This article is excerpted and adapted from How to Care for Aging Parents, by Virginia Morris; copyright © 2014. Reprinted by arrangement with Workman Publishing Co., Inc. All rights reserved.

You hoped it would never happen. Maybe you even promised yourself or your parent it would never happen. But at some point—often after great effort to avoid it, and agonizing days of sadness and guilt—it becomes clear that you need to move your parent into a nursing home.

It is a devastating decision. But in many cases, it’s the best option. Yes, there are horror stories, but there are also plenty of success stories. A good nursing home can provide a level of medical care, supervision, companionship, and activity that is often not possible at home. And if you are barely making it through each day, it’s best to arrange this move before you crash.

About 40 percent of people over the age of 65 will spend at least some time in a nursing home. Most stay for just a few months, recuperating after an injury or illness. Some are long-term residents.

You are in no way abandoning your parent. In fact, even though a move to a nursing home should relieve you of the daily demands of her care, your job is far from over. Your involvement, and that of other family members and friends, is vital to the success of this move.

Your parent needs someone to monitor her care and to act on her behalf. She needs someone who will talk with staff members regularly and speak up when things aren’t right. And of course, she needs your support, your love, and your warm touch now more than ever.

Sorrow may be unavoidable, but shake off any guilt. You are doing—and will continue to do—your best, and that is a gift.

The Decision: When Is the Time Right?

The mere thought of a nursing home may conjure up images of people warehoused in stench and isolation, but many nursing homes are well run; residents make friends, become involved, exercise, eat decent food, and are well tended to. Nursing homes are invaluable if your parent needs more care, therapy, or supervision than is practical or possible at home; when family members cannot handle the physical and emotional demands of caring for an infirm person; and when living in any other type of residence is not an option because of the severity of your parent’s disabilities or behaviors.

Most nursing homes offer basic medical care and around-the-clock nursing supervision in addition to meals, laundry services, personal care, counseling, recreation, social services, rehabilitative programs, and pharmacy and laboratory services. Some have “memory care” units for people with dementia, and others provide “subacute medical care”—special wings or floors that provide hospital-level care. Facilities are usually privately owned, publicly supported, or run by a nonprofit religious or civic group.

If a move is clearly on the horizon, don’t delay. Many of the best nursing homes have waiting lists, and it could be many months before a room becomes available. Also, if your parent is nearing Medicaid eligibility, it’s best to get into a facility that accepts Medicaid while he can cover six months of nursing home care out-of-pocket because he may have a better chance of being accepted by the home of his choice. And, finally, if your parent has dementia, it’s best to start this process while she can still be part of the deliberations and is lucid enough to adjust to new surroundings.

Starting the Hunt

Ideally, you’ll have time to do some research, tour a number of facilities, revisit one or two that look promising, and ask a lot of questions. Ideally, your parent will have time to live with this idea and begin to accept it.

In reality, however, time might not be on your side, and your search might be frantic.

Unless this is a temporary move (for respite or recuperation), try to buy yourself a little time. If your parent is about to be discharged from the hospital, you can usually get a reprieve of a day or two by appealing your parent’s discharge. If your parent is at home, see if you can hire temporary help while you review the options.

Moving is disruptive and stressful. If you “try out” a nursing home with the thought of moving your parent to a better one later, you will throw her life into chaos twice, create more work for yourself, and possibly hurt her chances of getting into another residence, as her placement may seem less urgent. It’s best to get it right the first time.

Start by putting together a list of local nursing homes. If you’re not sure whether your parent should stay in his community or move closer to you or one of your siblings, find out about residences in all of those places. Certainly, it’s best for him to be near family who can visit and monitor his care, but it’s also important to find a good residence.

A few resources:

Hospital Discharge Planner

If your parent is in the hospital, the discharge planner can guide you. Discharge planners should know quite a bit about local nursing homes, and they often have relationships with administrators, so they may be able to expedite admission. They also know something about your parent’s medical situation, so they can advise you on which homes are best suited for her. Sometimes nursing home administrators give priority to patients whose care will be covered, at least in the beginning, by Medicare.

Contact the discharge planner early in your parent’s hospitalization. Be aware, however, that a discharge planner’s main objective is to get your parent out of the hospital, so she may pressure your family to make a hasty decision. A hospital may also have a tie to a particular facility, biasing the planner’s recommendations.

Medicare’s “Nursing Home Compare”

On the Medicare website, you can learn about most nursing homes and get information about staffing levels, certain quality measures, and any problems that have been reported.

There are also several other websites that rate nursing homes. Be very cautious about using these to find a nursing home, as many commercial websites are extremely biased (“advisers” are simply salespeople who get commissions if you sign up with a community that pays them a commission).

Friends, Family, Clergy

Friends and relatives might have insight if they have had a family member in a nursing home. Members of the clergy, who visit people in nursing homes, might also have recommendations.

Area Agency on Aging or Long-term Care Ombudsman

There are local ombudsmen who provide information about nursing homes and help you sort through the facts, ratings, and inspections reports. The best ombudsmen visit nursing homes routinely and will know what each offers and the quality of care available. The nonprofit National Consumer Voice maintains a list of local ombudsmen.

Be aware, however, that an ombudsman can’t tell you which facility to choose or provide personal opinions about facilities. However, he or she might subtly try to redirect you if you are headed in the wrong direction. Why would you select Serene Acres? I think you should look at Barton’s Landing. Are you sure Cedar Hollow is right for your parent? Listen for those cues.

You’ll also find a list of resources in the "Aging in Place" section here at Checkbook.org.

Citizen Advocacy Groups

There are nursing home advocacy groups that keep tabs on nursing homes, guide residents and their families, and advocate for better regulations and policies. They might be helpful in your search for a good residence. To find an advocacy group, visit the website of The National Consumer Voice for Quality Long-Term Care.

What to Look For

Once you have a list of “maybes,” go on a formal tour, and then, if a facility seems promising, return during the evening or on a weekend, when staffing levels tend to be lower.

When you tour, don’t be blinded by fancy interior decorating, a glamorous lobby, or lush entrance gardens. Walk the corridors and observe how the residents are cared for, because that’s what matters. Visit common areas where residents spend time. Ask to see several bedrooms, the kitchen, the infirmary, and any dementia wing or other special unit. If possible, meet the manager of the residence, financial director, head nurse, activity director, social worker, and/or medical director.

Talk with residents, their families, and staff. If you don’t understand something, or if a situation seems amiss, ask. This will tell you far more about the home than you will learn on any guided tour.

When making a decision about nursing homes, or any senior housing for that matter, here are some things to consider:

Location, Location, Location

Being near family or friends who will visit regularly and keep tabs on care should be a primary criterion when selecting any housing. If your parent is mobile, find out whether the facility is near shops and restaurants and/or if a van or other transportation is readily available.

Certification and Licensing

All nursing homes must be state-licensed. A nursing home can choose to also seek certification from the federal government, which then enables it to receive Medicare and/or Medicaid payments.

It’s generally best to find a nursing home that is fully Medicare- and Medicaid-certified because this means that it meets federal guidelines, that any skilled care that falls under Medicare will be covered, and that if your parent becomes eligible for Medicaid he cannot be discharged solely because of finances.

Gut Instincts

Your first instinct is often a pretty good one. What turned you off? What surprised you? What did you like?

The Nose Test

That first waft is one indicator of the quality of a home. Is it fresh, airy, and odor-free? A facility shouldn’t smell musty or rancid, nor should it reek of perfumes or cleaning agents.

Well-Scrubbed and Maintained

Does it appear clean and well maintained, not just in the lobby and public rooms but elsewhere as well? Are the buildings and furnishings in good repair, or is there plaster cracking off the walls?

Your Parent’s Needs

Can this residence meet your parent’s specific needs? What sort of care is offered to residents with dementia or to those who are deaf? Are residents who are incontinent helped to the toilet immediately (or, better yet, before the need arises)? Are people on hand to help residents eat? Can they handle your father if he’s a curmudgeon or your mother if she has anxiety?

Money

Of course, this should be high up on your list, as it’s a major issue. What are the entry fees, monthly fees, and additional costs? Find out exactly what is included and what is extra—such as laundry, haircuts, special meals, outings, physical therapy, dental visits, lab work, medical equipment, and prescription drugs.

Find out how much monthly fees have increased over the past three years, and what sort of increases are expected in the coming years. Ask if contracts can be terminated, and if so, under what conditions. What is the refund policy? If a resident is discharged, how many days’ notice does he get? Who receives such notice? How stable is this residence financially? What happens to your parent if the home becomes part of another facility or goes out of business?

Unless your parent is quite wealthy, be sure a nursing home accepts Medicaid, as many people end up needing it.

Medical Care

What are the arrangements for medical care, dentistry, psychiatric services, foot care, eye care, preventive care, and other health-related needs? Does the facility arrange for residents to receive regular checkups by a doctor or nurse at the facility? Can they continue to use their personal doctors? (By law, they can as long as the resident can see the doctor, at the facility or at the doctor’s office, often enough to meet nursing home regulations.)

Are nurses available around the clock? Is there a doctor on call? Is the facility close to a hospital?

Are residents often restrained, either physically or with medications? Under what circumstances? Restraints should be used rarely, if at all.

What percentage of the residents are incontinent, and how is incontinence handled? (If a large number of patients are incontinent—half or more—it may be because the staff uses diapers and catheters in place of good toileting habits.)

A Plan of Care

In a nursing home, each resident should have a “plan of care” that outlines any therapies, treatments, meal requirements, special activities, and so forth. How is this plan determined? How much input does the resident and/or family have? How often is it reassessed, and how closely is it followed?

The Homeyness Factor

Is the residence well lit, attractive, and cheery? Would this be a comfortable place to live? Are the lounges cozy and the rooms adequate?

The Great Outdoors

Are there gardens or grounds where residents are free to roam? Are there benches and wide paths? Are residents actually enjoying the outdoors? Sitting in a dark room is not healthy.

The Folks Who Live There

Do the residents look well cared for and content? Are they groomed and neat? Are they alert, or do they look sedated? Are they restrained physically? What is their level of functioning, physically and mentally? Will your parent find people at his general level of functioning? Talk with residents and their family members out of earshot of staff so they can be candid. Are they happy with the care they are receiving?

Enough Staff

Do staff members seem harried and overworked? Are residents neglected and chores left undone?

Nursing homes are required to have at least one registered nurse on duty eight hours a day, seven days a week, and an RN (registered nurse), LPN (licensed practical nurse), or LVN (licensed vocational nurse) on duty 24 hours a day.

But this bar is exceedingly low. The National Consumer Voice for Quality Long-Term Care recommends that nursing homes have at least one “direct care” staff member for every five residents during the day. (These are people who directly care for patients, as opposed to those in administrative roles.) The ratio in the evening should be at least 1 to 10, and at night 1 to 15. Staffing should be higher if people have acute needs and in special wings, such as a dementia unit.

Caring Staff

Is the staff pleasant and helpful, or is everyone on edge? Do they interact easily and cheerfully with the residents? Do they treat residents with respect and kindness? Do they seem to enjoy their work? Are they open and direct in answering your questions? Do they seem knowledgeable? Is there a high rate of turnover?

Find out if the facility rotates staff or if one staff member on each shift will be assigned to your parent, so there is some consistency in her care.

Personal Freedom

Are residents encouraged to be independent, to care for and make decisions for themselves as much as possible? Can your parent eat when he wants, sleep in if he likes, leave his window open at night, and sit where he wants in the dining room? Can he have a pet? Can he skip breakfast if it’s not a meal he’s ever enjoyed? Can he watch television until 1 a.m. and have a snack at midnight, if that’s his habit? What if he’s a smoker?

He probably won’t get everything he likes, but is the facility flexible? If he’s not supposed to have salt in his diet, but he feels that he’s 92 and will have salt if he damn well pleases, how stringent will they be?

A Voice for Residents and Families

Is there a resident council that has some say in the operations of the home? Likewise, is there a council that provides a platform for families? How often do they meet? What kinds of issues do they discuss? How receptive is the home to suggestions and criticism? When was the last time the council recommended a change that was adopted?

A Room to Call Home

Are bedrooms private or shared? Are bathrooms private or shared? How are roommates matched? What if they don’t get along or have different lifestyles? Can they change rooms?

Are the rooms large enough? Are there windows that open? Are the rooms furnished nicely? Can your parent bring furniture and other items from home? Do the rooms reflect their individual inhabitants? Is there privacy? Are there curtains around the beds in shared rooms? Is there a locked place to store valuables?

What’s in a Day?

What are residents doing when you visit? Are they staring at a television screen or sitting alone in their rooms? Or are they engaged in projects and activities?

Is there a monthly activity calendar, and does it offer a wide range of choices? Are there frequent movies, lectures, classes, outings, games, and meetings that your parent might enjoy, given her interests and abilities? How many people actually participate in a given activity? Is the activities director willing to offer new classes or organize new events based on a resident’s interests?

Do residents get exercise? Is there a workout room? A pool? Is there a library? Lounge? Card room? Can residents do paid or volunteer work?

Is the nursing home involved with the community? For example, are there school groups that visit? Cultural activities from the community? Volunteer visitors?

What are the rules about leaving the grounds? Are there planned outings? How are residents monitored if they leave the building? What sort of transportation is available to residents?

Do residents who are confined to their rooms because of illness or disability receive any kind of physical and social stimulation? Does someone help get them to activities?

The Chow

When you visit, arrange to have a meal. Does it look appetizing? Does it taste good? Is it nutritious and well balanced? Does the daily menu change often? Are there ample choices? Can the kitchen accommodate special dietary needs?

Are meal hours flexible? Is food available around the clock? Can residents keep food of their own? Is the dining room attractive, neat, quiet, and intimate? How is seating decided? Can residents choose their own dining companions? Are staff members available to help people who have trouble eating on their own? Do patients confined to bed have help or company at meals?

The Head Honchos

Get a feel for the philosophy of the institution, as well. An administration that is genuinely concerned about residents will see to it that your parent gets good continuous care. If an administrator/director is willing to meet with you, and is open to your questions and concerns, that’s a promising first step.

The Visitor’s Role

Are visits encouraged and visitors made to feel welcome? Can visitors come for meals? Are young children allowed? Can residents have private time in their rooms with mates or spouses? Are there private places where you can be alone with your parent?

Room Changes and Discharge

You don’t want your parent moved from room to room or, for heaven’s sake, evicted. State and federal regulations cover these issues in nursing homes, but ask for specifics. Find out under what circumstances the home would move your parent to a new room or evict her.
How long will your parent’s bed be reserved in the event that she needs to be hospitalized or is temporarily absent for some other reason? What happens if she exceeds that limit? (This is particularly important if your parent is on Medicaid, as the facility’s time limit may be quite short or it may not hold a bed at all. If your parent loses her place, the residence must give her the first Medicaid bed available.)

Find out if your parent might be moved to another section of the nursing home once he is on Medicaid. It is disruptive for an older person to switch rooms, especially if he has made friends on a certain floor or wing and developed relationships with staff members. Furthermore, some nursing homes put all Medicaid patients onto a floor or unit that is not renovated, more crowded, and poorly staffed. If there is a separate section of the nursing home for those on Medicaid, tour this section as well.

Culture and Religion

Is the home sensitive to the ethnic and cultural norms of your parent? Are there other residents in the home who follow your parent’s religion or are ethnically similar? Do they serve appropriate foods? Are there plenty of people who speak the same language as your parent? How will medical and other information be provided if there is a language issue?

What provisions are there for religious worship? Are there services in-house? Can residents go to churches or synagogues in the community? Is transportation provided? Do clergy visit frequently?

Don’t pass over nursing homes sponsored by religious organizations just because your parent is not affiliated with that religion. Nursing homes affiliated with a religious group are often among the best ones.

General Safety and Accessibility

Is the facility set up to prevent accidents, and to be manageable for those with canes, walkers, or wheelchairs? Are there grab bars by the toilets and beds, and handrails along the hallways? Are pathways kept clear of clutter? Are there ramps, wide hallways, and elevators? (This should be true of all nursing homes.)

Is there ample security? Are there clearly marked fire exits, smoke alarms, fire doors, and alarms? Is an evacuation plan clearly displayed? Are there emergency call buttons that can be easily reached from both the bed and the toilet? Will your parent receive an emergency “HELP” button to wear?

Hospice Care

If hospice care is of interest to your family, ask if the nursing home has any arrangement with a nearby hospice or dedicated beds for hospice care. Find out how often hospice has been used at the facility, and how much the staff understands and accepts the philosophy of hospice.

Is a Bed Available?

If not, how long will your parent have to wait? If you and your parent like a particular home where a bed is not available, talk with the director of admissions at the nursing home about short-term possibilities. Could she be cared for at another facility until a bed is available?

Patient-directed Care

In some facilities, the focus is not solely what residents need (drugs, rehab, medical care), but what they want (companionship, independence, purpose). These residences often have homey living spaces and open kitchens, big gardens, sunlight, and, most important, a whole new philosophy of care. People wake up when they want, eat when they want, and do what they want, almost as if they were, well, people. Everyone who is able pitches in, setting the table, stirring the sauce, and arranging the flowers. The staff is more like family than overseers. For more information, contact The Green House Project, Eden Alternative, or Pioneer Network.

Special Care for Dementia

If a nursing home claims to have special programs and services for people with dementia, find out exactly what that means. A “memory care unit” may be a few rooms with a locked door, or it may be a carefully designed unit with a highly trained staff. The only way to know what’s really offered is to see for yourself.

A good unit should be quiet and calm, but also provide plenty of physical and mental stimulation. Residents should be encouraged to do simple exercises, engage in easy and entertaining projects, and receive lots of encouragement to do all that they can for themselves. They might be able to help with meals, fold laundry, set tables, and otherwise stay involved and feel useful.

The floor plan should allow them to find their way around easily and to wander safely. Doors, hallways, bathrooms, kitchens, and hazards should be clearly marked to avoid confusion.

The staff-to-patient ratio should be high, and schedules should be flexible to meet the diverse needs of residents, including those who are awake during the night or want to eat at odd hours.

The number of patients on sedatives or other psychotropic (mind-altering) medications should be low, and the use of physical restraints, such as straps or body vests, should be virtually nonexistent. Find out how the facility addresses behavioral symptoms.

Getting In

Finding a good nursing home is only half the battle; the other half is getting your parent accepted. In places where there are more beds than patients, getting in isn’t a problem. But in many areas, popular nursing homes will have plenty of candidates vying for admission, and administrators pick and choose freely when accepting residents. The person with the most money or the fewest problems or the easiest personality (and family) will be given priority.

When you meet with an administrator be honest, but also be discreet in what you say about your parent’s angry outbursts or demanding personality. You need to know that the staff can meet his needs, but don’t overemphasize any problems. If he’s calm and easygoing, make that clear. Likewise, although you shouldn’t hesitate to ask questions, be kind and polite. A family perceived as unreasonably demanding may be turned away in favor of one who understands the pressures of nursing home work.

You can’t hide your parent’s financial problems, because the nursing home will look through his records. Homes prefer self-paying residents and those who qualify for Medicare coverage. The longer someone can foot the bill privately, the better. If your parent is already on Medicaid, he may have fewer choices and may face lengthy waiting lists. It’s always better to enter a nursing home when your parent can pay out-of-pocket for six to nine months.

If he has trouble being admitted, talk to a long-term care ombudsman, a local citizens’ coalition, and, if possible, a savvy eldercare attorney.

Admission

The admissions process can be lengthy and exhausting, and it requires that you submit a variety of your parent’s personal, medical, financial, and legal records. The nursing home’s admissions or financial officer will tell you what is needed. Ask for all the paperwork in advance so you have time to review it and gather what you need before actually going through the admissions process.

A nursing home might ask for a large deposit before admission. Find out what this covers and whether it will be refunded if your parent leaves early. Get any agreement in writing. If your parent’s care is to be covered by Medicare or Medicaid, the home cannot require a deposit in advance.

Any nursing home contract should include detailed information about costs, payment schedules, services to be provided, penalties for failure to pay, the discharge policy, the rules of the house, the responsibilities and rights of residents, and the facility’s refund and bed-holding policies should your parent be hospitalized or temporarily absent for some other reason.

Read the contract carefully or have an experienced lawyer read it. Ask the nursing home’s director or a long-term care ombudsman to clarify any provision that confuses or concerns you or your parent. Beware of clauses in the contract that free an institution from liability for injury or lost possessions. It’s best not to sign any pre-dispute arbitration agreement (which gives the facility control over any arbitration process and limits your ability to seek justice or compensation if there is neglect or abuse).

Who Pays?

What shocks most families is not just the exorbitant cost of nursing home care, but also the fact that Medicare and private health insurance cover so little of it.

Nationally, the average cost of a semiprivate room in a nursing home is more than $80,000 a year. That’s only an average; in many parts of the country, the rates are much higher.

Furthermore, the daily or monthly rate quoted by a facility is usually just a base rate. Often, medications, doctor visits, wheelchairs, walkers, and other such services are extra (unless Medicare or Medicaid is footing the bill, in which case most of those services are covered). In some homes, doing laundry, monitoring catheters, and preventing bedsores are considered extras. A survey by Consumer Reports found that nursing homes sometimes charge up to $1,000 a month for such extras.

Medicare pays for nursing home care only when “skilled” nursing care is needed within 30 days of a hospital stay that lasts at least three full days (and it must be directly related to that hospitalization). A doctor must authorize the need for care, and it must require the oversight of nurses and/or rehabilitation therapists.

If your parent meets all of these requirements, Medicare will pay for 20 days in the nursing home, and then it will pay a portion of the tab for the next 80 days. After that, you’re on your own. Many supplemental insurance policies will cover the extra cost between days 21 and 100, but that’s it.

Private long-term care insurance will cover some of the cost of a nursing home (usually for some limited period of time), but most people don’t have such insurance. As a result, the majority of people who need extended nursing home care tap into their savings, and when that is used up they apply for Medicaid.

All of this comes as a great surprise to people who thought that they had a sufficient nest egg and then suddenly find that it is completely gone. Even a fairly hefty savings account can be depleted quickly.

Before your parent runs out of money, learn about Medicaid eligibility and ways that your family might protect at least some assets.
Unlike most other health insurance, Medicaid does cover nursing home care. In fact, Medicaid covers nearly half of all nursing home care in this country.

Most nursing homes accept Medicaid patients, but they favor self-paying and Medicare patients, and may limit the number of Medicaid patients they admit. For example, a nursing home with 200 beds might have only 20 beds earmarked for Medicaid patients.

If there is any chance your parent will end up on Medicaid, be sure that any facility you consider accepts Medicaid, and find out exactly what will happen if and when she switches to Medicaid.

If a nursing home is fully certified to take Medicare and Medicaid, it cannot legally discharge your parent for switching to Medicaid. Your parent should simply be able to stay put, without any changes at all.

The bottom line: Know the policies and get everything in writing before your parent enters any nursing home.

As for the sort of care your parent will receive, it’s true that most plush nursing homes do not accept people on Medicaid, but it is a myth that anyone on Medicaid will end up in a dreadful place. Some very good nursing homes accept Medicaid.

Remember, an expensive nursing home is not a guarantee that your parent will get loving, devoted care, just as a rundown exterior doesn’t always mean shabby care. Appearance is an important clue to what kind of service is provided, but the quality of care comes from the people who work in the facility. The philosophy of the administrators and the devotion of the staff is what matters most.