Section II: What to Look for When You Visit a Nursing Home - Selecting a Nursing Home in New York State
Visiting the Facility
You can find a great deal of information about a nursing home from the various resources and websites that are provided in this Guide. However, visiting any nursing home that you might consider as a future home is one of the best ways to determine if the facility is suitable for you. Call the nursing homes you are interested in and make an appointment to meet with the admissions staff.
Each nursing home has its own policies and procedures, but all must follow certain State and Federal regulations with respect to residents' rights. A copy of the nursing home's policies should be available upon request. Following is a list of some policies to check:
- the use of personal belongings and furniture
- the availability of ethnic foods or special diet preferences
- room assignments and changes
- reserving a bed if transferred to a hospital/therapeutic leave
- emergency procedures
- phone calls
- leaving the facility for short visits with family or friends
- procedures for handling theft
- complaint procedures
- access to personal funds
When you visit a nursing home, look for its license to operate. The license should be prominently displayed, usually in the lobby. It is also very important to see firsthand what the environment of the home is like. This will also give you an opportunity to ask questions on the care and services that the nursing home provides and clarify any issues with regard to placing an individual in the nursing home. During the visit, be observant of the interaction between caregivers and residents and take a good look at everything! Some important areas to consider are as follows:
- Do residents have personal belongings decorating their rooms?
- Does each resident have at least one comfortable chair?
- Does each resident have his/her own dresser and closet space with a locked drawer or other secured compartment?
- Is there an out-of-doors area where residents can walk or sit and is it used?
- Does the equipment (wheelchairs, therapy devices, etc.) appear to be in good condition?
- Is there a lounge or other area where residents can entertain visitors privately?
State and Federal standards require that nursing homes provide a safe environment for residents whether they are mobile or in wheelchairs, whether they are confused or have poor eyesight. Look for:
- handrails in hallways and other critical places;
- wide, clear walking areas;
- hazards that might cause accidents;
- good lighting;
- telephones and large-print notices placed so that wheelchair-bound residents can make use of them;
- appropriate inside temperature and whether or not residents are dressed appropriately;
- clearly marked exits and well-lit elevators.
Find out if the local fire department participates in fire drills and how often drills are held in the nursing home.
A good nursing home should be clean. Look in the corners of resident rooms, bathrooms, kitchens, nurses' stations, etc., as well as in the main visiting lounges. Look for cleanliness EVERYWHERE.
Unpleasant odors reflect problems. If there is an odor in a particular section of the nursing home, go back to see if it has been eliminated within a reasonable period of time. This will give you an idea of how long it takes the nursing home to deal with the cause of the unpleasant odor.
- Are residents out of bed?
- Are residents neatly dressed and do they appear to be wearing their own clothing?
- Are residents engaged in doing things or just sitting in a lounge or hallways?
- Is there activity in the corridors?
- Do residents socialize with each other?
- Do staff address the residents by name?
- Do staff interact with residents in a warm and friendly manner?
- Do staff respond to someone calling for help?
- Are people assisted in walking for the purpose of exercising or retraining?
Ask several residents how they keep occupied and what they particularly like to do at the nursing home.
- Do residents share rooms? How many people to a room?
- Does the facility select compatible roommates?
- Are rooms assigned based on severity of illness?
- How does the facility deal with problems between roommates?
Food and Dining
Mealtime is an important part of the residents' day. Many facilities try to be less "institutional" and use tablecloths, china and silver to enhance mealtime. Try to visit during mealtime and observe the way food is served and how the staff and residents interact.
- Does the food appear to be appetizing and of good quality?
- Do residents have an alternative to the main menu?
- Are residents encouraged and assisted with eating (if necessary)?
- Is socializing encouraged during mealtime?
- Is the dining room clean, attractive and colorful?
It is hard to observe medical/nursing practices, but you can ask questions.
- Does the same nurse or aide care for the resident during each shift?
- Will your physician be able to care for you in the nursing home?
- If you do not have a physician, who will the physician be and what relationship will you or a family member have with this physician?
- How often will visits be made and how will medical emergencies be handled?
- Ask how often assessments are performed to attain information regarding resident information, including the Minimum Data Set (MDS) and Patient Review Instrument (PRI).
- If more than routine medical care is needed, can a specialist be called in? How is this done?
If you might need speech, physical or special therapy, look at the therapy rooms. If possible, speak to the staff person in charge.
- How frequently is therapy offered?
- Can therapies be provided on an optional basis or a for-private-pay basis?
- Is the facility physician involved in assessing the therapy and your response to it?
Alzheimer's Disease and Other Dementias
The design and promotion of services for Alzheimer's Disease and other dementias are driven by the individual needs of each resident to maximize their physical and mental well-being (person-centered care). These services fall within general care standards. While a nursing home may assert to provide specialized services for Alzheimer's Disease and other dementias or operate a designated unit, NYS DOH does not license such services as a separate category. However, the Department partners with nursing homes to assure the highest quality of care for all residents, including those with Alzheimer's Disease and other dementias, as guided by Federal standards.
Consumers are encouraged to conduct due diligence in considering and selecting appropriate services. When evaluating services for Alzheimer's Disease and other dementias, be sure to ask the following questions:
- What specialized training does your staff receive to work with residents with Alzheimer's Disease and other dementias?
- What specialized services and activities do you offer these residents?
- Does staff from other areas of the nursing home fill in when staffing for this population is short?
- Is the physical space designed to ease agitation, confusion and difficult behaviors?
- Are specific precautions taken or safety features in place to guard against wandering out of the nursing home?
- Are there other types of safety features the nursing home offers?
- What are the nursing home's policies on toileting/incontinence care?
- Does the nursing home offer assistance or education related to Alzheimer's Disease and other dementias to family members?
- Is there a time or situation that my loved one would be required to leave the nursing home?
Mental Illness, Intellectual Disability and Developmental Disability Services
Anyone who applies for admission to a nursing home must be evaluated to determine if the nursing home can provide the services the individual needs. One of the tools that is used to conduct this evaluation is the Preadmission Screening and Resident Review (PASRR). The PASRR determines whether an individual seeking admission to a nursing home has a mental illness, intellectual disability and/or developmental disability.
The first step in the PASRR process is for the referring entity (e.g., a hospital or home health care agency) to complete what is known as a Level I screen. If there is no evidence of mental illness, intellectual disability and/or developmental disability, and the applicant is determined to be in need of nursing home care, the person may be admitted to a nursing home.
A Level II PASRR evaluation is completed when the Level I screen identifies the possible presence of mental illness, intellectual disability and/or developmental disability. A Level II PASRR evaluation may also be completed for individuals already residing in a nursing home who are suspected of having a significant change in their physical or mental condition.
If a Level II PASRR evaluation identifies the presence of mental illness, intellectual disability and/or developmental disability, a determination must be made whether the mental illness, intellectual disability and/or intellectual disability is severe enough to require specialized services or is less severe and requires less intense mental health services (services of a lesser intensity). This determination is provided to the applicant in writing (letter of determination).
If a nursing home applicant or resident is determined to require specialized services for mental illness, he/she MAY NOT be admitted to or allowed to continue to reside in a nursing home. Specialized services must be provided on an inpatient basis by a mental health facility, such as a psychiatric hospital, psychiatric center or, in the case of a minor, a residential treatment facility.
If a nursing home applicant or resident requires specialized services or services of a lesser intensity for an intellectual/developmental disability, he/she may be admitted to a nursing home, provided that the admitting nursing home is equipped to provide the services required or makes arrangement for the services. Nursing home applicants or their legal representative may appeal the Level II determination, as defined in the letter of determination.
When reviewing nursing homes, ask the following questions regarding the provision of mental illness, intellectual disability and/or developmental disability services:
- What specialized training does your staff receive to work with patients with mental illness, intellectual disability and/or developmental disability?
- What is the PASRR procedure for patients with mental illness, intellectual disability and/or developmental disability?
- What specific types of mental illness, intellectual disability and/or developmental disability services does the nursing home provide?
- Does the nursing home provide these services in-house or are residents required to travel elsewhere to receive the services?
- Does the facility have psychiatrists or other mental illness, intellectual disability and/or developmental disability professionals onsite?
- What types of therapeutic activities does the nursing home offer to meet mental illness, intellectual disability and/or developmental disability needs? Ask for a calendar of activities.
- What kind of follow up does the nursing home have in place to ensure that required services are being received?
Certain nursing homes in New York State provide skilled nursing care to infants and children up to 21 years of age with diverse and complex medical, emotional and social problems. Pediatric nursing homes are required to meet all of the same State and Federal regulations that other New York State nursing homes meet, in addition to meeting each child's educational, developmental, emotional and spiritual needs. If you are seeking admission to a pediatric nursing home, ask the following questions:
- Will the nursing home assist in admitting my child to the nursing home?
- What age children does the nursing home serve?
- Does the nursing home serve only pediatric residents?
- Are residents congregated based on age and clinical needs or by other definitions?
- Does the nursing home care for children that require mechanical ventilation?
- Does the nursing home care for children that require respiratory assistance at night (e.g., Bi-level Positive Airway Pressure [BiPAP] machine)?
- Can I bring in my child's medical equipment for use at the nursing home?
- What additional training does the staff receive to serve children?
- How many staff will be caring for my child?
- If there is a problem with my child, how quickly will I be notified?
- May I decide on which acute care hospital my child will be transported to in the event of an emergency?
- Will my pediatrician be allowed to maintain his/her professional relationship with my child during his/her stay at the nursing home?
- What services are offered?
- What are the age-specific activities?
- If my child has psychosocial needs, will a preadmission assessment be conducted?
- My child has a learning disability and many medical problems that contribute to his/her lack of coping. Does the nursing home offer assistance or programming to respond to these needs?
- Is there a pediatric respiratory therapist on staff? If so, how many hours a day is the therapist onsite?
- What safety checks are in place to ensure that the children are safe and being cared for by the staff?
- How does the nursing home assure that children will meet their education requirements?
- Do I have to pay for my child's education while in the nursing home?
- What are the visiting hours and rules for siblings and friends?
- Can I bring my child's clothes and will they be laundered for me?
- May I stay overnight with my child if I choose?
- How will my child be protected from other children, visitors and staff that may have behavioral problems and/or criminal backgrounds?
- Will the nursing home assist in my child's discharge to home?
- If I need assistance, education or support after my child is discharged to home, will the nursing home be the contact for me?
Other items to look for in pediatric nursing homes:
- age-specific decorations
- bright colors
- room and other area space
- amount of clutter
All nursing homes are required to offer an ongoing program of activities for residents. As you visit nursing homes, you may find a great difference in the way activities are offered. The program of activities should be designed to meet the interests and the physical, mental and psychosocial well-being of each resident and made available on a daily basis at various times of the day, including weekends.
- Are residents taken out for events in the community? How often? Where do they go?
- Are people in wheelchairs allowed to participate?
- How often are outside events brought in to entertain residents?
- What activities are provided for bed-bound residents?
- How many staff work on the unit where I will live?
- How many staff are on each shift?
- How does the nursing home ensure that the staff really know the resident to whom they are assigned?
- Is each resident cared for by the same staff?
- What religious denominations are served at the nursing home?
- What services are offered at the nursing home? How frequently?
- What system is in place for inventory of resident personal property?
- How is personal property safeguarded?
- Does the nursing home investigate missing items?
- Upon discharge, how is personal property handled and returned to the family?
State law prohibits residents from being asked to pay more than three months in advance upon admission. (If you are admitted under Medicare, you do not have to pay anything in advance).
If you will be paying privately for care, ask about the fee schedule. What services and supplies are not included? What do these items cost? How often were fees increased in the past? What were the increases?
Nursing Home Quality of Service Delivery
Standards governing the operation of a nursing home are set by State regulation (10 NYCRR Part 415) and Federal regulation (42 CFR Part 483). These standards are intended to assure the highest possible quality of care and most meaningful quality of life for all residents in nursing homes. Standards cover a range of requirements including, but not limited to, residents' rights, clinical services (e.g., nursing, dietary, medical and rehabilitation services) and administrative services (e.g., quality assurance and physical environment). There are specific regulations that also address care for people with traumatic brain injuries, those who are ventilator-dependent, people with AIDS and those requiring adult day health care services.
The Centers for Medicare and Medicaid Services (CMS) has developed a National process for nursing home inspections to ensure quality care. In New York State, this is carried out by NYS DOH. It is the role of NYS DOH to ensure that facilities are in compliance with State and/or Federal regulatory requirements, and to investigate occurrences of abuse, neglect or mistreatment. Inspections of each nursing home that participates in Medicare and/or Medicaid are conducted about once a year.
Inspection survey teams most often include a nurse, dietician, sanitarian and social worker, but other health professionals, such as physicians, physical therapists and pharmacists, may also participate. State surveyors undergo training and mentoring with an experienced survey team for a period of at least six months prior to participating in mandatory CMS surveyor training, testing and certification. Surveyors also receive ongoing training, as well as evaluation by their supervisors and Federal surveyors. Surveyors spend most of their time evaluating the care and services residents receive. They observe meals, drug administration and recreational activities and also speak with residents and their families regarding the treatment they receive and their opinions about the nursing home.
Inspection surveys include the following steps:
- touring the facility
- meeting with administrators and staff
- meeting with members of the resident council and/or other residents
- assessing the safety of the building
- observing meals
- interviewing residents
- examining medical records and observing clinical procedures
- summarizing the results and reporting findings to the nursing home administrator
When an inspection survey team finds that a nursing home does not meet a specific regulation, it issues a deficiency citation through a formal written report known as a Statement of Deficiencies (SOD). If the need arises, inspection survey staff may visit a nursing home more often to respond to complaints by residents or families or to monitor the progress in correcting deficiencies.
Based on the results of the inspection and the seriousness of problems noted, NYS DOH decides whether to take enforcement action. Repeat problems can result in fines and, in extreme cases, closure.
Nursing homes are required to make accessible in a public place the most recent NYS DOH inspection report. Look for the most recent report to see if the nursing home met the State and Federal standards.
Remember, deficiencies are not necessarily the only indication of the quality of care and administration of the home. Ask to look at the results of a few inspection surveys so you can see if there is a pattern of deficiencies in certain areas.
The New York State Nursing Home Profile on the NYS DOH website also makes information available about nursing homes in New York State and the quality of care they provide, including inspection information. For more information, visit the DOH website at profiles.health.ny.gov/nursing_home/. Information can also be obtained from CMS at www.medicare.gov/nursinghomecompare.
- New York State Department of Health
Division of Nursing Homes and ICF/IID Surveillance
875 Central Avenue
Albany, New York 12206