Ten Steps to Choosing the Right Nursing Home for You or Your Loved One

1. Determine whether a nursing home is actually the best option for you.

Considerations Related to Care

• People generally go to a nursing home either for short-term rehabilitation after a surgery or major injury or as a last resort when their caregivers can no longer provide the level of care they require at home, an assisted living facility or other form of senior living.
• Assess the level of personal care and medical care you require. Nursing homes generally offer the highest level of medical care, which includes both skilled nursing, physical therapy and other forms of therapy. They typically start by assessing how many activities of daily living you require assistance with and how much assistance you require. If you only require a few hours per day of assistance with activities of daily living, you may be able to stay in your home and simply pay for home health care. Occupational therapists also look at instrumental activities of daily living, which include more basic daily tasks to fully assess a person's ability to live independently. If you are struggling with multiple activities of daily living, however, there is a good chance you have been struggling with instrumental activities of daily living for quite some time. Families that are able to care for a senior at home often supplement that care with adult day care or respite care when caregivers are unavailable. Finally, in situations where a patient is terminal, hospice care (which may be provided at home or in an assisted or independent living facility) may also be an option.

Financial and Insurance-Related Considerations

• Take an inventory of your financial resources, as well as your cost of living. Consider how much your long-term care will cost and how you will pay for it. Nursing homes are the most expensive long-term care option, but they also provide the highest level of care. If you require this level of care around the clock, other options such as home health care may eventually be even more expensive. If you run out of resources, you may qualify for Medicaid, which is a federally funded and state administered program that pays for nursing home costs.
• If you are receiving Medicaid benefits, you will need to be evaluated to confirm that it is medically necessary that you reside in a nursing home. The basis for this determination is typically your performance of the six activities of daily living (bathing, dressing, using the bathroom, eating, bowel and bladder control and transferring). This evaluation is typically performed by both a field worker from the state and your physician.

2. Choose a geographic area to focus your search. Location, location, location...

Personal Considerations

• Consider where your friends and family are located.
• Take note of the proximity of the area you choose to your doctors, as well as hospitals, dialysis centers or other pertinent medical facilities.

Quality-Based Considerations

• Look at the general quantity and quality of nursing homes in your general area. Elder Guide’s state pages (located at the bottom of our national nursing home page) are a great place to start.
• If nursing homes in your town or city have received poor grades, we recommend expanding your search geographically. We list other nearby city grades in the right margin of each city page so you can see how your city compares to neighboring areas.

3. Make a list of all of the nursing homes located in your desired geographic area(s).

Making the List

• You can use the search tool on our homepage to search by zip code or city and find nursing homes in your area.
• Try not to have any preconceived notions about the type of facility you prefer. In some cases, a government-owned facility or nonprofit nursing home may be a better fit than a more expensive for-profit nursing home. Just try to keep an open mind. Start your search broad and narrow down your options later.

A word of caution if you are using a placement agent...

If you speak with a nursing home placement agent, don’t rely too heavily on their recommendations without considering their motives. Keep in mind that their primary objective is generally to place you in a nursing home that pays them the highest commission. They have often already crossed the nursing homes that don’t pay them commissions off their list, regardless of the quality of those facilities.

4. Determine which nursing homes are a good fit based on the services you require.

Knowing the Difference Between a Rehab Facility and a Long-term Care Facility (also known as a Convalescent Home)

• The first step is determining whether you are looking for rehabilitation or long-term care.
• If you require rehabilitation after a major injury or surgery, the hospital will likely place you in a facility that can provide the appropriate level of care. In fact, if you require extensive medical care in conjunction with your rehabilitation you may initially need to be placed in a hospital-based skilled nursing facility. For most people in other circumstances, this level of care is not required.
• If you are entering a nursing home due to old age or declining health, you likely need personal care more than rehabilitation services or advanced medical care. Some nursing homes are essentially convalescent homes which only provide long-term care.

Special Considerations

• Some prospective residents require more specialized care. The most common type of special care unit is known as memory care. This level of care is designed for residents with Alzheimer’s or other forms of dementia. Memory care facilities typically provide more security and are specially designed for those with cognitive impairments. However, many facilities that don’t have memory care units are still able to accommodate residents with early stages of dementia so if your condition is not advanced, give the facility a call and see if they sound like a good fit.
• You may want to make note of facilities with other special features that match your preferences. For instance, many seniors feel more comfortable in veterans facilities or church-affiliated nursing homes.

5. Determine which nursing homes are a good fit based on your financial resources and insurance coverage.

Short-term Care and Rehabilitation

If you are doing short-term rehabilitation, make sure the facility accepts Medicare, as your rehabilitation costs may be a covered service.

Long-term Care (Medicaid Considerations)

• For long-term care residents, Medicare and regular health insurance will not cover these services. Due to the high costs of nursing home care (typically over $100,000 per year) you should assess how long you can afford to private pay at each facility and what happens when you run out of resources.
• Most people in nursing homes for the long haul eventually run out of resources and end up on Medicaid, which is a poverty-based program that does cover long-term care costs. Not all nursing homes accept Medicaid and many of the facilities that do only set aside a limited number of beds for Medicaid residents. If you don’t have sufficient liquid assets to private pay for a facility for at least three years, you should consider some Medicaid planning. Most importantly, if you expect to exhaust your resources relatively quickly, you may want to avoid nursing homes that either don’t accept Medicaid or don’t have a Medicaid bed available in the near future.
• We highly recommend consulting a qualified elder law attorney licensed in your state to assist you with the Medicaid planning process.

6. Assess the quality of the nursing homes remaining on your list.

Our nursing home evaluations assess nursing homes in four major categories: inspections, short-term care, long-term care and nursing. You should look at all of these categories, as well as each facility’s overall grade. We have a detailed Guide to Evaluating Nursing Homes, which goes through all of the tools we offer for assessing the quality of a facility and narrowing your search using our evaluations. However, you should still prioritize aspects of our evaluation which are most pertinent to you.

Inspections

Inspections are probably the most important category regardless of which type of facility you are looking for. This category indicates the number and severity and deficiencies a facility has had on its inspection reports over the last three years, as well as whether it has received government fines or resident complaints. Facilities are dinged more for more severe deficiencies, which are labeled category G through L deficiencies. Similarly, we also downgrade facilities that have been flagged for abuse or labeled as special focus facilities.

Short-term Care (Rehabilitation)

Short-term care grades focus primarily on metrics that relate to rehabilitation, such as physical therapist and skilled nursing staffing. We also look at the percentage of residents who were able to return home.

Long-term Care

Long-term care grades are based on a variety of factors, including overall nurse staffing levels, hospitalization and nursing quality metrics. This category is critical for people who are going to a nursing home simply due to declining health and old age (as opposed to a sudden injury requiring rehabilitation).

Nursing

Our nursing category assesses all levels of nurse staffing, including registered nurses, licensed nurses and nurse’s aides. It also factors in a variety of nursing quality metrics, including the percentage of residents with pressure ulcers or who have sustained major falls resulting in injury. These are both viewed as a byproduct of poor staffing levels. Nurse staffing is important for any prospective resident.

Other Resources

You may also want to get a second opinion by looking at the grades provided by the Center for Medicare and Medicaid Services.

7. Visit several of the nursing homes at the top of your list.

Preparing to Visit

• It is always best to schedule a tour to ensure that someone is available to show you around the facility. However, you may also want to return unannounced for a second visit to make sure the planned visit was representative of the facility’s normal daily operations.
• Ask for copies of any contracts you will be required to sign before moving in, as well as the residents handbook, prior to your tour. This way, you can ask any questions that arise when reviewing these documents during your tour.
• Ask your physician(s) and other caregivers for their opinions of the facilities on your list prior to touring. If they raise any concerns about a particular facility based on past experience, you can then raise this issue on the tour and see if the facility has addressed the problem.
• Request a list of services provided and amenities offered at the facility.

Meeting Key Personnel

• Try to meet with as many key figures at the nursing home as possible, including the administrator, director of nursing, director of social services and activities director.
• Try to meet with a few residents of the facility, preferably ones of a similar age and in similar physical condition.

8. Carefully review and negotiate a contract with the nursing home of your choice.

It is usually best to have a legal contract reviewed by a qualified attorney prior to signing. Note that these contracts could be considerably more complex if you are moving into a continuing care retirement community.

9. Provide the nursing home with necessary documentation prior to moving in to a facility.

Financial and Insurance Information

• If Medicare or Medicaid (or a long-term care insurance company) is paying for your nursing homes costs, provide the nursing home with all of your insurance information. If you are using Medicare or Medicaid, the facility cannot require you to pay a cash deposit. While Medicare may require a co-pay, the facility cannot charge you more than the rates authorized by Medicare.
• You should also provide the nursing home with your health insurance information in case you are hospitalized or require medical care off-site.

Medical Information

• Make sure you provide the nursing home your relevant medical history, especially your medication list and any information your physician(s) deem relevant to your care.
• Be sure to prepare a living will, health care proxy or medical power of attorney and provide the nursing home with a copy.

10. Participate in the preparation of your assessment and care plan.

The nursing home is required to provide you with a copy of your assessment and care plan. You (or your family if necessary) have the right to participate in your care plan. This plan covers medical care, personal care, activities, nutritional plan, social services and other services you will receive at the facility. This will generally be completed within 14 days of being admitted to the facility. It is absolutely critical that an appropriate plan for your care be established from the outset.