients reside for their own protection or the protection of others in the facility. Some SNF's have a designated number of beds for long-term mental patients.

Licensing and Certification

All state governments require that nursing homes be licensed. The licensing requirements establish acceptable practices for care and services. State inspectors visit nursing homes at least once a year to determine their compliance with state standards and their qualifications to receive Medicare and Medicaid reimbursement. Most nursing homes are certified to participate in both the federal Medicare and Medicaid (Medi-Cal in California) programs. Some have been approved to provide both skilled nursing and intermediate care services.

Who Owns and Manages Nursing Homes?

Some nursing homes are operated as nonprofit corporations. They are sponsored by religious, charitable, fraternal, and other groups or run by government agencies at the federal, state, or local levels. But many nursing homes are businesses operated for profit. They may be owned by individuals or corporations. Sometimes they are part of a chain of nursing homes. 

Final responsibility for the operation of a nursing home lies with its governing body. It is the legal entity licensed by the state to operate the facility. The governing body sets policies, adopts rules, and enforces them for the healthcare and safety of patients. The person in charge of the day-to-day management is called the administrator.

Who Directs Care?

A person in a nursing home must be under the care of a physician. If the person's personal physician will not continue to provide care, a new physician must be chosen. It is the physician's obligation to evaluate a patient's needs and to prescribe a program of medical care for the patient's health and well-being. A nursing home is not free to initiate any form of medical treatment, medication, restraint, special diet, or therapy without the consent of a physician. 

Before a person is admitted to a nursing home, a complete physical examination should be completed. The results of this examination will determine whether skilled nursing care or intermediate care is required, the patient's diagnosis, the duration of the illness or need for nursing home care, what treatments are indicated, and the patient's rehabilitation potential.

What About Financing?

Nursing home care is expensive. Although prices vary, the basic charge for a double-bed room in a typical nursing home is in the range of $20,000 to $50,000 a year. Homes in rural areas tend to be slightly less expensive than those in cities. The cost of medications and physician visits are not included in the basic charge. Also, special treatments such as physical, occupational, and speech therapy often add to the cost. There are also possible additional charges for drugs, laundry, haircuts, and extra services.

Three out of four patients are dependent upon government assistance through Medicare and/or Medicaid. Other sources of financial aid might be available to the patient from private health insurance (possibly supplemental Medicare insurance, called Medigap). However, Medicare will partially pay for the first 100 days of skilled nursing home care and nothing for care in an intermediate care nursing facility. Medigap policies typically pay only a portion of the daily costs and then only for a limited number of days. Long-term or catastrophic care insurance is designed to provide benefits for this type of care.

Eligibility for Medicaid (Medi-Cal in California) is contingent upon the amount of a patient's (and spouse's) income and personal and real property. To receive nursing home services under the Medicaid (Medi-Cal) program, certain medical requirements must also be met. Financial assets accumulated by the patient and spouse could be exhausted through prolonged care in a skilled nursing facility. Therefore, it is extremely important to plan ahead by determining all of the benefits available under Medicare and Medicaid. Medicaid generally pays a daily rate that is significantly lower than private-pay residents. Hence, Medicaid residents are less preferred by nursing homes. Some nursing homes do accept Medicaid residents or retain residents whose personal resources have been depleted and who have become Medicaid recipients.

Federal and state laws are intended to limit discrimination against Medicaid beneficiaries yet they often face discrimination in admissions to nursing homes or the services they receive.

Most states determine Medicaid eligibility using the combined assets and income of a couple. A Medicaid applicant must deplete a spouse's income and assets before receiving coverage. Impoverishment of the spouse of a nursing home resident who is on Medicaid is not uncommon. Consult your state's policies as they relate to spousal assets and income.

Advance Planning

If you think you will need a nursing home at some time in the foreseeable future--for yourself or a relative--it will pay to plan ahead. Many good nursing homes have long waiting lists, and the chances of getting placed in the home of your choice will be greatly enhanced if placement is made on a waiting list prior to the actual time of need. Also, this will give a prospective patient time to get mentally adjusted to the idea of the change.

Unfortunately, the choice of a nursing home is often made in a crisis atmosphere when time is short and minds are troubled. Selecting a home is an important decision--one that deserves foresight and careful clear-headed consideration.

Here are some things you can do in advance that will help you in deciding on a nursing home:

  • Make a point of learning about nursing homes. Watch for articles in newspapers and magazines and for television programs that deal with nursing homes. Also, pick up brochures on the subject from social service agencies, senior centers, or your local health department.

  • Find out what nursing homes are located in your community and learn what you can about them. If you have friends or relatives who are familiar with the homes, ask for their opinions on them. If you know people who live in nursing homes, pay them a visit and gather some firsthand impressions.

  • If your county has published a nursing home guide, you can probably start by making a list of possible homes in your area. Or you may check with the State Department of Health Services' Licensing Field Office and ask to see the latest "Health Facilities Directory." Your local Area on Aging will also be able to help.

  • Each county has an ombudsman program that provides volunteer problem solving for relatives and patients in nursing homes. It may be helpful to contact your local ombudsman office for information about a particular nursing home. The ombudsman program, federally mandated, is designed to provide information to the public about nursing homes in a particular area and to resolve complaints on behalf of the nursing home residents. The ombudsman should be listed in the local government section of your telephone book. Your physician also may be able to suggest some nursing homes you might consider.

Nursing home inspection reports completed by the State Department of Health Services are also available to the public at the field offices. You may wish to review the latest inspection reports for various homes on your list before making actual visits to the facilities. Be sure to check for noncompliance pertaining to patient care, staff adequacy, and facility cleanliness and maintenance.

Selection of a Nursing Home

When you have compiled a list of the places that seem most appropriate, you should make a personal visit to each one. It is best to make an appointment with the administrator and take along a copy of the nursing home checklist.

When you do visit a home, there are a number of services and other matters that should be observed and evaluated:
  • Location -- Consider the home's location. It is not always possible, but it is preferable that the home be convenient for friends, relatives, and your doctor, as well as appealing to you. The home should be reasonably close to a hospital in case of a medical emergency.

  • Facility Size -- A large home may have more activities while a smaller home might be more personal. Decide which is best for your needs. You should also consider the quality--not just the quantity--of the services and activities offered.

  • Visiting Hours -- Find out whether the visiting hours are convenient. Often the best arrangement is one that allows visitors to come anytime.

  • Financing -- It is very important to check with the facility regarding what services Medicaid (Medi-Cal) or Medicare covers. Make sure you find out what extra costs are involved in addition to the basic daily room rate. Often extra charges are made for professional services beyond basic nursing care (also for things such as television and toiletries). Some homes only provide the bare minimum in the way of services.

  • Room Selection -- Find out whether attention is paid to roommate and room selection--two factors that can be very important to your happiness. You do not need to feel committed to your first roommate. If you are dissatisfied, see if you can change. Also, see if you can bring some of your own furniture.

  • Bedhold -- Ask if they reserve a bed if you need to be transferred to a hospital. Medicaid will pay for 7 days of bedhold. Medicare and private-pay residents will have to pay for each day the bed is held but not more than the regular daily rate. Sometimes if hospital stay is extended you can make an agreement with the nursing home.

  • Valuables -- Find out how valuables are protected. Theft is sometimes a problem in nursing homes. If at all possible, you should leave valuable items with friends or relatives.

  • Grievance Procedure -- Ask whether patients have some sort of grievance procedure. Find out if there is a patient's council and a way that patients can be involved in decision making.

  • Volunteers -- Find out if community volunteers are used at the home. Active community involvement by individuals and groups of volunteers can greatly extend the amount of patient services available and help reduce the isolation and loneliness that many nursing home patients feel.

  • Morale -- See how the patients' morale appears to be. Do they have privacy and respect? Do they have access to things like television and radio? Be sure you take into consideration what you are comfortable with when making your selection.

  • Food -- Check the food being served. Make a visit at the time of the midday meal which is often the main meal. Ask the other patients about the quality of the food. Is the dining room atmosphere attractive, pleasant, and clean. The cold food cold? Is some food available at times other than mealtimes? Do they supply food for special diets?

Nursing Home Admission Agreements

Once you have made a selection of a nursing home, you will want to review and be sure you thoroughly understand the home's contract or financial agreement. If you have questions, ask a lawyer or the local long-term-care ombudsman in your area (check in phone book). Since this agreement constitutes a legal contract, it is advisable to have a lawyer review the agreement before signing it. Free legal assistance is usually available to senior citizens. You can find out about this from your Area Agency on Aging (listed in your phone book) or from someone at the Senior Center. NEVER SIGN A LEGAL DOCUMENT THAT YOU DO NOT UNDERSTAND.

Your admission papers should include the following items:

  • The agreement stating the terms and conditions, the daily room rate, and what services are covered by it. States set licensing standards requiring nursing homes to provide a basic set of services (such as nursing and personal care, meals, activities). These are supposed to be covered by the basic rate.

  • A list of optional services and the charges for them. The facility must provide an itemized bill. Such optional services could include choice of meals, laundry, toiletry items, special trips, etc. If you are a Medicaid recipient, you should receive a special list of optional services (Medicaid pays for laundry and hair trims, for example).

  • A copy of each Patient's Bill of Rights.

  • A statement about eligibility for Medicaid.

  • A statement that the nursing home is or is not Medicare and Medicaid certified.

Illegal Actions

Certified nursing homes may not require Medicaid-eligible persons to make contributions, donations, or gifts as a condition of admission or continued stay in a nursing home. Private-paying individuals do not have this protection. When certified nursing homes sign with the Medicaid program, they agree to accept Medicaid payment as "payment in full." If you become eligible for Medicaid, then the nursing home will receive payment for care and may not discharge the patient on the grounds of "nonpayment." Certified nursing homes may not transfer or discharge you when your private funds have been exhausted and you become eligible for Medicaid unless the home does not participate in the Medicaid or Medicare program. If someone treats you in this manner check with a lawyer or ombudsman.


While in a nursing home, most problems can be worked out with the nurses, the staff, or the resident council. If they cannot, discuss the problems with family members. Persons who experience problems with nursing homes may obtain assistance from the nursing home ombudsman, a person in your state or local office on aging who is designated to investigate complaints and take corrective action on behalf of nursing home residents. Federal law guarantees your right to seek help from an ombudsman without fear of retaliation.

Making a Smooth Transition

Be prepared to make the transition into a nursing home easy as possible. Such a change may affect the whole family and it will take some time to adjust to the new living arrangements. Some nursing homes have a social worker or nurse specialist who conducts preadmission group sessions for family members. You can make the resident more comfortable by accompanying him or her on moving day, and by helping choose familiar items to bring along--family photos or favorite decorative items to make the room more attractive.

The frequency of visits to the resident is an individual decision, but keep in mind that the presence of family members greatly helps to create a more personal atmosphere in the nursing home. Family visits offer reassurance to the resident that someone still cares. In fact, those residents whose families are involved in their care usually have higher morale and receive better care from the staff. Taking the resident out occasionally is also helpful.