At Grove we always are trying to help our customers in any way we possibly can. One trouble we all face is the aging process. We all eventually have to face the hardship of finding the right nursing home for a loved one or ourselves. It is a process that can be very stressful and must be completely thought out as choosing how to care for an aging loved one is as important decision as any. Every year nursing home care improves in many ways. Options are as great as ever and it is important to be educated when making a choice of such magnitude. With that being said we want to provide a great Step-by-Step article filled with very valuable information on this life-changing process:
Step 1: Decide if a Nursing Home Is Necessary
If you can draw on good local resources, the best choice for now might not even be a nursing home.
No one looks forward to moving into a nursing home or putting a loved one there. But what to do when Dad is losing an alarming amount of weight because he lives alone and doesn’t eat well, or when Mom’s deepening depression and forgetfulness make her neglectful of vital medications? A nursing home may truly be the best option.
[See America’s Best Nursing Homes and search for one near you.]
You may be able to push back the day of reckoning for months or years. There is likely more support in your community than you suspect. Tap the local Meals on Wheels program to help your father stay well nourished, for instance, or adult day care to take the edge off your mother’s depression by connecting her with other people. However, a frail elderly person who may have already fallen and broken a hip or who has been wandering the neighborhood because of progressing dementia must have full-time care.
We have created a four-step tool that first will help you determine whether nursing home care can be put off at least for awhile. Then, if you conclude that a move can no longer be delayed, we will help you find a home that best meets your loved one’s needs—human as well as physical and medical. Finally, we will provide tips on how to stand watch so that he or she continues to receive skilled and compassionate care as time passes.
Arrange an evaluation. Your loved one should have a thorough geriatric assessment to evaluate his or her physical and mental status. A geriatrician, or a doctor or nurse practitioner with geriatric training, would be ideal, but such specialists can be challenging to find in some areas. Your mom or dad’s primary care physician is another option; phone ahead for reassurance that he or she can do a thorough assessment. The most important element will be your loved one’s degree of ability to conduct “activities of daily living”—sufficient upper-body strength to get out of a chair unassisted, adequate dexterity to bring fork to mouth, and enough range of motion to pull on pants or a sweater, for example. Balance will be checked to assess the risk of falls. Memory deficits, signs of depression or anxiety, and indications of dementia and Alzheimer’s will be evaluated. Simply identifying all the issues can take a big weight off a worried family’s shoulders. “When you frame it by what they need, then you can start putting together a plan,” says Cheryl Phillips, chief medical officer and geriatrician for California-based On Lok Inc., which provides long-term care and services for the elderly. If your loved one doesn’t have a doctor or the means to get to one, the local Area Agency on Aging may be able to come to the house or to do an initial, if less thorough, assessment over the phone.
Add your own insights. Input from family members should be integrated into the evaluation. The particulars of day-to-day concerns—trouble persuading Mom to take a shower, or her habit of forgetting to turn off the stove—will help guide the assessment, inform the plan of care, and narrow the choices that will have to be made.
Look to your community for help. “If they don’t need 24-hour care, many people could avoid a nursing home for one or two years,” says Susan Reinhard, AARP senior vice president for public policy. The Area Agency on Aging will have a list of local services, from volunteer groups that arrange rides for older folks to get to doctors’ appointments to the businesses that provide in-home nursing care and assisted living facilities. TheEldercare Locator Web page, maintained by the federal government, is a good resource to use as a starting point. You can search for help by ZIP Code.
Consider hiring a professional. Barbara Gortych, a Boston psychologist, recruited a geriatric care manager in Florida near her mother, to help find local resources and assist in care decisions. When Gortych was unable to visit, care manager Stephanie Swerdlow kept her informed about her mother’s status and services that were needed. Over the years, she helped Gortych arrange for occasional companion care to help her mother shop for groceries; she helped find a much-loved aide who was with her mother daily, an assisted living facility as dementia set in and, finally, a nursing home when 24-hour care was required. It was Swerdlow, in fact, who alerted Gortych that her mother needed the range of care that only a nursing home could provide. As her mother’s mind faltered and her health declined, Swerdlow would make unannounced visits to the nursing home to check on her care. “If something wasn’t right, she was the one who had the rapport,” says Gortych. She credits Swerdlow with bringing her peace of mind as well as local knowledge.
A geriatric care manager can be particularly helpful when you live far away but also can benefit anyone at a loss for good services for an aging loved one. You can search for one by ZIP Code on the National Association of Professional Geriatric Care Managers website. Many clients arrange for an initial consultation to help determine the kind and level of care required and plug the family into local options, says Phyllis Brostoff, the group’s president, and then call on them as needed. A consultation typically costs several hundred dollars; as-needed help generally costs from $80 to $200 per hour, depending on prevailing rates in the area.
Step 2: Build a Short List of Nursing Home Possibilities
Distance matters, of course. Our rankings will help by flagging top-performing nursing homes
With more than 15,000 nursing homes in the United States, even a modest-size city is likely to have 20 or more within a short drive. How can a manageable list be sifted out of so many possibilities?
[See America’s Best Nursing Homes and search for one near you.]
The guiding principle is to balance practical considerations, such as distance and expense, with issues of quality, such as results of health and fire safety inspections. You can readily obtain quality-related information by mining such resources as the new U.S. News “America’s Best Nursing Homes” rankings, which rely on information collected, analyzed, and converted into ratings by the federal Centers for Medicare and Medicaid Service (CMS). Some states also post data online.
You may find the thought of wading through data wholly unappealing, but the numbers have power well worth tapping. They will help you whittle down the nursing home universe to a short list of prospects and provide fodder for the types of questions to ask nursing home administrators when visiting the final candidates.
Make distance a priority. The best prescription for fending off depression and feelings of isolation in nursing home residents is to make sure they frequently see the significant people in their lives—adult children, of course, but also a neighbor dropping in for a meal or a grandchild coming to show off a good report card. Distance matters. “[A] facility that is a five-minute drive away may be best,” says Phyllis Brostoff, president of the National Association of Professional Geriatric Caregivers, even if its marks are comparatively lower than those of another home an hour away. Close proximity also makes it easier to keep tabs on the quality of care a loved one is getting.
Work from the top down. Charlene Harrington, professor at the University of California, San Francisco, and an expert in long-term care, suggests searching for places rated by the federal government at four or five stars overall and eliminating lower-starred facilities. “You might end up having to keep the threes in there, but start with the top,” she says. Consumer advocates are especially leery of a category of nursing homes labeled Special Focus Facilities by the government. Because of their history of poor performance, the 135 homes on the SFF list get twice the scrutiny that even one-star homes receive. But higher-ranking homes, she warns, are more likely to have a waiting list and may take only private payers. And while the star ratings are a good place to start, they cannot capture all of life’s aggravating realities—such as having limited choices if you live in a thinly populated part of the country.
Count the nurses. The number of nurses and nurse aides is one of the best indicators of good care. An ample supply means they have the time to help your mother out of bed and into her slacks or nudge her to engage with peers. It means her array of blood pressure and pain medications is closely tracked and she is monitored for side effects, drug interactions, and overmedication. You can easily compare staffing at different homes because those that take Medicare or Medicaid residents must provide CMS with nurse staffing data, which is converted into the amount of nursing time per resident.
But the numbers should be used only as a rough guide: They reflect the average number of nurses and nurse assistants in the two-week period before the most recent health inspection survey. While the surveys are unannounced—and alerting a nursing home to the date of a coming inspection is a federal crime—administrators know that surveys are conducted at least every 15 months. If it’s been 10 or 11 months since the last one, homes may staff up a bit more heavily in anticipation. Staffing information also is unaudited and its accuracy is suspect. Use the reported numbers to shape your short list, says Harrington, but draw conclusions only after visiting.
Good turnover data, if they were available, would be a much better indicator of the quality of staffing. It is not unusual for a home to have annual nursing turnover of 50 or 100 percent or even higher. Because of low pay and demanding physical requirements, turnover is especially high among aides, who have the most frequent direct contact with residents. The payroll data that would allow calculating turnover are not now collected. CMS plans to begin requiring homes to submit the information, but that could be a year or more away. It is a topic very much worth raising when you visit. Step 3 will give you turnover rates to compare with the answers you get.
Buddy up to an advocate. Every state has a long-term care ombudsman whose responsibilities include pursuing complaints made about a specific nursing home, usually by a resident’s family member or friend. The ombudsman is likely to know whether a facility has improved or has recently attracted a slew of complaints and should be willing to share these insights. You should also get his or her reaction to a nursing home’s star ratings in the Best Nursing Home rankings for overall quality, health inspections, staffing, and medical measures. “Ask if they think the ratings are accurate,” suggests Janet Wells, director of public policy at the National Citizens’ Coalition for Nursing Home Reform. Advocacy groups such as hers are another information source worth tapping—and the local ones may be more ready to dish about especially good or bad nursing homes, she says. The National Citizens’ Coalition for Nursing Home Reform lists contact information for all state ombudsmen and advocacy groups.
Ombudsmen and advocacy organizations should also be able to clue you in to disturbing events, such as an outbreak of C. difficile or MRSA infections, which are common in hospitals and nursing homes. And they can discuss a particular state’s nursing home regulations, which can be more stringent than federal standards, as well as details of citations for any violations. If a nursing home is implicated in a resident’s death in California, for example, the state ombudsman’s office can disclose the violation. Publicly available federal data might not reflect the specifics of the incident. “It might say there was a [citation that put residents in] jeopardy, but it might not be in there at all,” says Toby Edelman of the Washington, D.C.-based Center for Medicare Advocacy. Some state watchdogs are better than others, she adds. And the quality and level of knowledge varies widely: An ombudsman may be a part-time volunteer, for example, or might not be a particularly dogged advocate for nursing home residents.
Exploit state information. Some states have their own nursing home quality measures and post the results online. The trick is finding the information. It may be hosted by the department of public health or buried in nursing home “licensing and certification” sections. Dig around on the state’s home page, its department of public health page, and anything you can find on nursing homes or certification and licensing. Terms to guide your clicking: violations, deficiencies, state surveys, inspections, and 2567 forms.
The details can be telling. While some states simply rehash the federal information, others unveil specific results from the previous health and fire inspection as reported by the surveyors on federal form 2567, which describes investigations that earned violations for the facility—staff neglect that contributed to a resident’s injury from a fall, for instance, or a resident’s violent agitation because nurses failed to follow medication instructions. The Illinois Department of Public Health Website, for example, posts some 2567 forms online with their nursing homes. They also have a roundup section that lists, by quarter, the fines slapped on specific nursing homes, though not the details of the violations that garnered them. The California Department of Public Health website has a separate page that allows users to identify homes the state found responsible in the death of a resident and to read the 2567 forms to see what happened.
Broader nursing home information is not limited to federal or state websites. For example, the California Health Care Foundation website, which Harrington helped create, lists helpful information such as the percentages of residents at a home who require certain kinds of special care because of, say, reduced physical function or impaired cognition, compared with the state nursing home average. That will give you an advance sense of a home’s ability to provide a service that your loved one may need. Hourly nursing staff wages and rates of staff turnover, with comparisons to regional averages, also are available.
Step 3, Part 1: Size Up a Nursing Home by Visiting
Ask the right questions, know the signs of good and bad care, use your senses. It’s detective work
Once the universe of nursing homes has been whittled down to a few possibilities, it’s time for an in-person assessment. No matter how diligent your research, data are only part of the story, and glossy brochures are an unknown mix of facts and marketing. “A lot of facilities say they offer Alzheimer’s care, but it doesn’t necessarily mean they have [the correct staffing and] skills to do so,” says Cheryl Phillips, chief medical officer and geriatrician for California-based On Lok Inc., which provides long-term care and services for the elderly.
You’ll need to plan your tour in advance. Bring the U.S. News checklist to jog your memory. And be ready to use all of your senses, from sight to smell, to build a profile of each home. If time allows, visit more than once, ideally at different times of day and on different days of the week. On Saturdays and Sundays, for example, nursing homes may operate with lighter staff, which could compromise residents’ care. Mealtimes can be particularly revealing—the routine, the quality of the food, and the attention paid to residents who require help eating. As you look around, keep the following points in mind.
[See America’s Best Nursing Homes and search for one near you.]
Fancy wallpaper is nice, but… Institutional white walls are hardly inspiring, and a drab environment can sour the soul in people already prone to depression. It’s natural to equate a sunlit lobby and tasteful decor with high quality. But there are better ways to gauge a home’s overall vibe. Look for a full parking lot when you arrive, says Susan Reinhard, senior vice president for public policy at AARP and a former professor of nursing. Throngs of visitors tell you families and friends are welcome. Do you hear the chatter of grandchildren? Laughter? Music? The nursing home Barbara Gortych chose for her mother “may not have been the fanciest, but the quality of care I liked very much.” The Boston psychologist recalls observing the facility before moving her mother in and finding the staff plentiful, efficient, and tender. And her impressions remained consistent; “My mother could give you a run for your money,” she explains. “They never seemed to lose their sense of humor.”
Do you smell urine? Not only is it unpleasant—it suggests understaffing. The concern goes beyond keeping residents dry and comfortable. Incontinence is a major reason for moving someone to a nursing home, and urine-soaked pants or bedding can break down elderly skin. And while some residents may need a urinary catheter because of a temporary or continuing medical condition, catheterization should never be used to manage incontinence, says Phillips. Long-term use invites infection that can be deadly in individuals whose health is already compromised. Helping residents get on a regular bathroom schedule is one of the main tools for managing incontinence, but adequate staffing is essentiasl. Pay a visit in the morning to see how the staff handles residents who are just waking up and may have not been to the bathroom all night. No urine odor but a strong antiseptic smell? It might be an attempt to cover poorly monitored incontinence.
Quiz administrators who know the numbers. Bring along printouts or notes of Best Nursing Homes data, and ask for explanations in a friendly, nonconfrontational manner, suggests Phillips. “If they’re a five-star facility, ask how they got there,” says Janet Wells, director of public policy for the National Citizens’ Coalition for Nursing Home Reform, a Washington, D.C.-based advocacy group. If the facility is down at two or three overall stars, or performance in a particular area seems questionable, ask the administrators how they got those marks and what they’ve done to improve. The medical quality measures and staffing sections are based on self-reported data, so a touch of skepticism is healthy.
If you haven’t already absorbed the home’s most recent inspection findings, reported on Form 2567, by finding it on your state website (not all states post it), ask to see it. The home is required to let you read it. Ask for previous reports as well. Nursing homes don’t have to let you read reports other than the latest one, so it is a good sign if a home opens them up to you. Comparing several consecutive surveys could reflect a facility’s progress—or a slip in care. “If it’s thick, that’s already a warning,” says Wells of the survey report, which covers about 180 individual health-related requirements. If the home’s managers are too busy to help you understand the details—even if you made appointment in advance to do so—that, too, says something. The home could be short-staffed, reluctant to open up, or both.
The observations entered by the survey team on the 2567 forms will draw a picture far more candid and stark than one you’re likely to see on a carefully guided tour. The surveyors may observe a pile of soiled linens in the hallway or perhaps food left out to spoil for hours. Ask about the specific deficiences that were noted. The details can also inspire more pointed questions about corrective actions; the nursing home has to describe on the same 2567 form how each of the problems identified will be fixed. An inspection report may indicate, for example, that nurses didn’t wash their hands as they went from one resident to another. That’s worrisome because infections travel fast in nursing homes, and the elderly are particularly susceptible to them. So you can ask whether the plan to increase handwashing compliance is working. Other red flags, says Wells, include untreated weight loss, which can lead to significant frailty; medication errors; untreated pressure sores, which can be painful and can send a resident along a bedbound trajectory; and use of physical restraints. While declining in popularity, “safety belts” that strap a resident into a wheelchair or bed, says Wells, may actually trigger harm if a person already prone to poor balance tries to get free and falls in the process.
A report that can run 100 pages or more may seem picky and obsessive, but inspections often don’t go far enough. A 2008 report by the Government Accountability Office found that state surveyors frequently miss or understate serious care problems. Between 2002 and 2007, federal surveyors did follow-up inspections of nursing homes recently evaluated by their states. They found that 15 percent of the state surveyors had overlooked at least one problem carrying a risk of death or serious injury, such as untreated pressure sores or weight loss.
Discuss staffing with administrators. The National Citizens’ Coalition for Nursing Home Reform, which has a helpful explanation of the ways in which nursing homes are measured, suggests a ratio of at least 1 registered nurse, licensed practical nurse, or certified vocational nurse, plus 1 certified nurse assistant for every 5 residents during the day, every 10 residents during the evening, and every 15 residents at night. A home’s director of nursing should be able to give you these numbers, and the Best Nursing Homes page displays ratios of nurses to patients, although they are not broken down by time of day.
High staff turnover is a special challenge for nursing homes. “Three out of four staff leave every year,” says Charlene Harrington, professor at the University of California, San Francisco, and an expert in long-term care. “That’s a new staff person about every three months.” Studies show that high turnover rates lead to generally poorer care. One study suggests that families should look for a turnover rate below 30 percent for registered nurses, below 50 percent for licensed practical nurses, and below 40 percent for nurse assistants. Until CMS begins providing turnover data, all you can do is ask a home for its turnover rates. You could also chat up some of the nurses and aides about how often employees seem to come and go.
Even if turnover is low, scheduling can hamper care. “Does the facility tend to have the same caregivers day after day, or do they randomly assign…or rotate staff?” asks Phillips. The more consistent the contact between your mother and her nurses and aides, the better they will understand her needs and be her intelligent advocates.
As part of selecting trustworthy staff, nursing homes are required to run a state background check before a hire, but some facilities are broadening their due diligence by also conducting a national background check. The more thorough, the better.
Not all nurses are the same. Some homes make frequent use of temporary or “agency” nurses; others do so only occasionally, and still others have a policy against using them at all. Ask. “If they’re doing it regularly,” says Wells, “it probably means they’re desperately understaffed.”
A first impression of an abundant nursing staff may be misleading. Some may be private duty nurses hired by families to supplement the care provided by the home. Ask an administrator or nursing director.
Tailor your questions to your loved one’s needs. No one facility is best for everyone. Your 85-year-old father needs a shorter stay but a higher level and intensity of nursing if he is being discharged from a hospital after a bout of pneumonia than if he needs management of a chronic condition like diabetes or heart failure. If your mom recently had a stroke, ask about stroke rehabilitation and how she will be kept safe and mentally engaged. Don’t settle for “we have lots of residents who’ve had a stroke and plenty of services for them.” You want specifics, says Reinhard of AARP. First, find out from your mother’s doctor how many rehab hours of stroke care are needed, say, of speech and occupational therapy. Using this as a baseline, you’ll want the nursing home administrators to prove they’ve got a robust staff appropriately trained to provide the therapy your mom needs, she explains, not that their therapists come in for a few hours a week and serve a long list of residents.
A history of falls often leads families to consider a nursing home. If that is one of your concerns, ask how falls are prevented. “Do they just use lap belts?” says Phillips. Or, because nighttime trips to the john are a frequent cause of falls, “do they have exercise and balance programs, and creative ideas like [foot placement] maps on the floor” leading from the bed to the bathroom? A night light next to the bed may be helpful, she explains, or the family may need to goad staff to be proactive, checking on your mother every few hours at night to ask gently if she needs help going to the bathroom.
Observe and talk to the staff. Your loved one will spend more time with nurses and aides than with anyone else, so watch how they relate with residents and one another. When Michelle Becker visited a nursing home on the shortlist of possibilities for her grandmother, she saw a resident in a wheelchair laughing and joking with a nurse seated nearby. Becker, a registered nurse who works for an elder services company in Milwaukee but spent a few short stints working in nursing homes, wondered whether duties somewhere else were being shirked. She and her family ultimately chose that home, deciding that what counted was the evident caring and connectedness that Becker had observed. On a tour of a different nursing home, Becker was turned off when she saw call lights blinking outside several rooms, only to see the same lights still blinking when she swung back later. It suggested inefficiency, short-staffing, or plain lack of caring.
How staff members interact with each other is another tip-off. At yet another nursing home Becker visited, she was repelled by gossipy chitchat she overheard at a nursing station. “They were talking about how ‘So-and-so didn’t show up for work this morning—they were probably out partying,’ ” says Becker. And the cluster around the station made her wonder, again, whether residents’ needs were being neglected. Becker hardly felt comfortable at the idea of her grandmother in the care of such staffers.
At some point during a visit, go right to the source. Ask several nurses and aides how many residents they have to care for on a daily basis and how heavy they feel their workload is. Harrington has seen the threshold at some facilities reach 12 or 15 residents per staff member: “That is really not enough.”
Watch how they eat. Malnourishment is often a very real concern for elderly people and nursing homes alike. To gauge a home’s commitment, visit at least once during mealtime. “Some homes give hardly any help,” says Harrington. Enough aides should be available to help all residents who have trouble feeding themselves. “It takes at least 30 minutes,” she explains, to help such a person eat safely and have enough time to chew slowly without choking. Keep an eye out for untouched trays being picked up from the cafeteria tables or from residents’ rooms—a possible signal that staff isn’t giving those folks the assistance they need. Fresh water should also be readily available in all parts of a home because dehydration plays into the challenge of keeping residents properly nourished. Sparking residents’ appetite, too, must be taken seriously as they often take medications that can blunt their interest in eating. Phillips recalls how one nursing home piqued residents’ urge: As the time neared, a bread maker would be plugged in at the nurse’s station, and “the aroma of baking bread would stimulate their appetites.”
See how they play. No matter what age, everyone needs recreation and playful stimulation. Walk into a nursing home and see wheelchairbound residents parked in a semicircle around the television? “That’s kind of a bad sign,” says Harrington. Checking the activity schedule or, better yet, speaking with an activities director, will give you a feel for the facility’s level of creativity—even if funds are tight—and its commitment to residents’ emotional and cognitive health. Excursions should be expected, says Harrington, to the local art museum, a park, or a ballgame. And because volunteer groups are typically just a few phone calls away, Harrington says a facility should be able to recruit outside help, say, someone to come in and teach an art class, kids from a nearby school to do skits, or amateur musicians to perform. Special events—like a barbecue to which families are invited or holiday-themed parties—should be regular occurrences.
Talk to residents and their families. These people will have some of the best insights about the level of care at a given nursing home. But a generic question like, “Are you happy here?” will get you a generic response. It’s wise to tactfully inquire about the things that matter most to your loved one. If incontinence is a primary reason you’re considering moving your mother into a nursing home, ask residents if they get timely help to make it to the bathroom. Wells suggests also posing similar questions to family members: “If your parent needs to go to the bathroom, do they get help? Have you ever visited to find your mother sitting in her own waste?” If your concern about your dad is that he’s not particularly mobile, tailor the inquiry, says Wells: “If they have a pressure sore and need to get repositioned, does it happen?” Be sure to ask if the residents have the same nurses and aides caring for them most of the time. Being on the receiving end of a rotating staff schedule is unsettling, and the nurses and aides won’t get to know your loved one’s specific medical needs and personality quirks. Many facilities have resident or family councils that may be able to offer advice and comfort.
Step 3, Part 2: A Checklist for What to Ask and See at Your Nursing Home Visit
Don’t be overwhelmed. Read this aid and print out the take-along version. It will keep you focused
No one can remember everything to ask, see, and do during a nursing home evaluation visit. Look over this checklist of questions and tips. Then print out this special version, designed to be brought and consulted as you ask questions and look around. It will make the process more efficient— and ease stress when it’s hard to stay calm.
[See America’s Best Nursing Homes and search for one near you.]
Questions to Ask
Who: a top administrator or the director of nursing
About special problems or needs. How would your home deal with my father’s [dementia, difficulty maintaining weight, disability following stroke, or ____________________ ]?
About incontinence. How do you handle residents who are incontinent? Do you have them on a regular toileting schedule? If so, how often do staff members take them to the bathroom? Are many in diapers? Do you ever use catheters to manage resident incontinence?
About nutrition. What is your resident nutrition program? How do you identify residents who are losing weight? Do you regularly weigh them? What do you do to make sure residents are eating? How do you stimulate appetite in those who may have lost interest in food?
About falls. How often do residents fall here, and what do you do when that happens? What is your fall prevention program?
About health inspections. May I see your last survey inspection report? Do you have previous ones, and if so may I see those? How has your home remedied any problems that were identified?
About staff. What is your nurse and nurse aide turnover? What do you do to retain employees? How often do you use temp nurses from an agency? About how many families hire private nurses to supplement your staff nurses?
About worrisome or missing data. I saw a few things on “America’s Best Nursing Homes” that concerned me [such as a high percentage of residents with moderate to severe pain; entries of NA—not available; other examples]. Could we talk about them?
Who: nursing staff
About the workload. How many residents do you care for? Is that too many or about right?
About employee morale. Do you feel as if this is a good place to work?
About the nursing staff. Does this nursing home have a lot of turnover among staff? Does it use a lot of temp nurses? Do some residents have their own private nurse whom their family hired from an outside agency?
Who: residents
About their care. Do you have friends? Are you kept busy? Does the home arrange outside activities for you? [“Are you happy here” won’t yield much.]
About the nursing staff. Do you like the nurses and aides? Do you have the same ones most of the time, or do they change a lot? Do they help you to the bathroom, and if you need help, do you get it in time?
About nourishment. Do you ever need help eating? If so, is there enough staff to help you during meals? Are you often thirsty? Do you get enough to drink?
Who: members of other families
About the nursing staff. What are your loved one’s medical concerns? Is the kind and amount of assistance she receives sufficient?
About falls. Has she ever had a fall here? What happened? Were you satisfied with how it was handled? How confident are you that it won’t happen again?
About incontinence. Does she receive the help she needs to go to the restroom? Have you ever come to visit and found him sitting in his own waste?
About nutrition. Does your loved one need assistance eating? Does he get help? Does he have a good appetite? If not, does the nursing home do anything to help stimulate his interest in food?
About medications. How well do you think the staff here manages your loved one’s prescriptions? Have there been medication-related problems? If he is drowsy, confused, or inattentive, do you believe he may be receiving too many drugs or the wrong ones—or too much of one or more drugs?
About quality of life. Does your loved one participate in activities? Are there options beyond bingo and movies? Do residents take excursions outside the home? Is your loved one dressed in her own clothes when you visit, or is she wearing a hospital gown?
What to Observe
About visitors. Is the parking lot full? Are grandchildren or family and friends around?
About resident engagement. Are many activities available or just bingo nights? Is the facility creative, regularly offering outings to museums or baseball games, art classes, or gardening on the grounds? Does it bring in volunteers to perform skits or music? Are there younger people or kids doing activities with residents?
About quality of life. Are residents dressed in hospital gowns or their own clothes? Are residents out of their rooms and doing things, or are they just lying in bed or gathered around a TV? Do they appear groggy or unaware of their surroundings, or are they actively engaged with one another and with staff?
About incontinence. Do you smell urine or strong antiseptic cleaners that may be covering up the smell?
About staff. Are staff members busy helping and talking with residents? Or are they unengaged, standing apart and talking among themselves? What tone does the staff use with residents? Are they addressed politely, by name? Are call lights on or blinking because residents need help in their rooms? Do the lights go out—meaning the person got the needed assistance—in a reasonable amount of time?
About nourishment. At mealtime, are residents who need help with eating getting assistance from a staff member? Or are trays placed in front of them—or set in their room—and picked up untouched? Is fresh drinking water readily available in the rooms and common areas?
About Saturday and Sunday. Staffing may be lighter on weekends, but do residents still have the help they need? Are weekend activities scheduled?
Step 4: Follow Up to Be Sure the Nursing Home Does Its Job
You can’t stop paying attention after a loved one has moved in. Vigilance is the price of good care
You hope and pray the chosen nursing home is a good one. But the hard truth is that the first few weeks are bound to be difficult. And getting through them without trauma is no guarantee that the months and years ahead will be uneventful. You’ll need to keep all of your powers of observation and diplomacy intact in order to monitor your loved one’s care and be sure it remains as skilled and compassionate as possible. Here is time-tested advice from experts:
[See America’s Best Nursing Homes and search for one near you.]
Expect an adjustment period. Moving someone you care for into a nursing home will be tense and painful. “It was the worst day of my life because it was the beginning of the end,” Barbara Gortych says of moving her mother from assisted living into a nursing home in Florida. At every turn, she says, she asked herself: “Am I doing the right thing?” It is simply inevitable that family members as well as the newly admitted resident will experience some difficulty in the transition. Still, says Cheryl Phillips, chief medical officer and geriatrician for California-based On Lok Inc., a provider of long-term care and services for the elderly: “If after the first month or so your mom still seems absolutely miserable, it may be time to talk [and ask yourself], ‘Do we need to look for a different facility?’ “
During the first few weeks, watch for dramatic changes in the health, disposition, or appearance of your loved one. While illness and accidents are facts of life in a nursing home, says Janet Wells, director of public policy for the advocacy group National Citizens’ Coalition for Nursing Home Reform, “someone who is relatively active shouldn’t experience a steep decline.” A rapid change may be because of inadequate care or neglect or abuse. Is your mother losing weight? She may have an undetected medical condition, or she may not be getting enough calories. Malnutrition is a significant concern in nursing homes. Tremors can hamper the ability to feed one’s self and medications can cause appetite loss—or worse.
Broaden your focus over the long term. If your sharp and active mom becomes dull and lethargic, suspect drugs. An ongoing concern in nursing homes, says Wells, is “the use of medications to keep people quiet so they’re not a bother and don’t require staff.” Besides lessening mental acuity, anything that discourages residents from getting out of bed and being active can instigate pressure sores and muscle atrophy, she says. She points to January’s news that pharmaceutical company Eli Lily & Co. agreed to a $1.42 billion settlement with the federal government and the states for marketing Zyprexa, an antipsychotic, as a drug for dementia. Zyprexa is not approved for such use. In addition, says Wells, it is among the drugs sometimes given to nursing home patients to make them easier to manage.
Check for special skills. You want the staff not only to be alert for health changes but to be able to manage them before they become major concerns. If your mother develops a painful pressure ulcer, is she treated by staff members specially trained in wound care? The federal Centers for Disease Control and Prevention reported in February that only 33 to 40 percent of nursing home residents with significant pressure ulcers received such care in 2004.
Be firm, but don’t yell. Feeling guilty about having to admit a family member to a nursing home or distraught and helpless as a loved one’s health declines, some families take out their emotions on nurses and aides—the very people charged with the resident’s care. During her decades in the industry, Phillips, the California-based chief medical officer, has watched families explode at staff, shouting and making finger-wagging threats to sue. Bluster and anger never work, she says; “care for your loved one never becomes any better” because of such outbursts. The goal is to have these essential caregivers advocating on your dad’s behalf—especially when you’re not around.
One demand worth pressing, however, is that the same people care for your father regularly so that he gets to know them and vice versa. “A lot of nursing homes don’t do that,” says long-term care expert Charlene Harrington, professor of the University of California, San Francisco, because staff schedules traditionally rotate. “[You may have to] argue with the nursing director to get a consistent staff assignment,” she says, but “I think facilities will respond if families ask.”
Win over the staff. Identify your dad’s most consistent caregivers and ask them how you can make their jobs easier, Phillips suggests. Such efforts will reflect your respect for the people responsible for meeting the most basic and intimate daily needs of those unable to cope on their own. Get involved yourself if you can. Lighten an aide’s load by coming at mealtimes to help your dad eat if he needs assistance, or take him outside to walk the grounds. Employees at the nursing home should respond. “I think the people who get the best care have somebody going as often as possible,” says Harrington.
Share your inside knowledge. You can connect with staff by conveying information about personality quirks, special interests, or medical highlights. A father’s history of depression or anxiety should prompt the question, “What were the things [done] at home that worked?” says Phillips. If classical music or E-mailing the grandkids lessened his symptoms, pass that along—and then bring in or mail the nursing home his favorite Bach and Mozart CDs, or arrange for a laptop so he can E-mail.
Ask staff about specific problems. Phillips cites one resident with dementia who became highly agitated when staff tried to get her to take a shower in the mornings. When her adult daughter found out, she explained that her mother’s parents had been killed during the Holocaust. “Strangers taking her to the shower had a very different meaning for her,” says Phillips. So the routine was altered: The daughter brought her mother’s bathrobe—a familiar, safe reminder of a bathroom routine—and was present several times when her mother showered; the schedule was moved from the morning to later in the day so her mother wasn’t groggy and disoriented from just having awakened; and to avoid an unfamiliar face, the same aide provided assistance.
Be alert for nursing home shifts. Changes, not necessarily positive, can come suddenly and from unexpected directions. When her mother’s small nursing home was sold to a large chain, says Janet Wells, “the quality of care went way down.” Regularly chatting with staff and participating on the home’s family council might help you catch wind of potential changes before they happen.
Author: Sarah Baldauf
Thanksgiving is a particularly 
In a letter from “E.W.” (Edward Winslow) to a friend in England, he says: “And God be praised, we had a good increase…. Our harvest being gotten in, our governor sent four men on fowling that so we might after a special manner rejoice together….” Winslow continues, “These things I thought good to let you understand… that you might on our behalf give God thanks who hath dealt so favourably with us.”
W.S.L. Jewett, “A Thanksgiving Dinner Among Their Descendants,” Harper’s Weekly, 30 November 1867. Collection of Plimoth Plantation.
Sarah Josepha Hale (1788-1879).Many people felt that this family holiday should be a national celebration, especially Sarah Josepha Hale, the influential editor of the popular women’s magazine Godey’s Lady’s Book. In 1827, she began a campaign to reinstate the holiday after the model of the first Presidents. She publicly petitioned several Presidents to make it an annual event. Sarah Josepha Hale’s efforts finally succeeded in 1863, when she was able to convince President Lincoln that a national Thanksgiving might serve to unite a war-torn country. The President declared two national Thanksgivings that year, one for August 6 celebrating the victory at Gettysburg and a second for the last Thursday in November.
Tableau of John and Priscilla Alden, 1910. Collection of Plimoth Plantation.
This postcard shows quintessential Pilgrims in buckled hats and black clothes. The reverse side features a handwritten Thanksgiving greeting – in Polish. “Thanksgiving Greetings” Postcard, 1915. Collection of Plimoth Plantation.After 1890, representations of the Pilgrims and the Wampanoag began to reflect a shift of interest to the 1621 harvest celebration. By the beginning of the 20th century, the Pilgrims and the Thanksgiving holiday were used to teach children about American freedom and how to be good citizens. Each November, in classrooms across the country, students participated in Thanksgiving pageants, sang songs about Thanksgiving, and built log cabins to represent the homes of the Pilgrims. Immigrant children also learned that all Americans ate turkey for Thanksgiving dinner. The last lesson was especially effective with the recollections of most immigrant children in the 20th century including stories of rushing home after school in November to beg their parents to buy and roast a turkey for a holiday dinner.
The classic Thanksgiving menu of turkey, cranberries, pumpkin pie, and root vegetables is based on New England fall harvests. In the 19th century, as the holiday spread across the country, local cooks modified the menu both by choice (“this is what we like to eat”) and by necessity (“this is what we have to eat”). Today, many Americans delight in giving regional produce, recipes and seasonings a place on the Thanksgiving table. In New Mexico, chiles and other southwestern flavors are used in stuffing, while on the Chesapeake Bay, the local favorite, crab, often shows up as a holiday appetizer or as an ingredient in dressing. In Minnesota, the turkey might be stuffed with wild rice, and in Washington State, locally grown hazelnuts are featured in stuffing and desserts. In Indiana, persimmon puddings are a favorite Thanksgiving dessert, and in Key West, key lime pie joins pumpkin pie on the holiday table. Some specialties have even become ubiquitous regional additions to local Thanksgiving menus; in Baltimore, for instance, it is common to find sauerkraut alongside the Thanksgiving turkey.
“Hearty Thanksgiving Greeting” Postcard, c. 1910. Collection of Plimoth Plantation.Corn, sweet potatoes, and pork form the backbone of traditional southern home cooking, and these staple foods provided the main ingredients in southern Thanksgiving additions like ham, sweet potato casseroles, pies and puddings, and corn bread dressing. Other popular southern contributions include ambrosia (a layered fruit salad traditionally made with citrus fruits and coconut; some more recent recipes use mini-marshmallows and canned fruits), biscuits, a host of vegetable casseroles, and even macaroni and cheese. Unlike the traditional New England menu, with its mince, apple and pumpkin pie dessert course, southerners added a range and selection of desserts unknown in northern dining rooms, including regional cakes, pies, puddings, and numerous cobblers. Many of these Thanksgiving menu additions spread across the country with relocating southerners. Southern cookbooks (of which there are hundreds) and magazines also helped popularize many of these dishes in places far beyond their southern roots. Some, like sweet potato casserole, pecan pie, and corn bread dressing, have become as expected on the Thanksgiving table as turkey and cranberry sauce.
Thanksgiving Feast at Plimoth Plantation
Family at Thanksgiving – Themed Dining at Plimoth Plantation
take a step back due to reduced staff, postponed facility improvements and reduced therapy. 
The Healthcare Note 