12 Red Flags on a Nursing Home Tour

Check the data first — inspection record, staffing, turnover, ownership. Then go and stand in the building, ideally twice, and at least once unannounced on an evening or a weekend. Here is what to look for.

Before you go in

1. Turn up at a bad time. Late afternoon, mealtimes, or a Sunday. Every home is presentable at 11am on a Tuesday. Very few are at 5pm on a Saturday.

What you should notice in the first five minutes

2. Smell. A brief odour near a room is normal. A persistent smell of urine through the corridors means residents are not being changed promptly, which is a staffing problem wearing a different hat.
3. Call lights. Watch how long the lights above the doors stay on. Count. If lights are ringing for ten minutes with staff walking past, you have your answer.
4. Where are the residents? If almost everyone is in bed or parked in a corridor in front of a television at midday, the home does not have enough staff to get people up and occupied.
5. How staff speak to residents. Are people addressed by name? Is anyone crouching to eye level rather than talking over a head? Does the staff seem to know who they are talking to?

The harder things to see

6. Mealtimes. Ask to visit during one. Are residents who need help actually being helped, or are trays going cold in front of people who cannot lift a fork? Is anyone being rushed?
7. Residents' appearance. Clean clothes, brushed hair, trimmed nails, no visible bruising. Grooming is the first thing to go when a home is short-staffed.
8. The night and weekend shift. Ask directly how many nurses and aides are on overnight, and how that compares with days. Ask whether an RN is in the building around the clock or covering multiple sites.
9. Agency staff. Ask what proportion of shifts were filled by agency last month. Heavy agency use means the permanent team is not there.
10. How long leadership has been in post. A home that has had three administrators in two years is a home in trouble, whatever the current one tells you.

Answers that should end the tour

11. Evasiveness about the inspection record. Every home has citations. A good administrator will tell you what happened and what changed. An administrator who says there have not been any, when you already know there have, has just told you how they handle problems.
12. Pressure to sign today. Any push to sign an admission agreement — particularly one containing an arbitration clause — before you have read it at home is a reason to leave. Arbitration agreements are, in most cases, not a condition of admission. You can decline them and still be admitted.

Two questions people forget to ask

• "What happens when the money runs out?" Does the home accept Medicaid, and would your relative be able to stay in the same room, or would they be moved or discharged?
• "Who owns this home?" Not who manages it — who owns it. If the answer is a chain, look at how that chain's other homes perform. Budgets are usually set well above the building you are standing in.

Talk to someone who is not on the tour

Ask whether there is a resident or family council and whether you can speak to a member. Homes with an active family council tend to be homes that expect scrutiny. And call your state's Long-Term Care Ombudsman — the service is free, independent, and they know which homes generate complaints.