Things to look for and questions to ask when searching for a skilled nursing care and rehabilitation facility

This list is for people who are looking for a temporary facility and rehabilitation with the plan of returning home.  Medicare pays for 100 days in a nursing facility.  They pay 100% for the first 20 days and then 80% of the remaining days.  Supplemental insurance usually picks up the remaining 20%, but it is a good thing to investigate this prior to checking into a facility.  Fees are anywhere from $135.00 to $150.00 a day.  This should all be discussed with the administration when you visit.

I shall expound on the lists from various websites, using my own experiences in having a mother in a skilled nursing facility.

Basic questions for administrators during the initial visit:

Is this facility Medicare certified?  Is the staff licensed and certified?  Are background checks provided on the staff?

• If you are looking for a Medicare facility, this is the first question to ask.  Not all places take Medicare so it is important to make sure that the facility does accept it otherwise you will be wasting your time. Most of these questions will be answered before you have a chance to even ask them as the owner has access to the Internet just like you and most have trained their administrators to include this in the sales pitch.

What was the rating of the last state certification?  What did the state find that the facility needed to correct?  Are there any lawsuits against the facility?  Are there any filed complaints against the facility?

• Again this is standard in the sales pitch, but if it isn't beware and make sure to ask.  If an administrator is hesitant to answer these questions and/or refuses to give out information, walk away.  This information is public knowledge and can be found on the Medicare website.  You can print this information beforehand and take it with you to the interview.

Is there regular communication between families and administration?  Will there be conferences to discuss the loved one's Care Plan?  How often does this occur?

• Most places have weekly meetings where the rehab therapists and administrators discuss a patient's Care Plan.  This is a nice way to stay in touch with the caregivers who are taking care of your loved one and to voice any concerns you may have.  I would be wary of a facility that did not offer this.

What are the visiting hours?  Is there a code to exit the building after hours?

• Most facilities allow 24 hour visitation.  Be wary of ones that do not.  You want to be able to enter if your loved one calls you in the middle of the night.  Most facilities are locked so that patients can not wander off, but key pads are in place for visitors.  Make sure that the facility offers you the code.

Are the phone calls direct or routed through a switchboard?  Is the switchboard manned twenty four hours?

• In our last facility the phone lines were not direct.  I had to call the main number and ask for my mother's room.  This wasn't a problem until we found out the phones were turned off at seven o'clock every evening when the operator left for the day and were not turned on until seven in the morning. Not only could my mother not receive calls in that twelve hour period, but she could not make calls either.

What is the procedure for checking in?  When will happen once my loved one enters the the facility? Who will we see?  When will she see the doctor first?  How often will she see the doctor?  Is there a pharmacy in house?

• Knowing what the procedure is upon arrival is very important.  You and your loved one should be greeted, taken to your room, and introduced to a variety of people from hospitality to admissions. Paperwork is generally signed at this point and rules and regulations should be explained.  If there are items that your loved one needs that the facility is to provide, make sure that happens then and there. In one of our facility experiences we had to wait quite some time for an oxygen concentrator to be delivered when it was specifically marked that my parent was on oxygen 24 hours.
• In these facilities your loved one usually sees the doctor at check in and then once a week thereafter. Make sure that you see the doctor the very first day!  If you will not see a doctor, look into another facility.  The paperwork that comes with your loved one (usually via a hospitalization) isn't always accurate and a doctor must sign off on EVERYTHING.  If there is a discrepancy, it is best to catch that with the doctor there otherwise getting information to him can take hours and sometimes a day.
• When you see the doctor upon checking in this is a good time to go over the list you have brought of any special requests.  Ask for his business card and a number to reach him if he is willing.  Most doctors visit these facilities before or after seeing their own patients at an office.  If this is the case, ask if the nursing staff can reach him at all times.  Make sure that the nursing staff has his number.
• Go over all your medications with the doctor, including simple or specialized medications you may have brought with you.  Different states have different rules regarding these items.  At one facility we used my mother's A&D ointment and a foot cream were removed from her and placed at the nurses station.  This made it difficult to get to when needed.  This is another reason for the list you provide and have the doctor sign.  Most doctors are willing to allow these types of items in the patient's room.
• Ask the doctor if he is willing to call family members if they are not present at the time of his visit. Again, these doctors pop in and out quickly and without warning.  We had one doctor who made it a point to call me after each visit with my mother to keep me updated and to ask me questions or to hear my concerns.  That is huge!
• If your loved one requires medications, make sure that the pharmacy has been notified and note the time of arrival of medications.  A doctor must sign off on the medications before it can be sent to the pharmacy.  My mother did not receive her night time medications (10 of them) on her first stay at one facility, nor did her roommate five days later upon arriving, and that was after our filed complaints.

What times do you recommend being admitted?  Do you provide transportation from the hospital (or other facility)?  Can we request a time?

• Pay careful attention to these answers.  Timing matters when coming into a facility.  NEVER come into a facility when the nursing staff is changing shifts.  This causes great confusion on both ends and it is usually your loved one that gets the short end of the stick.  Narrow down a time and make sure that the facility adheres to it.  Provided transportation is better too as facilities respond to a vehicle and transporters much in the same way hospitals do to ambulances and paramedics.

Ask for information on the nursing staff's shift hours.  How many different nurses will your parent see in 24 hours.  How many days in a row do they work?  What is the nursing staff to patient ratio?  How many aides are there?  What are their hours?  How many days do they work in a row?

• In our experience the best place is the one in which the nursing staff works several days in a row so there is a consistency.  Most shifts are from 7 am - 3 pm, 3 pm - 11 pm, and 11 pm - 7 am.  If the same nurses work each shift even three days in a row, you will have someone who understands your loved one and his/her needs.  Problems occur, of course, when the nursing staff switches, and no matter what administrators tell you, while information is passed from one nurse to the next, important details do get left out.  
• Come up with a list of things that are important to your loved one and make sure that it is put into their chart.  This is a list that you can go over with the doctor at admitting time and have him sign if necessary.  For example, my mother uses a wheelchair which she likes by her bedside at night.  While she needs assistance in getting to and from the bathroom she is able to transfer herself from the bed to the chair if someone is unable to respond to her call quickly.  Problems arose when a staff member read "needs ambulatory help" and removed the wheelchair from my mother's bedside so that she "would have to call for help".  Had we had a list we could have referred this staff member to that list, signed by the doctor, in her chart.  Always keep copies of the list (with signature) so that the patient has one and so that you have one.

Does the nursing staff have mobile units with computers or does the staff manage from a central location or desk?

• In my experience, and in this day and age, better care is provided if the staff has a mobile unit that has a computer that keeps the patient's chart and medications.  If this is not available, then the staff has to always check in at a desk for answers and this definitely takes away from patient care and time spent with a patient.

How often will a loved one have rehabilitation therapy?  Is it one on one or shared with others?  If shared, with how many other patients?  Do you have a gym or do you work out in a room?  When will the first assessment be done?

• If your main goal is rehabilitation, these are important answers.  A gym, or multiple, gyms are the best as they are larger and offer more equipment and variety.  If rehabilitation is done in a small room it can get quite crowded and overwhelming for some patients.  One on one with a therapist is awesome, but not always a possibility.  Most centers have a ratio of one therapist to three patients which means your loved one is usually left on his own to complete an instructed exercise while the therapist works with one of her other patients.
• Hopefully, the assessments for therapy will happen on the first day of admittance, but that isn't always the case either.  It will depend upon the patient's entrance to the facility.  The later in the day your loved one arrives, the later the assessment; sometimes not until the next day.

Things to look for and questions to ask on the tour of the facility.  Always take a tour.

If it is possible, ask to see the room that your loved one will be in.  Is a private room available?  Will your loved one be sharing a room?  If so, which bed will he be in?  

• Seeing the exact room will help you determine if it is right for your loved one.  If a private room is available and you are interested, make sure that it is assigned to your loved one.  We were told we had a private room in one facility only to find that not the case upon entrance.  The room and bed my mother ended up in was not at all equipped for a wheelchair and she spent several miserable days before we got her moved into a private room.
• When touring a room check the things that are important to your loved one.  Is there a temperature control in the room that residents can manage?  If sharing a room, are there separate thermostats?  Is the bathroom big enough?  Is the bathroom arranged so that your loved one can maneuver in it?  Is there a shower in the bathroom or will your loved one be bathed elsewhere?  The bathroom in one facility my mother was in was not arranged well for a person in a wheelchair and she had great difficulty ending up with a huge hematoma on her arm from bumping up against the toilet paper dispenser jutting out from the wall.  Check for every little thing that will make or break your loved ones comfort level.

Is the facility clean?  Are the hallways well lit?  Is there a distinctive odor?  Do you smell bleach?

• Every facility is going to have some type of scent.  Make sure that it isn't overpowering, nasty, or smelling like bleach as a cover up to something more.  Make sure to look down at the floor and along the baseboards for cleanliness.  A well cleaned facility makes for a healthier one.

Tour the rehabilitation areas.  Are they large?  Do they have a variety of equipment?  Does the place resemble a workout gym?  Are the residents engaged or just sitting waiting for instruction?  

• This goes along with the questions you should ask the administrator in your interview, but seeing for yourself is a plus.  One facility I toured was under construction and not only was it noisy, but the gym was closed due to the construction and the residents were rehabbing in different rooms of various sizes.  We opted not to go with that facility because of the construction despite the rest of it passing our tests because rehabilitation was huge for my mother at the time.  She ended up staying in another facility with a large gym, with wonderful therapists, and where she could interact with other rehabbing patients.

As you tour look at the residents.  Are they up and out of bed?  Are they dressed in clothes or in robes?  Do they appear well cared for?  Do they look happy?  If possible, talk to some of them.

• A facility where the patients get up in the morning and get dressed in their clothes is more like what your loved one does at home.  This is a facility that means business in rehabilitation and not just minimal care.  Not ever resident is going to be smiling or appear happy as you tour, but you can tell if they appear well groomed.  If an opportunity arises and you are able to talk to a resident ask him questions.  I spoke to one woman who was sitting outside a facility enjoying the sunshine.  She was quite happy to tell me about the facility, the positive and the negative, and whether or not she recommended it.  

Is there a dining room for residents to eat in?  How big is the dining room?  Is it a nice room?  Well decorated?  Can residents eat in their rooms?  Is there a choice on meals?  A menu?  How is the food? Ask if the tour guide eats the meals.  Ask to see a meal if available.  Does it look like something you could eat?  If your loved one requires special menus, will that be available?

• Most facilities offer in room and/or a dining room eating.  Residents can do either depending on their mood.  If your loved one has restrictions, make sure that that is discussed at admittance.  My mother came from one facility where "mechanical" meant cutting up her meat for her to another facility where "mechanical" meant pureeing her food so that it looked like something one would feed an infant.  If the food doesn't appear appetizing, it makes it hard to consume and not eating leads to many other problems.  In one facility they offered a menu and choices.  In another facility everyone was given the same meal.  Having choices is much better.

Are their activities outside of rehab?  What sort of activities?  Can residents come and go on their own from their rooms to activities?  

• Most facilities offer various activities.  Ask for a list.  Most facilities have the month's activities on a calendar and will post them in the resident's room and in the hallways.  In one facility my mother stayed in she worked on puzzles with residents in the game area, took exercise classes, and watched movies in the common area while eating popcorn.  If your loved one using oxygen will he be able to switch out to a tank to be mobile?  

It isn't easy picking out a skilled nursing and rehabilitation center.  So far we have not found the perfect facility.  We have found some with great rehab and not such great care.  We have had facilities with little rehab.  We have had places with no problems and places with many problems.  Each of those facilities seemed great when touring them and speaking with the administrators.  Reality was much different.

Remember that the administrators are sales people and that you are the buyer.  Ask questions.  If able, pop in several different times at different hours and take tours.  Check the facility out on Medicare's site.  Ask for recommendations from doctors, nurses, and from people who might have been in a facility.  Also, in the end, ask the administrator if he would put his own loved one in this same facility.  If he hesitates, find a different facility.