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The Michigan Long Term Care Companion
How to make the system work for you and what to do when it doesn’t.

Chapter 17

Evaluating and Selecting a Nursing Home

Finding the right nursing home is all-important to you or your loved one’s well-being. But it can be a difficult, time-consuming task, filled with bewildering information and uncertainty. Fortunately, there are some simple steps you can take to minimize the complexity of this challenging task.

The first step is to develop a plan to find the best available facility. Your plan should include identifying local nursing homes, gathering information about facilities from reliable sources, calling and visiting these facilities, and then evaluating your options. Some important factors to consider include the location of the home, its participation in the Medicare and Medicaid programs, and whether the home offers services that meet your needs and desires.

As with most important decisions, it is best to plan in advance. Ideally, you should try to visit local nursing homes before you need care so that you can identify facilities you like and can afford. Many nursing homes have waiting lists, so you may not be able to get in if you have not applied in advance.

Although advance planning is very helpful, most people seeking nursing home care start looking during a crisis. This often occurs when a person becomes seriously ill, suffers an injury, or home caregivers become unavailable. More than half of people entering nursing homes are admitted from hospitals, following treatments for illness or injuries. If you are in this situation, it is still very important to plan your search because you may have little time to make a decision.

Try to find out how much time you have to make a decision. If you are helping a relative who is hospitalized, consult with the doctor to determine how long hospital care will continue and how long the nursing home care may be needed. Then set up an appointment with the hospital’s discharge planning staff to seek assistance with nursing home placement or to discuss other options. The discharge planning staff should assist you by making referrals and sending medical information needed by facilities you are considering.

Sometimes hospitals pressure people to leave before they are medically stable or before alternative care arrangements have been made. People on Medicare have the right to challenge hospital discharge decisions and to stay in the hospital without extra cost until their appeals have been reviewed. Chapter 4 fully explains these rights. Make sure the hospital fulfills its obligation to help you obtain needed care and gives you enough time to make appropriate arrangements.

During a crisis, you may find that you do not have enough time to arrange admission to facilities that interest you or to evaluate nursing homes under consideration. If this is the case and you can afford it, it may be best to arrange temporary nursing care at home while you continue the search. This option can be very expensive, especially if 24-hour care is needed, but it will remove some of the pressure to make a hasty decision. You can continue your nursing home search, with the peace of mind that your relative is receiving one-on-one care during a critical period. Money spent on a short period of home care might otherwise be spent on nursing home costs, so this approach may not cause an adverse financial effect.

Family Discussions and Shared Decision Making

Arranging nursing home care is hard work, so it is best to share responsibilities among key family members and friends. While it may be easier said than done, seeking family agreement on a plan can help ease the emotional stress for all involved.

There may be conflict over whether nursing home care is needed, who should make arrangements, and which facility or location is best. Sometimes family members feel guilty about their own inability to provide enough support or are upset about lack of assistance from others with caregiving responsibilities. Families need to work through these problems and seek harmony about care arrangements. The person entering the nursing home will need full emotional support from the entire family.

It is very important to include the person needing care in the decisions. He or she will have to live with the results. The individual entering the nursing home should be involved in the process of selecting the home every step of the way. Families will have to consider, however, when it is appropriate to involve the person who is not mentally alert or is in an unstable medical condition. The individual’s ability to understand presented information and medical prognosis should help guide these decisions.

Identifying Local Homes

You will need a list of local nursing homes. Your local ombudsman office (see appendix 1) can give you a list of all the nursing homes in your area.

Nursing home names are often misleading. The term “nursing home” is rarely used. Instead, nursing homes use terms such as care center, skilled nursing facility, convalescent center, extended care facility, and similar names.

Some homes use names that falsely suggest a religious or non-profit affiliation. Unless you are sure, ask homes if they actually have a religious affiliation. Be wary of facilities that use religious names when they are not religiously affiliated.

Location

Many people report that residents who have frequent visitors get the best care. Consider which family members and friends are most likely to visit regularly, and the facility’s distance to them.

Location of the facility is very important. If the facility is too far away, its other advantages may not make up for infrequent visits by family and friends. Many people report that residents who have frequent visitors get the best care. Consider which family members and friends are most likely to visit regularly, and the facility’s distance to them. Is there a relative, perhaps a spouse, who will not be able to visit unless the home is nearby?

Seek References

Before visiting nursing homes, seek information about facilities from people you trust. Relatives, friends, clergy, local senior citizen groups or clubs, support groups for people with Alzheimer’s Disease or other illnesses, hospital discharge planners, doctors and others may have had recent experiences with nursing homes you are considering. Ask them about their opinions. Recent experiences are the most helpful, since conditions in nursing homes can change significantly over time. Pay attention to any patterns in their comments, since repeated opinions from several people are more likely to present a true picture of the home.

Also review the nursing home’s most recent inspection report. Nursing homes are inspected about once a year by the Michigan Department of Consumer and Industry Services. Homes are supposed to post the inspection reports in a prominent place. Look for them during your visits. You can also obtain information on inspection results from your local ombudsman office (see appendix 1).

Medicare and Medicaid Programs: Not All Homes Participate

Medicare pays for very limited nursing home coverage for persons needing skilled nursing or rehabilitative services. Less than 10 percent of nursing home costs in Michigan are paid by the Medicare program. Chapter 8 gives information about Medicare’s nursing home coverage.

Medicare and Medicaid will not pay for your care unless it is given in a certified facility.

Medicaid is the dominant source of government funding for nursing home care. It helps pay for nursing home care needed by persons with limited incomes and resources. Because of the high cost of nursing home care, most people in nursing homes eventually qualify for Medicaid. About two-thirds of Michigan’s nursing home residents receive financial assistance from Medicaid. Chapter 9 explains Medicaid eligibility for nursing home residents.

If you need or want Medicare or Medicaid to help pay for a nursing home stay, select a facility that participates in these programs, for not all nursing homes do. Homes that do participate in these programs must meet federal standards and are called certified facilities. Medicare and Medicaid will not pay for your care unless it is given in a certified facility. Most Michigan nursing homes participate in both programs. Only a few of Michigan’s nursing homes do not participate in either program. Non-participating homes are sometimes called private nursing homes.

Even if you do not need Medicaid assistance now, it is best to select a Medicaid-certified facility.

Even if you do not need Medicaid assistance now, it is best to select a Medicaid-certified facility. Facilities not certified by Medicaid can evict you when your money and insurance runs out. If this happens, you may find it very difficult to get accepted by a Medicaid-certified facility of your choice. Medicaid-certified facilities must allow you to stay and must accept Medicaid payments on your behalf if you qualify.

Some people believe that private nursing homes (homes that do not participate in Medicare or Medicaid) offer better care. There is no basis to support this myth. In fact, Medicaid and Medicare-certified facilities must meet higher standards and are inspected more frequently than private homes. Citizens for Better Care recommends that you seek the best possible Medicare- and Medicaid-certified facility.

Give preference to facilities that have all of their rooms or beds certified for Medicare and Medicaid. Some homes have chosen to limit the number of rooms certified for Medicaid or Medicare. In these homes, Medicaid and Medicare will only pay for your care if you are staying in a certified room. In addition to payment problems, partial certification also causes unnecessary room changes for residents when payment sources change. These room changes are often very distressing to residents who have become familiar with roommates, caregivers and their surroundings.

Full Medicaid certification is especially important, because so many nursing home residents qualify for Medicaid coverage. Your local ombudsman office can tell you if a nursing home has full or partial Medicaid and Medicare certification.Cost of Care

If Medicare and Medicaid or other insurance coverage is not available, you will have to use your own funds to pay for your care. Paying for care out of your personal funds is called private payment. Private paying residents usually pay higher prices.

The average cost of nursing home care in Michigan for private paying residents is $40,000 to $50,000 per year. Daily rates range from about $100 to several hundred dollars per day. Most homes charge between $100 to $150 per day. Rates usually vary based on room size, number of roommates, and the type of care needed.

Beware of hidden costs. Many nursing homes imitate hospital billing practices, by charging separately for routine supplies and nursing care. For example, nursing homes often charge extra if residents are incontinent or confused, claiming that they need extra care. These extra charges may come as a great surprise, because incontinence and confusion are very common symptoms in nursing homes. What may seem basic or routine to you may seem otherwise to the nursing home billing office. Ask for a copy of extra charges and review it carefully.

Ask about pharmacy charges. Many Michigan nursing homes require residents to use a specific pharmacy. Residents paying for their care from personal funds often discover that their drug expenses increase dramatically because of very high prices charged by the facility-selected pharmacy.

You will need to decide what you can afford. If you anticipate qualifying for Medicaid within a short time, differences in nursing home costs may not be very important to you. Higher costs will result in speedier Medicaid qualification, with no increase in total cost to you. This is because Medicaid requires you to spend down your assets to certain amounts, no matter how long it takes.

If you have substantial savings and income that you will be using to pay for your care, nursing home rates may be very important to you. Find out how often prices have increased in recent years and if there are any plans to increase the rates.

Chapter 18 explains nursing home admission contracts, deposit requirements and other money matters. Review it carefully before signing an admission agreement with any nursing home.

Evaluate Your Needs

It is very important to identify what nursing home features are most important to you. Since nursing homes are not all alike, you will want to find one that matches your needs and desires. Start by asking yourself these questions:

What kind of care do you need?

What type of lifestyle are you looking for?

Some people want a safe, comfortable place with basic nursing care and pleasant companions. Others may need specialized nursing or rehabilitation services. You may want a home that places special emphasis on religious or ethnic traditions.

For example, if you need short-term therapy to enable a return home, you should place great emphasis on the quality, availability and cost of therapy services. In this situation, other factors such as activity programs, building features and Medicaid certification may be less important than for someone expecting a long term stay.

Call First

It is best to call homes first before visiting. Once you identify what you want and need in a home, simply telephoning some of the nursing homes on your list may eliminate the need to visit them. Ask each home if it offers the services you are looking for. Request information on costs, including extra charges not included in the daily rates. Ask if it is a Medicaid-certified facility.

Just as you are trying to be particular about the nursing home you select, some nursing homes are very selective about the applicants they admit. They are likely to ask you several questions before telling you if you will be considered for admission. Their questions will probably include:

What are your care needs?

How do you plan to pay for your care?

How much income and resources do you have to help pay for care?

Your ability to get into some nursing homes will depend on your answers to these questions. Many facilities favor applicants who have more money and need less care. While this type of discrimination is unfair and illegal at Medicaid- and Medicare-certified facilities, it is a widespread practice. You can save time by eliminating facilities that are not interested in you.

CBC is working to seek enforcement of laws against discrimination by nursing homes. Chapter 18 has more information on your nursing home admission rights.

Visiting Nursing Homes

Visiting nursing homes is the most important part of choosing one because it gives you an opportunity to observe the quality of life and care in facilities. You will want to tour the facility and speak to as many residents and family visitors as possible to find out what they think about the home.

The first time you visit, make an appointment to see the admissions coordinator. This will give you an opportunity to ask questions about admissions policies and procedures as well as to see the home. Ask for a guided tour of the facility so that you can become familiar with its layout, programs and services. Request that you be shown the entire facility and the room that is available for your relative. Sometimes, tours are limited to the nicest, higher-staffed sections of the home. After the tour, ask if you can visit unescorted, so you can observe meals or activities, and talk to residents and visitors.

Follow-up visits should be unannounced, at different times than your initial visit. Again, weekends and evenings are good times to evaluate how well the home is run. These visits will give you an opportunity to compare the level of attention that staff give to residents and whether the attitude of staff is the same during the night and day and during weekdays and weekends. There are usually few administrative staff members present at night and on weekends. Observe if there is adequate supervision of the staff and residents.

What to Look for During Your Visit

Ideally, you should visit a nursing home more than once and at different times of the day. If possible, try to visit during the morning, evening and on a weekend. During morning visits, look to see if residents have been helped with morning care, are dressed and out of bed. Are residents participating in activities or just sitting around waiting for lunch? Evening and weekend visits

Evening and weekend visits give you an opportunity to view the home when it has a smaller staff. Observe if the staff responds to residents in a timely and pleasant way when they need help. Are meals pleasant? Are there enough staff members to help residents with eating? Do residents have anything to do or are they kept in bed?

give you an opportunity to view the home when it has a smaller staff. Observe if the staff responds to residents in a timely and pleasant way when they need help. Are meals pleasant? Are there enough staff members to help residents with eating? Do residents have anything to do or are they kept in bed?

During your visits, there will be many questions to ask and things to look for. Take time to look, listen, and smell. If you are arranging placement for a relative or a friend, try to put yourself in his or her shoes. Trust your instincts and perceptions. If you are uncertain or confused about the appropriateness of something you observe, ask questions of the staff.

It is a good idea to take notes, because it is easy to lose track of details during this difficult task. You may want to use the checklist at the end of this chapter to help compare homes. Many of the questions asked in the next few pages are included on the check list.

Your review of the home should evaluate its quality of care, quality of life, medical services, food services, environment, administration and how it addresses your own special needs. The following sections identify issues and questions to consider during your visits. You can answer some of the questions through your own observations. Others need to be answered by staff, residents or visitors. You will probably not have enough time to answer them all. Emphasize those that seem most important to you.

You may also want to review the information in following chapters about residents’ rights and nursing home standards before you visit. Familiarity with rights and standards will help you evaluate whether the home is meeting basic expectations.Quality of Care

The true test of a nursing home is its care and attitude toward residents. Pay special attention to how staff members treat residents and whether they seem well-trained. Are there enough staff? Do they respond to resident needs in a timely way? In a courteous manner? What are their qualifications? On average, how many residents is each nurse aide or nurse assigned to care for? What are the averages at night and on weekends?

Observe whether residents receive help with grooming and personal hygiene. Are residents dressed appropriately? Are they clean, shaved? Is their hair combed or brushed?

Good care will help restore health, not foster dependence. Residents should be encouraged and helped to maintain, regain or improve their abilities. Look for signs that nursing and therapy staff attend to resident needs in a way that promotes independence.

Are residents invited and encouraged to participate in planning their own care?

Are residents encouraged to help in their daily care? With dressing? With eating and drinking?

Are residents helped and encouraged to make full use of eyeglasses, hearing aids, dentures and other aids?

Are residents helped and encouraged with walking? Do chair- and bed-bound residents receive help with exercises to maintain their mobility and use of their limbs?

Are bedfast residents taught how to turn themselves? Are residents taught how to safely move from bed to chairs and vice versa?

Do residents receive needed physical, occupational and speech therapies? Who provides these services? How often are they given and how long do they last? Do nursing staff continue therapy services after a licensed therapist is no longer needed?

Are incontinent residents helped to use the toilet as needed? Kept clean and dry? Is there a program to help residents restore bowel and bladder control?

Are feeding tubes and catheters used only as a last resort?

Is skin care given routinely to help prevent or treat pressure sores and other skin conditions?

Are residents comfortably positioned in chairs and their beds? Is water within their reach? Can they reach their call lights when they need help? Does the staff respond to call lights promptly?

Are residents kept restrained or drugged? There are many more appropriate care methods to meet safety needs. If more than a small number of residents are restrained, it may indicate that this is done for staff convenience or to discipline residents.

Medical Care

Nursing home residents must be under a doctor’s care. They have the right to use their own physicians but many physicians are unwilling to visit residents of nursing homes. Nursing homes have doctors, called attending physicians, who will treat residents of the home.

Only the resident’s attending physician can make a diagnosis and order medications, nursing treatments, therapies, tests, special diets, medical equipment and hospitalization. It is important to find out if the facility’s medical services are satisfactory, particularly if your own doctor will not serve as your attending physician at the nursing home.

How many attending physicians are there? Which one is considered best? Why? How many residents use this physician?

How often does the physician visit the home? Is he or she easily accessible?

Is the doctor’s name and number given to residents and relatives?

Who takes the doctor’s place if he or she is not available? Is the alternate doctor’s name and phone number given?

Are relatives notified when there is a change in a resident’s condition? How soon? Who will be notified?

What hospitals are used when hospitalization is needed?

What arrangements are made for specialist services such as vision, hearing, dental, and podiatric care?

Ask residents if they know who their doctor is and if he or she visits often enough. Do they find the doctor courteous and competent? Does the doctor keep them informed about their conditions? Does the doctor respond quickly and appropriately when they are ill?

Quality of Life

Good medical and nursing care are very important, but they are not substitutes for the relationships, interests and activities that give meaning to our lives. A good nursing home treats residents as individuals and helps and encourages them to maintain lifestyles of their choice.

People do not give up their rights when they enter nursing homes.

People do not give up their rights when they enter nursing homes. In addition to their basic constitutional and civil rights, they have the right to privacy, to be treated with dignity and respect, to be free from inappropriate use of restraints, to participate in planning their care, to refuse medical treatments, to participate in activities within and outside of the facility, to have visitors, to keep and use personal possessions as space permits, to review and copy their medical records, to complain without retaliation, and many others.

Nursing homes are the residents’ homes. They should provide a homelike setting that enables residents to live as normal a lifestyle as possible. Individual needs and preferences should be accommodated. As you visit, think about lifestyle preferences of the person needing care. How will they be met in the facility?

Do residents talk and spend time with each other? Is it done in a positive way? Do they appear to enjoy each other’s company?

How does the facility ensure that roommates are compatible?

Are there sufficient religious, recreational, educational, and social activities for residents? Do residents attend and participate in these activities? Are activities based on residents’ interests?

What type of activities are there for residents who cannot attend or are uninterested in group activities? How often do these occur?

Does the home help residents keep in touch with friends, relatives and community organizations?

Is there a telephone available for residents? Is it suitable for private conversations, adapted for the hearing impaired, and easy to reach from a wheel chair?

Do staff members treat residents in a friendly and respectful manner? Are residents treated as adults rather than children? Do residents appear to like the staff?

Do residents have an opportunity to influence facility policies and programs? Is there a resident council? What are some of its recent suggestions? Do family members have similar opportunities?

Are residents allowed and encouraged to follow their own daily routines? Are bed, care and meal times flexible? Or are all residents forced to wake-up and go to bed at the same time?

Is there a volunteer program? If so, how many volunteers participate? What do they do?

Is privacy respected, especially during care, treatment and toileting?

Are beauty and barber services available?

Is the resident’s language spoken? If not, how will staff communicate with the resident?

Social and Mental Health Services

Living in a nursing home is a big adjustment for most people. Even if residents were in the best of physical and mental health, living with dozens of strangers would be a big challenge. Residents’ many health problems make adjustment much more difficult. Not only must they understand and accept their own health problems, they have to adjust to the health needs of other residents.

Social services should be provided to help residents adjust to the facility, to each other, and to their illnesses. These services should also respond to other psychosocial needs such as grief, depression, anxiety, loneliness or fear. Residents may also need help with financial or legal problems or assistance in preparing to return home. Find out how and who provides these services.

How does the facility help new residents adjust?

Is there a full-time social worker? What are his or her qualifications?

What kind of social services are provided?

How often does the social worker meet with individual residents?

How does the social worker help address residents’ emotional needs?

More than half of nursing home residents have mental impairments, often resulting in behaviors that threaten their safety and well-being. Their behaviors may be very disturbing to other residents, especially those who are mentally alert. Find out how and who responds to residents’ mental health needs.

Does the local community mental health agency evaluate and treat residents with mental health needs?

How does the staff respond to inappropriate behaviors? Are they able to comfort and distract residents? Or do their actions agitate and frustrate residents?

What kind of training has the facility staff received on mental health disorders? Have they been trained to detect and respond to the causes of inappropriate behaviors?

Are psychoactive drugs used only as a last resort and only in conjunction with a treatment program? Do residents appear heavily drugged or sedated?

Are methods used to help minimize resident confusion? For example, does the facility avoid roommate, staff and other changes that increase disorientation?

Food Services

Meals and mealtimes are very important parts of daily life in a nursing home. They provide an important opportunity for social gathering and sharing. Many residents have special nutritional needs that must be met to maintain or restore their health.

As you watch residents eat their meals, note whether they seem to enjoy the food. Talk to them about the quality and variety of their meals. Look at the posted menus and ask residents if they are followed. Ask to speak with the dietitian about special diets. Consider the dietary needs and food preferences of the person needing care. How will they be met by the facility?

Are residents’ food preferences considered or are all residents given the same food?

If residents don’t like prepared foods, are adequate substitutes offered? What kind?

Is food served at appropriate temperatures? Are meals served on time?

Is there a pleasant atmosphere in the dining room during meals?

Are residents given enough time and assistance to eat their meals?

Who monitors residents to make sure they get enough to eat? Do meals seem adequate in amount and quality?

How are bed-ridden residents served? Do they get help willingly and promptly?

Are between-meal and bedtime snacks served to residents whose diets permit?

The Environment

People sometimes over-estimate the importance of an attractive building. While a nursing home should be safe, clean and comfortable, it need not be fancy. Money spent on fancy accommodations will not address resident care needs. It is important that the facility have enough space and that resident rooms be livable. Ask yourself these questions:

Are residents’ rooms clean, attractive and pleasant? Do they contain personal possessions and mementos to create a homelike appearance?

How many people share a room? Is there enough space and privacy? Are there comfortable furnishings, including chairs for visitors?

Are bathrooms in or near resident rooms? How many residents share a bathroom?

Does the home appear clean and well-maintained? Are there any unpleasant odors or strong disinfectant smells? Is there adequate ventilation?

Are temperature levels comfortable for residents?

Are sound levels comfortable? Is it too loud? Too quiet? Is the public address system disruptive? If music is played, is it selected by residents or by the staff?

Is lighting adequate?

Do residents use day and dining rooms to socialize? Are these rooms inviting? In use?

Is space and equipment available for therapy services?

Is there a safe, outside area where residents can walk and get fresh air?

Are reading materials available? Is there a library?

Safety is also very important. Observe if a disaster plan is posted. Ask about staff training on emergency procedures and how often fire drills are held. Check the home for these safety features:

Functioning sprinkler system and fire extinguishers,

Supervised or monitored exit doors,

Wheelchair access throughout the building and at entrances and exits,

A functioning call light system in resident rooms and bathrooms,

Handrails in all corridors,

Bathroom safety features such as grab bars and safety mats or grip strips in showers, and

Non-skid floors and non-cluttered hallways.

Administrative Issues

The administrator is responsible for the total operation of the home while the director of nursing is in charge of nursing services. Their knowledge, experience and leadership qualities usually determine if the home is well-run. Ask about their training and experience. How long have they been at the facility? Ask to meet with them at least briefly to form an initial impression. Do they seem like people you can trust and who will be responsive to your concerns?

Ask if the home has a stable staff. Is there much turnover? Does the home rely on any temporary staff hired from outside agencies? This is not desirable since temporary staff are not familiar with residents’ needs and preferences.

See if the home has posted the results of its most recent inspection. The report should be displayed in a prominent place. Ask the home about actions taken to correct recent violations. Are these changes noticeable?

Ask for a copy of any rules residents must follow. Do they seem reasonable?

Special Considerations

You may have special needs or desires to consider. For example, terminally ill individuals may want hospice care. Although a growing number of nursing homes are affiliated with hospice programs, some still do not offer this care option. Ask if the home offers hospice care. Who provides these services? What do they consist of? How is the care different from what other residents receive? Is there an extra charge? Chapter 13 gives more information on hospice care.

Some people seek short-term nursing home care to provide a break for family caregivers. This is often referred to as respite care. Nursing homes with vacancies are often willing to accept people for short-term stays. If respite care is needed, find out how the facility will ensure that all staff are familiar with the person’s needs. Is a minimum stay required? Are there extra charges?

Others may want a home with a special unit for people with Alzheimer’s Disease or other type of dementia. A unit for people with dementia may be special if it is well-run but some so-called special units simply segregate demented residents without providing any special services. Chapter 15 gives information on how to evaluate facilities that offer special dementia care programs.

Some people prefer a nursing home that has a religious or hospital affiliation or one that is operated on a non-profit basis or by a county government. These affiliations are no guarantee of better care. While some homes with these characteristics are excellent facilities, others have been cited for widespread and serious violations of state and federal standards. Some nursing homes are “non-profit” in name only, as in the case of some hospital-owned nursing homes that are operated as profit centers for the hospitals. It is best to choose a home based on its own merits.

You may want to consider whether a facility offers other levels of care, so that you can remain in one place if your needs change. This may also be important if you wish to live in the same place as a spouse or relative who has different needs.

A small number of Michigan nursing homes are classified as life care facilities. In these homes, payment of a substantial initial fee and monthly fees guarantees an individual the right to stay in various living options and to receive most types of health and social services for the rest of his or her life. Your local ombudsman office can identify life care facilities in your area.

Nursing Home Checklist

Quality of Care

1. Are residents and their families allowed and encouraged to participate in planning their care?

2. Are there programs to maintain and restore residents’ physical abilities and reduce their dependence on caregivers?

3. Do residents receive needed help with bathing, personal hygiene and grooming?

4. Do staff members respond promptly when residents need help?

5. Are residents in beds and chairs comfortably positioned?

6. Is there a program to restrict use of physical restraints?

7. Do residents receive care to prevent pressure sores?

8. Are incontinent residents kept clean and dry?

9. Is there a program to help incontinent residents restore bowel and bladder control?

10. Do residents receive sufficient fluids?

Quality of Life

1. Do residents seem to enjoy being with each other?

2. Do staff members treat residents with dignity and affection?

3. Are activities tailored to residents’ individual interests?

4. Are residents involved in a variety of activities?

5. Are daily routines tailored to residents’ individual needs and preferences?

6. Does the resident council influence decisions about facility policies and resident life?

7. Are residents informed of their rights and encouraged to exercise them?

8. Does the home use care in selecting roommates?

Medical Care

1. Is a qualified doctor available and accessible?

Social and Mental Health Services

1. Are residents helped to adjust to the facility and their illnesses?

2. Are mental health services available and delivered as needed?

3. Are staff trained to understand and respond to inappropriate resident behaviors in a sensitive and professional manner?

Food Services

1. Are resident food preferences accommodated?

2. Are meals varied and attractive?

3. Is there a pleasant atmosphere in the dining room during meals?

4. Are residents given enough time and assistance with meals?

5. Do residents with nutritional problems receive special diets?

The Environment

1. Is the facility clean, comfortable and well maintained?

2. Are resident rooms attractive and individualized?

3. Do resident rooms have enough space and afford privacy?

4. Are bathrooms clean and accessible?

5. Are temperature, lighting and sound levels comfortable?

6. Are day rooms attractive and in use by residents?

7. Is there a safe outside area for residents?

8. Are there adequate safety features?

Administration and Staffing

1. Do there appear to be enough staff to meet resident needs?

2. Does the facility avoid use of temporary staff?

3. Are the administrator and director of nurses well-qualified?

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