The idea of being placed in a nursing home is not usually included in the top things we think about in our younger years.  There are however many reasons individuals go to a nursing home facility.  This can include things such as becoming incapacitated, care for disabilities or chronic illness, as well as serious injury or cognitive issues.  During these difficult times, nursing care almost inevitably rises to the top of things we must consider.  In the below article we will discuss what nursing home care is, other available care options, what to look for when choosing a nursing home, and more.   

*This blog is for educational purposes only and should not be considered legal advice. The use of the Paths Law Firm website does not constitute a client-lawyer relationship.

What is Nursing Home Care?

Nursing home care can vary depending on the level of care a person needs and the type of facility they are in and provides a wide range of services.  The services provided most generally include 24-hour supervision, custodial care i.e., help with bathing, dressing, and eating.  Depending on the level of care an individual needs, they may also receive skilled nursing care for medical treatments and monitoring, as well as rehabilitation services such as occupational, physical, and speech therapy?  

If an individual is unable to care for themselves for some time, nursing home care may be needed.  There are four primary reasons individuals are most often admitted to a nursing facility:

1. Functional Issues: If an individual is unable to manage their activities of daily living (ADLs) such as eating, using the toilet on their own, bathing, or dressing. 
2. Behavioral Issues: Individuals having difficulty controlling their moods or actions, whether it is caused by a medical condition or a psychiatric condition.
3. Cognitive Issues: Individuals suffering from memory loss due to dementia or Alzheimer’s or individuals not able to process information.
4. Medical Issues – Individuals requiring help with things such as catheters, IVs, ventilators or medical devices, wound care, and more.

Jane and Bob

Knowing when it is time for nursing home care is a big decision only you can make.  Let’s take a look at Jane’s situation and the health decline of her husband Bob.  Jane was concerned about her husband and had reached the point she felt she could no longer care for her husband due to a decline in his mental cognition.  Jane’s husband Bob had increasing memory loss, worsening over the last month.  Bob set the house alarm off twice in the same week at 2:00 to 3:00 am and Jane found Bob outside in the bitter cold.  Bob claimed he was taking the dogs for a walk; however, the dogs were inside with Jane the whole time.  This is one of many examples of Bob’s cognitive decline causing Jane to contact Paths Elder Law.

Jane’s questions were centered around Bob getting proper care in a setting safe for him as well as her ability to pay for his care and protect her assets if keeping Bob home was not in his best interest.  Although Bob has a monthly pension of $4,000 per month, Jane was concerned the Nursing Care facility would deplete their funds leaving her in a less than desirable position to care for herself.  Also, Jane was worried about having to sell her home to cover the cost of Bob’s care.  Although Jane works, her health was declining as well, and she was considering filing for social security disability.       

Considerations for Jane 

A couple of “rules of thumb”:

• Make sure the one who can’t keep himself safe is safe, and
• Always keep the horse in front of the cart.

Keeping Bob safe:

1. Is the house the best environment?

• • • Bring in help,

1. • • • Would you need periodic, respite-type help, or permanent?
       • This can be expensive, and you have another person in your house.
     • Move to a house more conducive to Bob and Jane’s future.
       • Given the trajectory of Bob’s decline, would the effort required be worth the possible enjoyment/benefit before the next stage?
     • Move Bob to a more appropriate environment.
       • If he won’t cooperate the only choice is guardianship.
         • A power of attorney gives another person the authority to make decisions on Bob’s behalf, but
         • No power of attorney gives a person authority over another person taking the person’s legal decision-making away from them. 
         • Only a guardianship, through the probate court, gives a person appointed by the court legal authority to take such drastic action.
2. Environment choices other than the house:

• • • Independent senior living.  Not much different regarding his need to care for himself, just a few more amenities. Just the apartment likely $1,300-2,000/month.
    • Assisted Living Facility. 

• • • • • Depending on the level of care Bob requires, these are likely $4,000-$5,000/month and there is limited government assistance.

• • • • • These places do have “Memory Care” (secured areas with other memory care amenities) for an additional cost.

• • • Skilled Nursing Facility.

• • • • • Bob would need to be evaluated to consider if a locked/secure area is required.  If so, this reduces the facility options.

• • • • • Private pay is about $6,500/month, but gov’t assistance IS available. 

• • • • • • • Additional and more detailed asset and income evaluation would be required to determine how much of Bob’s income would need to be paid to the nursing home and how much the gov’t (Medicaid) would pay.

First Things First:

1. Can you physically/emotionally continue to care for Bob?
2. Does Bob need to move?

• • • Not yet?  Use this time to investigate the above sources of care because the time will come when a choice needs to be made.

• • • Yes.

• • • • • • What is the appropriate level of care in the above list of categories considering his needs and the costs?

• • • Does Bob have the cognitive ability to make these decisions or cooperate?

• • • • • • If not, would a physician provide an opinion of his incapacity for the court in a guardianship?

The negative aspect of all of this for anyone going through a situation like Jane’s is that only you can answer these questions.  Family and friends can help by being available and supportive, however, the decisions can only be yours.

If you decide to move forward with nursing home care, many things should be considered to ensure you or your loved one receives the best possible care in a suitable environment.

How do I Choose a Nursing Home?

Choosing a nursing home is a very personal decision with many factors to consider.  To choose a nursing home we suggest the following steps.

Identify Nursing Homes in Your Area

• Check out the directory listing of care facilities on the Health and Senior Services Website: https://health.mo.gov/seniors/nursinghomes/pdf/DIRECTORY.pdf
• Talk to family members, friends, and neighbors to see if they have recommendations.
• Ask your physician if they can provide some references to nursing homes in your area and if they provide care at any of the nursing homes.
• If you are currently in the hospital, talk to a social worker about discharge plans as soon as possible.  The social worker can provide a list of nursing homes in the area that meet your level of care requirements before you are discharged.

Review the list of Nursing Homes You are Considering.

Once you have created a list of Nursing homes to be considered, it is important to review the homes on your list to get as much information as possible so you can narrow the list.  Check ratings and reviews online.

• Check ratings and reviews online.
• Contact the state licensing agency or health department to find out if they have information related to the quality of care for each facility you are considering as well as any complaints or investigations on each facility.
• Use Medicare’s website to check rating information and to compare facilities at https://www.medicare.gov/care-compare/. Here you can review information on overall ratings, staff ratings, quality of resident care ratings, and more.

Location of Care Facility

When looking for a nursing home facility, the location and size of the facility will be a factor to consider.  If you are the individual needing care, you will probably want to be close to family and friends.  This allows you to have visitors more often and to feel comfortable and supported during your stay whether it is a short stay or a long stay.  If you are looking for a nursing home for a loved one the travel time to the facility will play a factor in how often you can visit.  A 30 to 45-minute drive may seem short, however, depending on weather conditions or schedules, the drive may become an issue.  It is important to consider proximity when choosing a nursing home.

Visit Nursing Homes That Make Your Final List

Once you have made your final list of nursing homes to consider, based on your findings, call to schedule an appointment for a tour with each facility.  Visiting the facility allows you to see the nursing home in person, see residents, staff, and allows you the chance to ask questions.  You may even want to talk with residents about their experiences at the facility as well as members of their family.  Never be afraid to ask questions and be sure to ask staff to go over anything you do not understand.  Be sure to ask the staff who you should contact if you have additional questions once you leave the facility. 

If you are unable to visit the nursing homes, ask your family members or a trusted friend to take a tour of the facility for you and make a list of questions for them.  While calling the facility is often helpful to get information, a visit will provide you with more information. 

If you can visit the facility, there are some things to consider during your visit.

What Services Are Offered

While all nursing homes offer long-term care services, many facilities offer different services and care programs.  It is important to know what is provided by each of the homes you are considering.  Some services are required to meet specific criteria for residents and others are important to improve quality of life.  One example is the food and dining experience which is shown to make a difference in the overall satisfaction of residents. 

Other factors often playing a role in a residence’s experience are the planned activities and whether a resident plays a role in helping plan activities. 

Special care services should be available to meet patient’s needs.  This often includes care for patients suffering from dementia.  In this example, it would be important to choose a facility with memory care services.  If an individual needs physical rehabilitation, make sure the facility has rehabilitation services on-site.

• Is transportation available at the facility to attend outside community activities?
• Does the facility have specific or private areas when visitors come to see you?
• Will you be able to see your regular physician and if not, who are the physicians willing to provide care for you?
• Does the nursing home provide meals meeting your nutritional or religious needs?
• Does the facility have physical, occupational, or speech therapists on staff?
• Does the facility provide memory care services?

Staffing

The staff at the nursing home facility will play a vital role in caring for you or your family member and ensuring they are safe, comfortable, and well cared for.  It is important to ask questions and observe interactions between staff and residents. 

During your observation of staff, look to see if they are polite and respectful.  The relationships created between staff and residents should be warm and welcoming, and never harsh or rough.  

• Does the facility and staff help residents participate in social activities, recreational events, religious activities, or community activities?
• Will specific nurses or caretakers be assigned to care for you?
• What is the caretaker to resident ratio during the daytime and in the evening hours?
• What is the employee turnover rate?

Independence

Going to a nursing home can be a scary experience for most individuals.  Many people feel as if they are losing their freedom and the ability to make independent decisions.  Residents should have the ability to make personal decisions to ensure their comfort such as choosing certain foods to eat, daily activities they will participate in, what time they go to bed, what time they get up, shows they watch, and more. If the individual is moving to a nursing home and has good mental health, the last thing they want is to be somewhere their every move is under the control of facility staff.

Red Flags to Watch For

While both state and federal agencies have strict guidelines and regulations in place for nursing homes, there are always facilities not appearing to follow the rules.  Online research is a good start for discovering the reputation of a facility as well as ratings and violations.  Medicare provides a helpful resource tool comparing nursing homes based on geographic location.  You can research this at https://www.medicare.gov/care-compare/.  The information found using this tool are things such as star ratings, staffing violations, health inspections, and much more.  There are other helpful tools online providing a great start to researching nursing homes such as US News.   

Violations

When researching nursing homes, the number of and type of violations should be considered.  Many facilities will have minor violations, but the severity of the violation is important.  For example, a facility may have a violation for not treating bedsores, medication errors, or physical abuse.  These are serious and dangerous health violations.  Another example could be a violation of cobwebs or dust found in the facility.  While these are important violations, they are considered to be minor violations.

Nursing Home Considerations Checklist

To help you decide on which nursing home facility is right for you, consider putting together a nursing home checklist or profile for each facility.  Below is a list of questions to help you choose a nursing home. 

1. Name of nursing home
2. Address
3. Phone Number
4. Date of visit
5. Has the nursing home passed state inspections, Medicaid or Medicare-certified?
6. Is the nursing home and administrator licensed in your state?
7. Is there a bed available at the facility?
8. Do they offer special services for dementia or ventilator care?
9. Does the facility have policies related to care for dementia patients?
10. Does the care facility have specific programs for memory care and other rehabilitation services?
11. Is the facility close to family and friends?
12. Does the facility have set policies to follow?
13. Are there extra fees for services such as a beauty shop visit and if so, is this in writing?
14. What are the facilities’ ratings?
15. Does the nursing facility have a quality improvement program in place?
16. Are you able to see your physician and if so, will the facility provide transportation?
17. What hospital(s) does the nursing facility work with in the event you need hospital care?
18. Does the facility have regular care plan meetings with residents and family members?
19. Can the nursing home provide you with their most recent inspection report?
20. If the inspection report had any violations, have they corrected them?
21. Are staff members polite and respectful?
22. What is the nursing facility’s policy to vet potential staff to ensure there is no history of abuse or neglect of residents?
23. What are the facilities’ policies on reporting abuse and neglect?
24. What steps does the nursing home take to ensure their residents are safe from abuse and neglect?
25. Have there been reports of neglect against the care facility?
26. Are the residents well-groomed and dressed appropriately?
27. Is the nursing home clean with no unpleasant odors?
28. Is the furniture clean and sturdy?
29. Is the temperature in the facility comfortable?
30. What are the noise levels in the common areas?
31. Are there quiet areas for visitors?
32. Are all exits marked?
33. Are there smoke detectors and sprinklers in the facility?
34. Are all areas wheelchair accessible?
35. Are there handrails or grab bars in bathrooms and hallways?
36. Is there a choice of nutritious food items meeting your dietary needs?
37. Is there staff available to help at mealtimes?
38. Do staff members show respect for residents such as in the way they address or speak to residents and knocking on doors before entering rooms?
39. Does the facility provide its staff members with continued education to ensure proper care of residents?
40. What is the resident-to-staff ratio during the day and evening hours?
41. Can residents have personal items in your room?
42. Do residents have personal storage space for their clothing?
43. Does the facility provide internet access, a computer, telephone, and television for residents?
44. What are the policies to protect residents’ possessions?
45. What activities do residents have available to them and can they choose what they want to participate in?
46. Are there outdoor areas available for residents?
47. Are there set times to wake up, go to bed, or bathe?
48. How early or late can residents have visitors?
49. Can residents leave the facility, if they are able, to participate in events or visit family?
50. Does the nursing home offer religious services to meet your desires?

Trust Your Instincts

The bottom line, trust your instincts.  This applies to choosing the right nursing home for yourself or your loved one.  When you visit each facility, be sure to take notice of the environment, atmosphere, cleanliness, how the staff interacts with residents, and even how the facility smells.  Choosing a nursing home is a difficult decision.  After all, you are placing your trust and the care of your health in the hands of the facility you choose.  Make sure you do your research, and you are sure to find the right nursing home to meet your needs.  

At Paths Elder Law, we have dedicated close to 30 years providing legal representation and support with a focus on helping seniors and their families.  As we age, we inevitably need more care.  During this part of the aging process, it is important to understand all of the available options.  Our staff is here to listen to your concerns and needs to come up with a plan to assist you in your journey.  We are here to provide guidance related to Elder Care Issues to include nursing home care and the process of nursing home benefits.  If you or a loved one need assistance,  schedule a consultation with Paths Law Firm today.