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Thinking strategically about nursing homes

by Isabel Fawcett, SPHR

Researching nursing homes and grocery shopping may have more in common than first appearances might suggest. Experts advise taking a list to the grocery store to avoid impulse shopping. Savvy shoppers conduct extensive online searches and wade through Sunday newspaper retail inserts for coupons and for comparison shopping bargains. With the precious human cargo in the long-term care industry, why should family members settle for anything less rigorous for their elders and themselves when looking at nursing homes?

Procrastination is Non-Strategic


For a period of time, the U.S. Department of Homeland Security's slogan was, "We can be prepared or we can be scared." When it comes to homeland security and long-term care, which would you rather be - prepared or scared? I'm guessing that most of us would rather be prepared. Yet, there are those who bury their heads in the sand. Some individuals avoid doing their homework on nursing homes, assisted living, adult day care programs other eldercare services.


It is perfectly reasonable that few individuals wish to relinquish individual or social control in life. That just may be the most compelling reason to get a head-start on nursing home research long before finding ourselves between a rock and a hard place. Some folks go to great lengths to think through and plan their wills. Others defer the judgment, in-fighting and interventions to other family members and sometimes courts, to make their long-term care decisions.


Procrastinating never solved anything. Individuals' advancing age and chronic health conditions keep moving right along.

Start Online

Like savvy coupon and retail sales seekers, you may choose to start your nursing home research online. There are a number of comprehensive and reputable websites which publish a soon-to-be-replaced (or upgraded) star-rating system for nursing homes across the U.S. While the existing star rating system has its detractors, it may be the best thing consumers have going for the time being.


With the March 21, 2010 passage of the Patient Protection and Affordable Care Act's sweeping healthcare reform legislation, the star-rating system will undergo close scrutiny by the Government Accountability Office (GAO) within 2 years of the law's enactment. The GAO's legislatively mandated mission is to issue recommendations that will result in greater transparency and substantive information made available online to the general public about nursing homes. In theory this will mean greater transparency for the public. Time will tell.


Until such time as the GAO recommendations are submitted for legislative review, the general public may visit the Center for Medicare Services' (CMS) Nursing Home Compare website. Eldercarelink.com also offers a free Needs Assessment online to assist elders and their family members in finding eldercare services across the U.S.


Elicit Input From Others

Talk to friends, family members, neighbors and your state and local health and human services agencies. Ask as many questions as possible. Friends, family members, and sometimes neighbors, may be willing to share their candid observations with you.

There is always more than one side to any story. Individual perceptions may or may not be the reality in a particular nursing home. Multiple overlapping perceptions of a nursing home should be a red flag that signals a need for additional consumer research and careful deliberation, however.


Informal Family Testimonials

On the way in and out of your nursing home prospects, don't hesitate to engage in friendly conversation with other visitors as they enter or leave the nursing home. Ask them how long their elder has been in the home, whether they have had any formal or informal concerns in that time and other tough questions. Ask whether they transferred their loved one from another nursing home, and why they chose this particular home over the releasing nursing home.

Texas: That's What Friends are For

*Please bear in mind that what may be important to my friends and/or to me may not be meaningful to anyone else.

  • Several of my friends have placed elders in Texas nursing homes within the past 5-10 years, some as recently as the past year.
  • More than 5 of my friends felt a need to transfer their elders in and out of multiple Texas nursing homes prior to finally settling on a home they perceived to be minimally satisfactory.
  • With one exception, my friends' elders resided in their last Texas nursing home placement until death. The exception was a situation where my friend was not satisfied with the many nursing homes she had researched and selected. Ultimately, my friend relocated her elder to another state. Years later, my friend's elder still resides in the same out-of-state nursing home. I've long considered whether I would prefer an out-of-state nursing home for my mother if the need were to arise. That is neither a good nor a bad choice, and certainly not a reflection on good Texas nursing homes. It is my consumer choice. Elders and their caregivers are consumers of healthcare services. Guilt is not an option.

In the examples I have shared, the Texas nursing homes were not limited to any one geographic or regional area in-state, nor did any of my friends work collaboratively with each other. Time frames also varied. These were random care circumstances as may happen to any caregiver and elder individuals doing the best they could to advocate for their elders' long-term care.

  • Another one of my friends made a compelling case that many of the nursing homes she researched in a Texas metropolitan area averaged only 60+ points out of a possible 100 rating. She, too, claims to have found few nursing homes "even in the 80's." She also relocated her elder multiple times in-state, searching for a *minimally acceptable nursing home. I've started mirroring my friend's informal research, just for kicks. I'm surprised that her informal observation is proving true.

Multiple and Random On-site Visits

  • It is a best consumer practice to make multiple random, unannounced visits to your short list of nursing home prospects, any time of the day or night. Allow your senses to lead the way in taking in the sights, sounds and smells in the nursing home.
  • Request a copy of the two most recent state-issued inspection reports. Read the reports at your leisure. Ask whether there is a family council, how often they meet, and other related questions. If necessary, ask your state's Department of Health and Human Services for assistance in interpreting state inspection findings and remedial steps taken by the nursing home.
  • Take the CMS Nursing Home Checklist with you on each visit. Use the Checklist to observe safety practices, residents' grooming, staff interactions with residents and visitors and more. Although not authorized to conduct a formal inspection of nursing homes, nothing precludes you from doing your homework without interfering with nursing home operations, resident privacy, safety or the home's administration. Be reasonable and non-disruptive while you are on-site.

If you do make unannounced visits to any nursing homes, be sensitive to the industry's need to maintain effective resident, staff and visitor security protocols. If you are able to roam throughout a nursing home undetected and not questioned by at least one staff person, consider it a red flag on the nursing home's lax safety and security, and possible negligence. Would you want your elders to reside in a nursing home where security is not a priority to staff?


A Long-Term Care Vision of the Future

Recent healthcare reform promises to deliver additional consumer information, including state-issued nursing home inspection reports online, information on the number, type, severity and outcomes of substantiated complaints against the nursing home, and select criminal violations committed on-site, including resident abuse. This information is legislatively mandated to be available to the general public within one year of the law's enactment.

Individual states are required under the new law to have the state-issued nursing home reports online, including remedial measures taken by nursing homes.

Having worked in long-term care as part of a regional management team before, I welcome the 2010 legislative mandates in long-term care. If implemented in accordance with legislative intent, they will comprise a system of additional checks and balances in an industry that needs to open its blinds and let the sunshine in.

Then again, that's just my take. My vested interest is being a carer and an aging Baby Boomer. My nouveau elder credentials are undeniable. There is still time for many Baby Boomers to think strategically about eldercare options for ourselves, and in some instances, our elders. No hand-twisting allowed or required, just keeping those options open in our golden years.

Resources and Related Information

CMS' Nursing Home Compare

Texas Department of Aging and Disability Services' Website

Texas Advocates for Nursing Home Residents


"Medicare to Start Comparing Nursing Homes With Star Ratings
," Dallas News Online, July 4, 2008