User Guide

All questions that appear in our checklists serve a purpose and help you gather the right information to make an informed decision about a provider. However, the implications associated with some of the questions may not be completely obvious.

This user guide addresses those questions in particular; it is organized to match checklist categories.

Location questions:

Staying connected to family and friends is important to the well-being of a person in a nursing home – not only for social engagement and stimulation but also to ensure that the nursing home resident has an advocate for good care. Sometimes this gets overlooked.

There are times when you may have to make a trade-off between accessibility and quality. Quality is important—but not always more important than having regular visits from family and friends and an advocate who lives nearby.

Building maintenance questions:

Building maintenance provides a window into management’s commitment to the nursing home and the nursing home’s financial well-being; it should be considered as part of any provider evaluation.

With that, facility odors often indicate insufficient staff and/or poor care. If you notice or ask about odors, particularly of urine or feces, the facility may explain that there had been a recent accident; if so, you should visit another time to verify. There should not be ongoing odors if the facility is clean and incontinent residents are cared for properly.

Amenity questions:

Make sure to ask about the amenities on the checklist, as well as any others that are offered or important to you. Do not assume that an amenity exists without verification.

Service questions:

Make sure to ask about the services. Again, do not assume that a service is available without verifying that it is.

Ask specifically about activities and outings; these should be varied and appropriate to the level of functioning of residents. Ask to see a monthly calendar, and observe an activity, if possible. Make note of how many residents actually attend the activity. Ask residents if they enjoy the activities.

Care questions:

Not all nursing homes offer the same type of care. Most nursing homes offer long-term care for residents who need assistance with activities of daily living. Some nursing homes specialize in particular types of care. It is important to find out if the facility provides the care you need.

Ask about the availability of on-site medical specialties, such as podiatry, dentistry and vision, since it is often difficult for a nursing home resident to get to their former providers.

It is also important to understand how nursing homes deal with residents who exhibit difficult behaviors, such as, wandering, aggressiveness or agitation due to mental illness or dementia. Does the nursing home have a psychiatrist, geriatric psychiatrist or other specialist who is available for a consultation, or who comes to the nursing home if there is problem? Is the staff skilled in handling difficult behaviors without the use of physical restraints and with minimal use of chemical restraints? What types of behaviors trigger the nursing home to ask a resident to leave or start involuntary discharge proceedings?

You may wonder about the rationale for hiring a private caregiver for someone in a nursing home. Nursing home staff is responsible for the care of a number of residents, and often lack time to give one resident special attention. A private caregiver is able to give a resident that important extra attention and may even plan a lunch or shopping trip, with permission and when appropriate. This type of one-on-one relationship can make a huge improvement in the quality of life for a nursing home resident.

Current resident questions:

The best advertisement for any community is well cared for, happy, engaged residents. Along those lines, the way staff members interact with residents will tell you a lot.

For example, when staff know residents by name, it is a sign of respect and consistent, ongoing engagement – and generally associated with better care and happier residents. The use of ‘honey,’ ‘dearie’ and/or other generic names, unless invited to do so, is demeaning.

Resident and family councils are very important as well – and generally mean more accountability among staff and as such, better care. Councils provide a forum where residents, including their family members, can voice requests and complaints as a group.

Staffing questions:

Nurses, dietitians, social workers, activity directors and certified nursing assistants (CNAs) bring important professional and paraprofessional expertise to nursing homes. Here is an explanation of the types of healthcare workers – and what they do:

  • A registered nurse oversees and provides healthcare and medication management.
  • Licensed practical nurses have less formal education than registered nurses; they perform many nursing tasks but must work under the supervision of a nurse.
  • A dietitian ensures that meals are nutritionally-sound and that residents who require special diets are accommodated.
  • Social workers assess residents and address their social and psychological needs.
  • An enthusiastic, involved activity director sees to it that residents have an interesting and robust schedule of activities and outings.
  • CNAs provide hands-on personal care, such as bathing, grooming and dressing.

States set minimum standards for staffing ratios. However, as an outside observer, it is difficult to determine if there are enough nurses and CNAs at the nursing home to provide timely assistance for those who need help. Ask questions about the ratio of nurses and CNAs to the number of people needing physical assistance during the day and at night. Notice if you see unanswered call lights, and ask residents if they have to wait a long time when they call for help.

Questions about the amount of time staff have worked at a community are important as well because stable staffing is typically a reflection of good management, which translates to better care for residents.

Exception: There are always exceptions. Sometimes stability is the result of tolerance of low standards and poor performance. A change in management and/or staff may represent efforts to correct such a problem. If you encounter a situation where major changes have occurred or are in process, you should probe further. Ask about prior problems, current goals and the corrective measures that new management is putting into place.

Contract and Cost questions:

Contracts are tedious to read and can be difficult to understand. Unless you are familiar with contracts it is advisable to ask an attorney who is knowledgeable about nursing home contracts to review the paperwork before you sign it. Make sure you understand your contract and are satisfied with the agreement. Never sign a contract under pressure.

Ask about costs. There is a difference in cost between a semi-private and private room. There may be other costs beyond room and board and different costs for different levels of care. Dementia care is usually more costly. Before you sign the paperwork, make sure you understand what the cost of your care will be and, importantly, what may cause your cost to increase in the future.

Medicare and Medicaid bed questions:

If the nursing home is Medicare and/or Medicaid certified, Medicare quality ratings are available for you to review. These ratings are helpful but should never substitute for your in-person evaluation.

When talking about whether a nursing home has an opening for a new resident – private pay, Medicaid or Medicare – nursing home professionals refer to the number of beds that are unoccupied. Often there are only a limited number of Medicaid beds and all of them may be occupied. Incoming long term care residents should count on paying privately, at least for a period of time, unless they are already on Medicaid and require a Medicaid bed. If you anticipate applying for Medicaid in the future, it is important to look at the Medicaid rooms, ask how long the waiting time is and how the nursing home handles applicants in your position.

Licensure questions:

If the nursing home you are considering is not licensed—run. Similarly, if the nursing home you are considering is not forth coming about whether its license is in good standing or its annual survey results—run.

All states have an ombudsman program. An ombudsman is an advocate for nursing home resident. Their role is to assist residents get their complaints addressed. A nursing home should display information about the ombudsman program / contact information and residents’ rights prominently.

Accreditation is voluntary, and generally, a sign of commitment to high standards and continuous quality improvement. When a facility goes this route, a third party, the accreditation organization, reviews all aspects of the community’s operations, including policies, procedures and protocols.


Remember that you are looking for a home for yourself or your loved one. When you have completed your investigation, it is helpful to ask yourself the following five simple questions:

Did you feel well treated when you visited the nursing home?

Was the staff forthcoming with information?

Were your questions answered to your satisfaction?

Did the residents look happy, well cared for and engaged with life?

Would you or your loved one feel comfortable living with the staff and residents?