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How to Choose a Nursing Home


Updated 9/7/2021


Choosing a Nursing Home During the Pandemic

Choosing a nursing home for a family member is most difficult in the best of times. It is a stressful, time–consuming task that is often made worse by the fact that a loved one has suffered a medical crisis.

These are not the best of times. COVID-19 is devastating to nursing home residents and they remain at high risk of harm from isolation caused by extreme visitation restrictions in some facilities. Despite lower rates of COVID infections and deaths in nursing homes due to vaccines, many California nursing homes are still limiting visits from families and friends to 30 minutes per week or less. Other facilities, in stark contrast, are permitting extensive visitation.

The State has enabled the wide range of visitation policies among facilities by continued waiver of laws that normally give residents the right to have visitors at any time.

Avoid nursing homes with restrictive visitation policies.

All other things being equal, select a nursing home that allows robust visitation. Ask for written copies of each facility’s current visitation policy and for details on how it is implemented. Don’t select a facility that tolerates isolation of residents.

Personal Visits

Nothing substitutes for a personal visit to the facility. Personal visits have always been the most important way to assess the quality of a nursing home, yet this option has not been available during the pandemic while facilities have been closed to visitors. However, some nursing homes are now allowing potential residents and their representatives to make personal visits onsite to assess their services.

All other things being equal, select a nursing home that has allowed you to observe its care and services. Beware of nursing homes that expect you to select them sight unseen.

When visiting facilities under consideration, ask to see the entire facility, not just the nicely decorated lobby or a designated unit. Try to get a feel for the quality of care and how residents are treated by the staff. Resident appearance, use of restraints, residents’ rooms, quality of food and activities are all–important factors in evaluating a nursing home. However, nothing is more important than the quality and quantity of nursing home staff.

How do you feel when you visit the facility? How does it compare to others? How did the administrator and staff treat you? Remember that you’ll be depending on these people to take care of your loved one. If you don’t like visiting there, imagine what it would be like living there.

People sometimes over–estimate the importance of an attractive building. While a nursing home should be safe, clean and comfortable, it doesn’t do the potential resident any good to choose a “fancy” nursing home if the resident can’t afford it, if it can’t meet the resident’s needs or if it is too far away for family and friends to visit.

Do comparative shopping. Use CANHR’s Fact Sheet, Nursing Home Evaluation Checklist, to help you evaluate facilities under consideration.

COVID-19 Status and Vaccination Rates

It is important to consider vaccination rates at nursing homes and whether a nursing home has or had a COVID-19 outbreak.

Unfortunately, California is only publishing the numbers of residents and staff who have been vaccinated at individual nursing homes, not the current percentage of them who have been vaccinated. Its vaccination data gives a very incomplete picture of the current COVID risk at facilities. The State’s data on the numbers of nursing home residents and staff at individual facilities who have or have had COVID, or died from it, is more helpful, however, it is of unknown reliability.

The State’s vaccination and COVID infection data on skilled nursing facilities is posted on a spreadsheet that is available on this page.

The federal Centers for Medicare and Medicaid Services (CMS) separately publishes data vaccination rate data on its COVID-19 Nursing Home Data webpage that is updated weekly showing the percentage of residents and staff who are vaccinated.

Medicare and Medi–Cal Considerations

If you want Medicare or Medi–Cal to help pay for the nursing home care, you must select a facility that is certified by these programs. Due to the extremely high cost of nursing home care – which averages well above $300 per day – few people can afford to pay privately for very long. Most California nursing homes participate in both Medicare and Medi–Cal.

Medicare’s short–term skilled nursing facility benefit is very limited, but is often helpful to gain admission to a nursing home, especially when skilled nursing care or therapy are needed after hospitalization due to a stroke, surgery, injury or other medical conditions. With some exceptions, Medicare covers up to 100 days of skilled nursing care following a hospital stay of at least three days.

Medi–Cal helps pay nursing home care for two–of–every–three residents in California. Due to the high cost of nursing home care, most people in nursing homes will meet Medi–Cal’s financial eligibility requirements sometime during their stay. CANHR’s website provides extensive information on Medi–Cal eligibility for nursing home care.

Even if you don’t need or qualify for Medi–Cal now, it is best to select a Medi–Cal certified facility. Uncertified facilities can evict you when your money and insurance runs out. Your choice of other facilities at that point may be very limited. Medi–Cal certified facilities cannot evict residents who qualify for Medi–Cal during their stay.

Although it is illegal for a certified nursing home to require a resident to pay privately for any set period of time, many nursing homes give preference to applicants who can pay privately. The longer you can pay the private rate, the more options you will have when looking for a facility.

Location

It is important to select a nursing home that is close and convenient to the person(s) who will be visiting the resident most often. Residents who have frequent visitors often recover faster, are happier and healthier from the love and attention received and tend to receive a higher quality of care. When family members and friends are close enough to visit frequently, they can monitor the resident’s condition, participate in care planning and respond quickly to emergencies.

Special Needs

Always seek a nursing home that can meet any special care needs your loved one may have. For example, some residents need specialized respiratory care, such as a ventilator, that is only available at certain facilities. Or someone with dementia may need extra supervision and assistance with daily needs. Ask detailed questions to make sure facilities under consideration are currently able to provide the necessary care.

Seek References

If possible, seek information about facilities under consideration from people you trust. Relatives, friends, clergy, local senior groups, ombudsman programs, Alzheimer’s support groups, hospital discharge planners, doctors and others may have recent experiences with nursing homes in your area. You can also seek opinions from residents and visitors while making visits to check on nursing homes.

Inspection Histories

It is a good idea to check the inspection history of any facility that you are considering. However, as is discussed below, be alert that this information is likely to be incomplete and misleading.

The California Department of Public Health (CDPH) conducts inspections and complaint investigations of nursing homes in California. Its Cal Health Find website provides information on every licensed nursing home, including Medicare and Medi-Cal status, and the recent history of complaints, deficiencies (violations) and citations (financial penalties).

It is best to avoid nursing homes that have many complaints, deficiencies or citations. For complaints, consider all complaints that have been filed against a nursing home, not just those that CDPH has substantiated. CDPH only substantiates a small percentage of complaints due to serious problems with its investigation system.

Be aware that inspection histories may be misleading right now. Due to suspension of routine inspections and to visitation restrictions imposed during the COVID-19 pandemic, nursing homes received far fewer complaints, deficiencies and enforcement actions in 2020 and 2021 than in prior years. Consequently, Cal Health Find data on performance histories may not reflect actual conditions in facilities during these years.

ProPublica’s Nursing Home Inspect site also provides access to nursing home inspection histories, with advanced search features.

Nursing Home Ratings

Many people consult online nursing home rating systems when selecting a nursing home. As with inspection histories, nursing home ratings are also likely to be misleading right now because of the suspension of full inspections during the pandemic.

The most popular rating site is Care Compare, which is operated by the federal Centers for Medicare and Medicaid Services (CMS). Due to serious flaws, its ratings are not reliable. However, they can be useful in narrowing your choice since it is almost always best to avoid lower rated nursing homes if you can.

One major flaw in the federal rating system is its reliance on quality and staffing data that is self-reported by nursing homes. Nursing homes are able to game the rating system because this data is not audited.

Another major flaw is that Care Compare ratings do not take into account any violations of California nursing home standards or California citations to nursing homes.

Also keep in mind that the quality of California’s nursing home inspection system is poor, at best. Inspections often overlook or understate serious problems. These failures tend to inflate nursing home ratings.

You cannot rely on ratings to find a good nursing home.

Yelp and Other Web-Based Reviews

A growing number of nursing homes are reviewed on Yelp and other web-based review sites. Reviews offered on these sites offer a much more individualized perspective on the quality of care and the treatment of residents. Use your best judgement when considering online reviews to determine if they appear to be trustworthy. Some nursing homes arrange for fake reviews, so beware of comments that seem unreliable or too good to be true.

Arranging Care During Hospitalization

Many people are admitted to nursing homes from hospitals. If your family member or friend is hospitalized, contact the hospital’s discharge planning or social work office as soon as possible to request assistance in arranging nursing home care or home and community-based services. Hospitals are required to help patients locate and obtain care and services they will need upon discharge. Some hospitals are more helpful and cooperative than others but all are equally responsible to give you professional, timely assistance.

Hospitals cannot discharge patients to nursing homes without their consent and cannot charge for extra days of care if they have not met their discharge planning responsibilities. See CANHR’s Fact Sheet, Challenging Hospital Discharge Decisions, for more information on hospital discharge rights.

 

More Information

It is a good idea to review CANHR’s Fact Sheet on California’s Standard Admission Agreement for Nursing Home Residents before admission to a facility. CANHR also publishes several other fact sheets on nursing homes, such as Residents’ Rights and Making Care Plans Work, that give important information about your rights and how to get the best possible care.

 

Page Last Modified: September 7, 2021