How to choose a nursing home

Amy Fontinelle

By Amy Fontinelle
Amy Fontinelle is a personal finance writer focusing on budgeting, credit cards, mortgages, real estate, investing, and other topics.
Posted on Mar 29, 2021

A nursing home can be a place for short-term recovery after a hospital stay. More often, it is a permanent residence for someone needing extensive care. Either way, choosing the right nursing home can mean the difference between a good quality of life and a poor one, and even between life and death.

Usually, we aren't choosing a nursing home for ourselves, but for a loved one who depends on us to make a good decision for them. Fortunately, there are nursing home ratings and checklists to make the process easier. You'll want to start your search by reviewing these to create a short list of possible homes and questions to ask when calling or visiting each one. Then, you’ll want to concentrate on other considerations, such as staffing levels, infection controls, and cost.

Nursing home ratings

The preeminent source of nursing home ratings is the Medicare website. Because Medicare pays for nursing homes stays of up to 100 days after a hospital visit with a doctor's referral, the government has a vested interest in making sure its tax dollars are directed to facilities that produce the best outcomes.

The Centers for Medicare & Medicaid Services uses a five-star quality-rating system. Ideally, families would stick to homes rated four or five stars because they provide above-average care. Families should also look at the individual components that make up each overall rating (health inspections, staffing, and quality of resident care) to make sure that a high score in one area is not compensating for a poor score in another area. (Related: Talking money with your aging parent)

Proximity to friends and family

To prevent your loved one from getting lonely and to facilitate checking up on their care, experts advise choosing a nursing home near a trusted friend or relative, to the extent that you can do so without compromising on care.

“It is important that your loved one have a support system nearby to be their advocate in the facility, which is infinitely more effective if you can drop in at different times of the day, unexpectedly,” said Naomi Becker Collier, co-chair and partner in the trusts & estates and elder law practice at New Jersey-based Pashman Stein Walder Hayden. “Furthermore, if your loved one has ties to the community that remain strong — such as with local family, friends, and religious and civic organizations — it is important, when appropriate, that they be able to continue to actively participate.”

Specialized care

If your loved one is recovering from a routine illness or injury, any highly rated nursing home may be fine. However, if your loved one needs more specialized care due to a condition such as dementia or cancer, it is imperative that you find a home that can treat these conditions at a high level.

For example, if your parent has dementia, you will want to know that the home has protocols to prevent residents from leaving the facility on their own and getting lost. You will also want to ask about their policies on administering antipsychotic medication to patients with dementia. Some facilities have abused administration of these medications to make dealing with difficult patients easier. (Related: Planning for diminished capacity as you age)

Other circumstances that may warrant specialized care include not speaking English fluently, requiring a special diet, strong religious beliefs, or being LGBTQ.

First-person experience

During the worst of the COVID-19 pandemic, nursing homes severely restricted who could enter to keep residents and staff safe. Many families had to choose facilities without being able to tour them or meet workers in person.

Virtual tours and videoconferencing with staff are options when you have to quickly place a loved one in a home you can’t personally visit. If you can check out homes in person, though, the experience can be invaluable.

“Visit the potential locations and get a feeling for how friendly the staff is,” said Philip D. Rogero, a financial professional and founding partner with MassMutual’s First Coast Legacy Group in St. Augustine, Florida. “Are they polite and respectful or cold and short with responses? You’re trusting this facility and the staff to spend most of every day with your family member. You’ll want to know that they’re in good hands.”

Neglect and abuse

One of the scariest prospects for anyone seeking a nursing home for a loved one is possible mistreatment. When your loved one needs 24-hour care, assistance with activities of daily living like toileting and bathing, and rehab services such as physical therapy, speech therapy, and occupational therapy, they are extremely vulnerable.

Besides checking the Medicare ratings, ask local hospitals, doctors, and elder law attorneys about the reputations of any nursing homes you are considering. Also search for news stories about the homes.

Infection control

Even before COVID-19, infection control was a major issue in nursing homes. Because residents live in close proximity, are indoors most of the time, share common spaces, and are attended to by shared staff, infections such as influenza, pneumonia, norovirus, antibiotic-resistant staph, and Clostridium difficile can easily spread throughout the home and cause unnecessary deaths.

COVID-19 brought national attention to the challenges of keeping nursing home residents safe from infection. Checking a nursing home’s record during the pandemic provides another way for families to see how safe their loved one may be in a particular facility.

Staff turnover and staffing levels

Problems like infection control and mistreatment can be exacerbated if nursing home staff work at more than one location, which is a common practice in the industry. Many nursing homes use staffing agencies to fill vacancies and turnover is often high.

High turnover among staff and administrators is not a good sign. It can mean the home is not well-run. It also means that you and your loved one will not be able to develop ongoing relationships with the people providing your loved one’s care.

Frequent turnover can hamper observations that indicate your loved one may need a different treatment: Perhaps a new medication has altered their appetite, sleep patterns, or personality, for example. Further, it will be frustrating for both you and your loved one to constantly re-explain your loved one’s condition, needs, and preferences. (Related: The advantages of personal health records)

The higher the staffing levels and the lower the turnover, the more likely your loved one is to get timely attention on a daily basis and speedy assistance in an emergency.

Autonomy

While some nursing home residents may require a high level of supervision, most will want some say in their daily lives. They may prefer to wake up, go to bed, and take naps at certain times of day. They may prefer to eat at certain times and enjoy a variety of nutritious food — or they may need the occasional nudge toward healthier options, especially with health conditions like diabetes or heart disease.

Also, some people want more social interaction than others. It's important that the nursing home you choose does not force all residents to follow the same schedule, eat the same meals, and participate in the same activities. Needing nursing home care means your loved one has already lost a significant amount of autonomy. Good nursing homes make sure residents retain control over their lives wherever possible.

You should also investigate the kind of activities a nursing home offers. Will they be the kinds your loved one will enjoy?

Medical care

Your loved one probably already has doctors who are familiar with their condition. Will your loved ones still be able to see those doctors as a nursing home resident, and if so, how? Does the home have a service to take residents to local doctors’ appointments? What type of medical staff are on-site at the home? Will your loved one’s doctors make visits to the nursing home? Also, how will your loved one get eye exams, hearing exams, dental care, and haircuts?

Find out what the home’s emergency protocols are, too. Do residents have call buttons in case they fall or otherwise need urgent assistance? How close is the nearest hospital, and is it a high-quality facility? What happens if residents need to be evacuated due to a natural disaster?

Payment

Since Medicare provides limited coverage for nursing home stays, many patients end up paying out of pocket. Days 1 through 20 are covered at no charge, while days 21 through 100 require a coinsurance payment of $185 per day in 2021.

While costs can vary considerably by facility, geographic location, and the level of service your loved one needs, one industry survey puts the national median monthly cost at $8,821 for a private room in 2020. Opting for a semiprivate room saves about $1,100 per month. A semiprivate room might sound unappealing, but having a roommate can provide companionship and an extra set of eyes and ears to monitor your loved one. (Related: Are you liable for your parent’s nursing home bills?)

Medicaid will cover long-term care, but only after your loved one’s assets are nearly depleted. Middle- to upper-middle-class families who cannot afford to self-insure but who don't want to spend down to qualify for Medicaid stand to benefit the most from a long-term care insurance policy or a long-term care rider on a permanent life insurance policy. Wealthier families may also appreciate how long-term care coverage helps preserve their assets. (Related: Long-term care & life insurance combination)

If running out of assets is a concern, however, make sure to choose a facility that accepts Medicaid patients.

Conclusion

Choosing a nursing home can be a stressful process, and the stakes are high. Securing excellent care is essential, but keeping one guiding principle in mind might make your decision easier.

“The nursing home will be your loved one’s new home and, ideally, it should feel like it,” Collier said. “Keep that goal in mind when researching different facilities and listen to your gut.”

Learn more from MassMutual…

9 financial questions to ask your mom

Three ways to pay for long-term care

Why single seniors pay more for health care

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The information provided is not written or intended as specific tax or legal advice. MassMutual, its employees and representatives are not authorized to give tax or legal advice. You are encouraged to seek advice from your own tax or legal counsel. Opinions expressed by those interviewed are their own and do not necessarily represent the views of Massachusetts Mutual Life Insurance Company.