Choosing A Nursing Home

By Dn. John Jillions

The second stroke did not kill eighty-year old Peter Vorman, but it severely paralyzed him. He lived—but he needed care twenty-four hours a day. Someone had to be there all the time to feed him, bathe him, dress him, take him to the bathroom, and medicate him. Neither his wife, a semi-invalid herself, nor his children, who were married with families of their own, could give him the care he needed. There were only limited community services in the small town where they lived. The family made a careful study of available nursing homes and settled on the one they felt would suit Mr. Vorman best. Once he had moved in and was comfortably settled, his family left, relieved.

But Mrs. Vorman could not forgive herself for “abandoning” her husband, and the children never lost the feeling that they had failed their father, “locked him up,” “put him away.”

The Image of Nursing Homes

The Vorman family is not alone. The very term nursing home conjures up a series of unhappy, even terrifying images in the minds of old and young alike. The words suggest coldness, impersonality, and regimentation, at best—at worst, neglect, mistreatment, cruelty, loneliness. Unfortunately, negative images can legitimately be used in describing some institutions. But they cannot be used across the board. While there are too few excellent nursing homes and too many disgraceful ones, the majority lie somewhere between these two poles.

When nursing home placement is necessary for an elderly parent, sons and daughters must face an imperfect situation and at the same time face two other painful realities: the irreversible deterioration of a person they love, and their own inability or unwillingness to care for that person.

Institutionalization, although often a tragic step, is not tantamount to dying. It is a step closer to death, admittedly, but there still may be some gratifying living ahead. Nor does institutionalization necessarily imply family rejection. But those are widely held suppositions often reinforced by the elderly themselves. A patient-oriented, professionally guided, intelligently-operated nursing home often is the most humane alternative open to many old people. Far from being a waiting room for death, nursing homes can even represent, for some, a new and meaningful phase in their lives.

Most families have two obstacles to hurdle before accepting a nursing home solution: they must overcome both their own aversion and the opposition of the potential nursing home resident. It is hard to pinpoint the exact moment when institutionalization becomes a necessary move—what provides the “tipping point” which forces the decision. In cases of severe incapacity, the need for such action is more obvious. But the “tipping point” may also come from a combination of factors: partial incapacity, inadequate help in the home, increasing personality conflicts. The “tipping point” may arrive sooner for an elderly relative who is difficult, demanding, and uncooperative, or in families heavily burdened with their own problems. But for most families, whenever the “tipping point” comes—whether it is early or late—it is painful to accept, for it may represent failure to them, and a finality in terms of their parents’ lives.

Thinking Ahead

The longer people live, the greater is the likelihood that they will develop disabling conditions requiring protective or skilled care. That care can, of course, be provided outside the institutional setting. Some old people can stay right where they are if enough money is available in the family and enough services in the community. But often neither money nor services can be found and institutionalization is the only solution. Many families prefer to ignore the future, coasting blithely along as if no such possibilities lay ahead. Such families may spare themselves anxiety by not dwelling on a disaster that might never happen, but consider the odds: at some point, one out of every four older people will enter a nursing home. Those who have investigated nursing homes in advance will be in an infinitely advantageous position to make a sound choice.

When there is no immediate crisis demanding solution, there is time for a thorough review of all possibilities, as well as a thorough analysis of the preferences and attitudes of the older person involved. Nursing home placements made on the basis of impulsive, frantic decisions usually produce disaster all around. The mother or father in question may feel bewildered, coerced, infantilized, and rejected. In addition, rushed placements allow no time to investigate the quality of an institution or to find the one offering rehabilitative, restorative, and supportive services. “Who’s got room for Morn right away?” is the only question there is time to ask, rather than, “Which is the best place for Morn? Where will she be happiest?” An essential ingredient in all of this planning is to make sure that Morn is involved step-by-step. She, after all, has the ultimate right to make the final choice if she is still capable mentally,

A Checklist for Nursing Home Evaluation

The following checklist for evaluating services at nursing homes should help in what otherwise can be a bewildering process. There are generally three types of nursing homes, each providing a different level of assistance. These levels of service are:

1. Assistance with personal care (such as the O.C.A.‘s Saints Cosmas and Damian Adult Home in Staten Island, New York).

2. Regular nursing care.

3. Continuous nursing care.

A family’s physician should provide guidance in determining the level of care needed for the person in question. Keep in mind that not all categories listed in the checklist will apply to every level of nursing home.

  1. Where to start
    1. Get a list of nursing homes in your area from
      1. Hospital Social Service Departments
      2. Local Department of Health and Department of Social Services
      3. State Department of Health and Department of Social Services
      4. County Medical Society
      5. Social Security District Office
      6. State and Local Office of the Aging
      7. Your priest, relatives, friends
    2. Visit several before making a decision.
  2. What to notice about the general atmosphere

    1. Are visitors welcome?
    1. Are you encouraged to tour freely?
    2. Do staff members answer questions willingly?
    3. Is the home clean and odor-free?
    4. Is the staff pleasant, friendly, cheerful, affectionate?
    5. Do non-English speaking residents have someone on staff with whom they can speak?
    6. Are lounges available for soci alizing?
  3. Is attention paid to the residents’ morale?

  1. Are they called patronizingly by their first names or addressed with dignity as “Mr.,” “Mrs.,” “Miss” ____?
  2. Are they dressed in nightclothes or street clothes?
  3. Do many of them appear oversedated?
  4. Are they allowed to have some of their own possessions?
  5. Are they given sufficient privacy?

  1. Are married couples kept together?

  • Is good grooming encouraged?
    1. Beautician and barber available?

    1. Is tipping necessary to obtain services?

  • What licensing to look for

    1. State Nursing Home License
    2. Nursing Home Administrator License
    3. Joint Committee on Accreditation of Hospital Certificate
    4. American Association of Homes for the Aging
    5. American Nursing Home Association

  • Location

    1. Is it convenient for visiting?
    2. Is the neighborhood safe for ambulatory residents?
    3. Is there an outdoor garden with benches?
  • Safety considerations
    1. Does the home meet federal and state fire codes?
      1. Ask to see the latest inspection report.
      2. Are regular fire drills scheduled?
    2. Is the home accident-proof?

      1. Good lighting?
      2. Hand rails and grab bars in halls and bathroom?
      3. No obstructions in corridors?
      4. No scatter rugs or easily tipped chairs?
      5. Stairway doors kept closed?

  • Religious observances
    1. Is there a chapel on the grounds?
    2. Are religious services held regularly for those who wish to attend?
    3. If the home is run under sectarian auspices, are clergy of other faiths permitted to see residents when requested?

  • Living arrangements
    1. Are the bedrooms comfortable and spacious?
    2. Is the furniture appropriate?
      1. Enough drawer and closet space?
      2. Doors and drawers easy to open?
      3. Can residents furnish their own rooms with personal items?


    3. Can closets and drawers be locked?
    4. Is there enough space between beds, through doorways, and in corridors for wheel chairs?
    5. Are there enough elevators for the number of residents?
      1. Are elevators large enough for wheelchairs?

  • Food services
    1. Is there a qualified dietitian in charge?
      1. Are special therapeutic diets followed?
      2. Are individual food preferences considered?
    2. Are you welcome to inspect the kitchen?
    3. Are menus posted?
      1. Do the menus reflect what is actually served?
      2. Are dining rooms cheerful?
      3. Are residents encouraged to eat in the dining room rather than at the bedside?
      4. Is there room between the tables for passage of wheelchairs?

    4. Are bedridden residents fed when necessary?
      1. Is food left uneaten on trays?

    5. Are snacks available between meals and at bedtime?
      1. Are snacks scheduled too close to meals in order to accommodate staff shifts?
      2. Is there too long a period between supper and breakfast the next morning?


    6. Medical Services

      1. Is there a medical director qualified in geriatric medicine?
      2. Are residents allowed to have private doctors?
      3. If there are staff physicians, what are their qualifications?
        1. Is a doctor available 24 hours a day?
        2. How often is each resident seen by a doctor?


      4. Does each resident get a complete physical before or upon admission?
      5. Does the home have a hospital affiliation or a transfer agreement with a hospital?
      6. Does each resident have an individual treatment plan?
      7. Is a psychiatrist available?
      8. Is provision made for dental, eye, foot care as well as other specialized services?
        1. Are there adequate medical records?
        2. Nursing Services
          1. A. Is the nursing director fully qualified?
          2. B. Is there a registered nurse on duty at all times?
          3. C. Are licensed practical nurses graduates of approved schools?
          4. D. Is there adequate nursing staff for the number of residents?
          5. E. Is there an in-service training program for nurses aides and orderlies?
        3. Rehabilitation Services
          1. Is there a registered physiotherapist on staff?
            1. Good equipment?
            2. How often are residents scheduled?
          2. Is there a registered occupational therapist on staff?

            1. Is functional therapy prescribed as well as diversionary activities?
          3. Is a speech therapist available for poststroke residents?
          4. Is the staff trained in reality orientation, remotivation, and bladder training for the mentally impaired?
          5. Group Activities
            1. Is the activities director professionally trained?
            2. Is a variety of programs offered? (Ask to see a calendar of activities.)
            3. Are there trips to theaters, concerts, museums for those that can go out?
            4. Are wheelchair residents transported to group activities?
            5. Is there a library for residents?
            6. Is there an opportunity to take adult education courses or participate in group discussions?
            7. Social Services
              1. Is a professional social worker involved in admission procedures?
                1. Are both applicant and family interviewed?
                2. Are alternatives to institutionalization explored?
              2. Is a professionally trained social worker available to discuss personal problems and help with adjustment of residents and family?
              3. Are social and psychological needs of residents included in treatment plans?
              4. Is a professional trained social worker available for consultation to the staff?
                1. On social and psychological problems of residents?
                2. On roommate choices and tablemates?
                3. Citizen Participation
                  1. Is the resident Bill of Rights prominently displayed and understood?
                  2. Is there a resident council?
                    1. How often does it meet?
                    2. Does it have access to administrator and department heads?

                  3. Is there a family organization?
                    1. How often does it meet?
                    2. Does it have access to the administrator and department heads?
                    3. Do the residents vote in local, state, and federal elections?
                      1. Are they taken to the polls?
                      2. Do they apply for absentee ballots?


                    4. Financial Questions
                      1. A. What are the basic costs?
                      2. Are itemized bills available?
                      3. Are there any extra charges?
                      4. Is the home eligible for Medicare and Medicaid reimbursement?
                      1. Is a staff member? available for assisting in making application for these funds?
                      2. Is assistance available for questions about veterans’ pensions? Union benefits
                      3. What provisions are made for residents’ spending money?

                      With this checklist in hand, a person can make an intelligent decision for the elderly family member. The situation is never an easy one, but it can be made less painful and have a more satisfactory result, if we know what we are looking for.

    Adapted by Deacon John Jillions from YOU AND YOUR AGING PARENT, by Barbara Silverstone and Helen Kandel Hyman. Copyright 1976 by Barbara Silverstone and Helen Kandel Hyman. Reprinted by permission of Pantheon Books, a Division of Random House, Inc.