Here are some guidelines to help you know what to look for when visiting nursing homes. There are a wide array of characteristics that affect quality of care in nursing homes, and some of these will affect your care or your loved ones care more than others. So don't be overwhelmed by the sheer number of qualities and questions. It would be nearly impossible to examine every detail over the course of a single nursing home visit.

Instead, use this document to train your eye and help you become a more informed consumer. Keep in mind your particular needs as you read through, as some of the points will be more relevant than others to the care you are seeking. Think of this as a first time nursing home walkthrough that will enable you to approach your first real nursing home visit with the confidence that you know what you are looking for.

GETTING STARTED

To set up a tour of a nursing home, call the facility and ask to speak to someone in admissions. You should have no problem scheduling a meeting within the week. As you drive to your appointment, think about the length of the ride from your home to theirs. Many people stress proximity when choosing a nursing home for the simple reason that a shorter car ride will facilitate visits.

As you pull into the driveway, think about the specific location of the building—namely whether it is located on a busy street or a more rural setting. Location affects the residents' access to green space, their general quality of life, and their safety. Say for example, that a facility has a great deal of traffic directly outside of its front doors and that facility does not have a Wanderguard system that prevents confused residents from leaving the facility. This may not be a safe place for someone who has dementia or Alzheimer's.

FIRST IMPRESSIONS

You will develop a first impression of the home when you walk through the front door and take a seat in the lobby. Lobbies are often the most aesthetically pleasing parts of nursing homes. But don't let a chandelier delude you into concluding that a facility is top-notch. Lobbies are adorned for the purpose of making a positive first impression and in many facilities the resident rarely use them, particularly if they are located with the administrative offices in the front of the building.

If there are residents in the lobby as you wait for your guide, chat with them! Ask them how long they have been residing in the home and how they feel about it. It is also a good idea to talk with residents' family members if you have the opportunity. They have probably spent countless hours in the facility and their recommendation or discouragement can be very telling.

Also if you are waiting in the lobby for awhile, look for the official inspection report. Nursing homes are required by law to make their most recent report available for public viewing. Feel free to ask where it is, to ask for assistance interpreting it, and lastly ask about how the home has addressed any inspection violations listed in the report.

Your tour guide will come out to the lobby to greet you. She will most likely be the director of the admissions department—someone who is hired to present the facility to families and potential residents. In some larger facilities marketing representatives often give tours, while many smaller facilities rely on administrators, social workers, or directors of nursing to give them. An administrator, social worker, or nurse will probably have a better sense of how the facility runs from the inside and know more about working with the elderly. The expertise and training of a typical admissions director lies somewhere in the middle between sales and care of the elderly—they are involved in both aspects. Sometimes tour guides have a fixed route that they take visitors on. These routes may limit your tour to the nicest parts of the building and bypass what is less impressive. So make sure you see different kinds of rooms (private, semi, and bedrooms for 3-4), all of the dining areas, all of the common spaces and special departments.

Also, you will probably have some time to sit down and talk with the nursing home's representative before you begin your tour. Use this time to inform them about your background, preferences, needs, or anything at all that you think might be helpful to know, so that they can cater the tour to your individual case and interests. Give your tour guide a sense of your priorities and they will be able to respond accordingly, by showing you what they have to offer. Don't hesitate to ask questions, and hopefully they will be addressed throughout your visit.

There are a few general characteristics that you may want to touch upon before you get into the specific offerings shown in the tour. For example, inquire whether the home is for-profit or not-for-profit, and whether the home has a religious or fraternal affiliation. You may want to ask to see a list of board members. Not-for-profit nursing homes often have local community leaders on their boards, whereas a for-profit facility might be run by a corporate board across the country. Other general attributes you can discuss are size (number of beds), multiple levels of care, whether the home is JCAHO accredited (JCAHO is a nonprofit health care accreditation organization), staff to resident ratio, restraint policy, and visiting physicians.

OBSERVING AS YOU GO

As you begin the tour, try to note the way people are interacting around you. You may find it helpful to observe if your tour guide says "hello" by name to residents as you walk through the hallways. Because the admissions director is in charge of admitting new residents, it is reasonable to expect that she know a good number of the residents by name. If a resident is calling out for assistance or holding out a hand, note how your tour guide or the other staff members handle it. No nursing home staff member, regardless of who they are, should ignore a resident. It only takes a minute to hold someone's hand and listen to his or her needs. The staff should not be yelling at residents that are hard of hearing, but rather enunciating in a slightly louder tone.

The smell of a nursing home is only an issue if you detect one, which you should not. Odors usually indicate either that linens not being changed promptly or bedsores are not being properly treated.

You will have a clearer view of the residents you pass in the hallway so observe their hygiene and the effort that was put into their appearance (jewelry, festive accessories, painted nails). These details are a reflection of how much effort and consideration the nurses aide's put into a resident's dressing. But also keep in mind that by late afternoon, a disheveled looking resident may not reflect anything more than a day's toil.

Another thing to notice as you walk down the halls is the effort made to make the common spaces homier. Most facilities do not have carpet for sanitation reasons, but a few have carpet in at least the front of their building, which adds a nice touch. Plants, paintings, lamps (in place of overhead lighting) serve the same purpose. Some facilities might have pictures painted by their residents in art therapy or quilts that the residents had worked on hanging on the walls.

Your tour guide will probably point out lounges and sitting areas as you pass down the halls. Take a minute to step inside these little rooms. Look for comfy chairs that will encourage residents to utilize the space. Also, see if there are any sources of entertainment other than television available (for example, puzzles or a current daily newspaper). Lastly, think about whether people are using the lounge. Even the most beautiful won't be used if it is located far away from the residents rooms near the administrative offices.

As your tour guide leads you throughout the facility, think about how easy it is for the residents to get around. First of all, there should be handrails lining the hallways. Also, note whether rooms are clearly marked and important information is on display. For example, the activities calendar should be in very large print in a popular location, like next to the nurse's station.

Many facilities tack up a star in the date box to highlight the current day on the calendar. If the facility has more than one floor, observe how crowded and hard to catch the elevators are. A number of nursing homes have their activities departments and/or rehab departments in the basement. This location is not necessarily a draw back, as long as the staff makes a concerted effort to transport the residents where they need to go. Therefore, it is important to ask about transporters.

RESIDENTS' ROOMS

Your tour guide will show you a resident's room to give you an idea of what they are like. The room she chooses to show will likely be a spacious and well-decorated room so make sure to peek in random rooms as you walk down the hallways. Also if a facility has any rooms for three of four residents, make sure to request to see them. These are often the most crowded rooms.

Space is something that is hard to gauge if you are only visiting one or two facilities because you have little to compare the rooms with. But for the most part, you can use your common sense to evaluate space. Think about how much room there is to get around between the beds and between the foot of he beds and the wall, and keep in mind that wheelchairs will likely have to be maneuvered in these tight areas.

Look around the walls when viewing residents' rooms. Many homes wallpaper their residents' rooms or at least put a border up to make them homier. Some even give every individual room a different pattern or color scheme, with a flowery bed spread to match the walls. These little touches make the difference between a hospital room and a bedroom. A home's policy on personal belongings can also serve to deinstitutionalize the residents' bedrooms. Some homes encourage residents to bring personal belongings (even furniture) from home, and these policies are usually evident in the homey décor in their resident's rooms. Because residents keep the doors open for most of the day, personal belongings soften the atmosphere and benefit everyone in the home.

If you are very sensitive about privacy, note how your tour guide shows you the model resident's room and make sure they do not show you a room or open up a resident's closet without his or her permission. Another thing to look for is a curtain or divider between the beds of a semi-private room. Also look closely in the bathrooms to see if they are for just the residents in that room, or residents in the adjacent room as well.

As you peer into residents' rooms, notice what they are doing—walking around, sitting up, reclining on their beds, or lying in them. While a nurse or nurse's aide cannot keep a resident awake and alert all day, he or she can at least get residents out of bed and dressed. Lying in bed all day is detrimental to a resident's state of mind and furthermore, it can result in bedsores. Observing whether residents are up and about may also shed l ight on the vitality of the nursing home's resident population (If everyone is in bed, there won't be much going on!). Bear in mind the time of day you are touring and know that in the early morning and afternoon, residents will be more likely to doze off.

RECREATION

When your tour guide takes you into the recreation room, look carefully around. Some dining rooms double as recreation rooms, which may limit activities. Some nice touches in recreation departments are seasonal decorations, monthly birthday boards, and photo displays of the residents doing activities.

Make sure to ask the recreation director how he or she goes about gathering residents to participate in activities. No matter how prominently displayed an activities calendar is, some residents will forget about activities they want to participate in. A good recreation worker will go out into the hallways and into residents' rooms to announce activities and encourage the residents to join in. Take a look at the recreation calendar.

Every facility will have games, typically every variation of BINGO you can imagine! But there should also be a healthy variety of activities that serve a number of purposes. Here is a chart that may help.

Type of Activity	Examples
Mental stimulation	current events, library cart
Entertainment	singers, performers
Reminiscing	sing-a-longs, memory lane
Religious services	bible study, communion services
Social events	happy hour, coffee hour
Fitness/locomotion	morning stretch, balloon games
Interaction with community	out-trips, activities run by volunteers
Seasonal activities	gardening club, holiday crafts
Creative opportunities	art therapy, ceramics
Smaller group activities	baking club, monthly birthday dinners

Having this kind of wide array of activities may not be as important to you if you or your loved one is more likely to spent the majority of the time in his or her room. If this is the case, at least check the activities calendar for "room visits," which are scheduled time slots during which activities workers visit with the residents who attend activities less often. You may want to ask about this type of recreational outreach if you do not see it on the calendar, because it may be done informally. Lastly, remember to ask if every resident receives a copy of the monthly activities calendar.

You may pass a chapel, meditation room, or some other type of religious room. Ask about what kinds of services are held there. Some homes have their own chaplain, daily services, prayer groups and special holiday services. Other facilities have only a weekly Sunday service.

THERAPY

You need to be equally as observant when your tour guide takes you to the therapy department. If you or your loved one will be in a short-term rehab unit, this may be the most relevant and crucial part of your tour. First, ask about the staff of the department, namely their qualifications (whether they are licensed therapists, physical therapy assistants, or therapist aides) and whether or not they are staff employees or employees of an outside contractor.

Regular staff employees can usually offer greater continuity of care and are usually more accessible because they are in the facility daily. With outside contractors you are usually not going to find this regularity and continuity because staff can change from day to day. Keep in mind though, that some facilities, due to their size, do not have the need for regular therapists and outside contractors are their most reasonable option. Also, some facilities do outpatient therapy. This may be a good indicator of a therapy department's extensiveness.

Once you have this basic information about the staff, watch how they operate their department. Ideally, the therapists should be working with residents one-to-one. If the room is overcrowded with residents it is more difficult for herapists to focus on the individual treatment and maintain overall organization. The room itself should be designated for therapy only and spacious, with plenty of room for therapy equipment.

Quite a few therapy departments have a model kitchen/bathroom/bedroom area for occupational therapy. These practice areas help to ensure that short-term residents can manage in their home setting and perform their activities of daily living before returning home or to another level of care.

Some occupational therapists go the extra mile and go out into homes to do home evaluations. If this sounds like something that would benefit you, ask about it. If you have the chance to talk to a therapist, ask how long their individual treatments typically run. A thorough treatment usually lasts about a half hour to forty-five minutes.

DINING

The dining room will undoubtedly be another stop on your tour. You may notice that the fancy formal dining room looks too small to accommodate all of its residents. The truth is, usually only residents that don't need any assistance with their meals can enjoy these restaurant style arrangements (often these meals are served by course, rather than all on one tray). So if you find yourself viewing a lovely dining room that looks like it could seat about 40 of the home's 90 residents, ask to see where everyone else eats.

Often times, residents who cannot feed themselves eat in small lounges at semi-circle tables that seat a nurse's aide in the middle of the semi-circle on a wheelie chair. The aide spoon-feeds or assists all of the residents at the table. Some facilities find other set-ups more social for their dependent residents. If you are touring during mealtime, observe how much attention residents get and whether they finish their meals. Also, ask your tour guide what happens if a resident misses a meal. Because the elderly are often at risk for malnutrition, staff should always follow up to make sure that every resident gets the daily nutrition they need.

In addition, you may want to find out the facility's policy on allowing residents to eat in their rooms. It is a resident's right to eat in their room, but staff should always encourage residents to come out of their rooms and dine socially. If your tour guide happens to introduce you to a dietician, ask if special recommendations can be made if a resident does not like the meal choices and try to get a feeling for how flexible the dietary staff is. You might ask if they ever do anything in collaboration with the recreation department such as a monthly theme dinner. Lastly, look at the food they are serving, or better yet, give it a try! If nothing else, at least glance over the day's menu (which should be posted) and see if the main meal or alternative choice sounds appetizing.

SPECIAL UNITS

If the facility you are touring has any special units separate from the main long-term care unit, make sure that you pass through those as well. Most Alzheimer's/dementia care have very different feels. You need to find out what makes this unit different from the main long-term unit other than the l ock or alarm on the door. The unit should have a simple layout (often circular) that allows for safe wandering and that is clearly marked. The staff in this unit should be specially trained to deal with Alzheimer's and dementia residents.

Furthermore, this unit should have a separate recreation program designed specifically with its participants in mind. Look to see if they have activities scheduled more frequently than the regular recreation department (some have activities continually throughout the day). Something else to look for is an enclosed outdoor area with a circular path. Noting these specifics should help you to determine whether the special unit has much to offer its Alzheimer's and dementia residents.

Another special unit that you may pass through is a short-term unit designated for rehab residents. Keep in mind that these rooms will be decorated with fewer personal belongings due to the brevity of the residents' stays. It is really up to the home to set up these rooms for the comfort and convenience of the short-term residents as much as possible. Some homes include phone and cable free of charge for their short-term residents.

If the facility you are touring has no separate unit for short-term, find out whether these residents share rooms with long-term residents. While it may be nice for long-term residents to have short-term residents because they will meet more people, remember that it may be difficult for a long-term resident to be paired with transitional roommates. On the flip side, it may be disheartening for a completely coherent short-term resident to be placed with a long-term resident with severe dementia.

STEPPING OUTSIDE

The last major stop on your tour will likely be the outdoor area of the facility. You can easily evaluate this part of the facility by simply viewing it, but there are a few specific things to look for. The first and most important is the accessibility of the area. It should ideally be located in a place that is easy for residents to get to (i.e. not at the end of a long hallway). The paths and doorways should not create obstacles for someone in a wheelchair.

There should be ample sitting areas and a way for residents to enjoy the fresh air without being in the sun (an awning or gazebo). Nice extras include wheelchair accessible gardens and wheelchair swings. Some homes in the city may have atriums in the center of the building rather than backyard-like areas. Many of these are very nice, but if they are small and used by smokers, they may not offer residents the chance to get a breath of fresh air like an outdoor area should.

CONCLUDING

Once your tour is complete, you will probably return to the admissions office to talk with your tour guide about any questions that you have. Fire away! Although admissions directors are eager to portray their home in a positive light, they should generally very honest and helpful. Use this time to get a better feel for the nursing home's philosophy, because the attitude of the staff is ultimately what nursing home quality boils down to.

Maybe start by asking what makes this nursing home different from others. When you initiate a conversation like this, the admissions director will probably take over if she has anything special to say about the facility and enthusiastically tell me about their strong points. You will be able to me whether your tour guide is just delivering generic sales slogans ("You'll find a fuller life here in our family") or is speaking genuinely ("Many of our staff members have been working here for 10 to 20 years, and we really work collaboratively to care for our residents and overlap as far as duties go.").

Listen for mention of things like efforts to make their facilities homier, accommodating the needs of the individual over conforming to company policy, or the tight knit community of residents and staff. If the person you are meeting with has pride and personal investment in the home—which is obviously a wonderful thing for nursing home employees to have—it will come across in this type of conversation.

If family involvement is an important issue for you, ask your tour guide to talk about how involved family members can be in their relative's care. They may mention a family council, which is a great way for a resident's loved ones to actively participate in the nursing home. They should also mention the resident's care plan at this time. To design a resident's care plan, different members of a facility's staff meet to come up with an interdisciplinary plan of care. Some facilities invite family members to be active participants in these meetings.

Another topic you may want to introduce is resident autonomy. Ask if the nursing home makes any efforts to give their residents control over their own care or the operation of the facility. There are wide-ranging examples of these efforts. Some homes have small kitchens or snack areas that are open all day so that residents can have more control over their food and fluid intake. Other homes have ways for residents to take part in the running of the facility. For example, some facilities have their own facility newsletter written by residents, or a resident-run convenient store in the lobby. Pet therapy allows residents the chance to take part in the care of facility pets. Intergenerational daycare programs allow residents to have contact with children and even take part in their care. All of these are ways to give residents a sense of purpose and autonomy and to enhance their quality of life.

Also, remember that there is often a correlation between worker satisfaction and resident quality of life. You may want to talk to some staff members, particularly direct care workers (nurses and nurses' aides) who will provide the majority of your or your loved one's care, about their work environment. You can also ask your tour guide about staff benefits and educational opportunities.

If at the end of your appointment, you still don't feel as though you have a feel for the staff's attitude towards its residents, ask to make an appointment with a staff member who is involved with the residents' care like a Director of Nursing or a social worker (just say that you are interested in talking to them about their role in your or your loved one's care). Some people recommend going back to the nursing home without an appointment. You will have to decide for yourself what will be more helpful and appropriate for your decision-making process.