1. Location, location, location. No single factor is more important to quality of care and quality of life of a nursing home resident than visits by family members. The quality of care is often better if the facility staff knows that someone who cares is watching and involved. Visits can be the high point of the day or week for the nursing home resident. So, make it as easy as possible for family members and friends to visit.
   
    
2. Get references. Ask the facility to provide the names of family members of residents so you can ask them about the care provided in the facility and the staff's responsiveness when the resident or relatives raise concerns.
   
    
3. Check certifying agency reports. CareScout is an unbiased source for ratings and reviews of eldercare providers nationwide. Detailed, 7-10 page Nursing Home reports are available for a small fee, and include over 100 pieces of information on quality, resident population profiles, and health violations. Another source for nursing home reports is HealthGrades. For a fee, HealthGrades will provide you with a report that rates the nursing home and provides information on inspections and complaint investigations. You can also get a report that compares the nursing homes in your area.
   
    
4. Talk to the nursing home administrator or nursing staff about how care plans are developed for residents and how they respond to concerns expressed by family members. Make sure you are comfortable with the response. It is better that you meet with and ask questions of the people responsible for care and not just the person marketing the facility.
   
    
5. Tour the nursing home. Try not to be impressed by a fancy lobby or depressed by an older, more rundown facility. What matters most is the quality of care and the interactions between staff and residents. See what you pick up about how well residents are attended to and whether they are treated with respect. Also, investigate the quality of the food service. Eating is both a necessity and a pleasure that continues even when we're unable to enjoy much else. It is also advisable to try and get a tour of the facility that is not prearranged. While this is not always possible, it does give you the opportunity of seeing an unrehearsed atmosphere.
   
    

Few decisions are more difficult than the one to place a spouse or parent in a nursing home. Since nursing homes are seen as a last resort, the decision is generally overlaid by a sense of guilt. Most families try to care for loved ones at home for as long as (or longer than) possible, only accepting the inevitable when no other alternative is available.

The difficulty of making the decision can be compounded when family members disagree on whether the step is necessary. This is true whether the person disagreeing is the person who needs help, his or her spouse, or a child.

The placement decision can be less difficult if, to the extent possible, all family members are included in the process, including the senior in question, and if everyone is comfortable that all other options have been explored. This will not ensure unanimity in the decision, but it should help.

We recommend the following steps:

1. Include all family members in the decision. Let them know what is happening to the person who needs care and what providing that care involves. If possible, have family meetings, whether with the family alone or with medical and social work staff where available. If you cannot meet together, or in between meetings, use the telephone, the mail, or the Internet.
   
    
2. Research other options. Find out what care can be provided at home, what kind of day care options are available outside of the home, and whether local agencies provide respite care to give the family care providers a much-needed rest. Also, look into other residential care options, such as assisted living and congregate care facilities. Local agencies, geriatric care managers, and elder law attorneys can help answer these questions.
   
    
3. Follow the steps above for finding the best nursing home placement available. If you and other family members know you've done your homework, the guilt factor can be assuaged (at least to some extent).
   
    
4. Where necessary, hire a geriatric care manager to help in this process. While hospitals and public agencies have social workers to help out, they are often stretched too thin to provide the level of assistance you need. In addition, they can have dual loyalties, to the hospital that wants a patient moved as well as to the patient. A social worker or nurse working as a private geriatric care manager can assist in finding a nursing home, investigating alternatives either at home or in another residential facility, in evaluating the senior to determine the necessary level of care, and in communicating with family members to facilitate the decision. To find a geriatric care manager in your area, visit the Web site of the National Association of Professional Geriatric Care Managers at www.caremanager.org.

While residents in nursing homes have no fewer rights than anyone else, the combination of an institutional setting and the disability that put the person in the facility in the first place often results in a loss of dignity and the absence of proper care.

As a result, in 1987, Congress enacted the Nursing Home Reform Law that has since been incorporated into the Medicare and Medicaid regulations. In its broadest terms, it requires that every nursing home resident be given whatever services are necessary to function at the highest level possible. The law gives residents a number of specific rights:

1. Residents have the right to be free of unnecessary physical or chemical restraints. Vests, hand mitts, seat belts and other physical restraints, and antipsychotic drugs, sedatives, and other chemical restraints are impermissible, except when authorized by a physician, in writing, for a specified and limited period of time.
   
    
2. To assist residents, facilities must inform them of the name, specialty, and means of contacting the physician responsible for the resident's care. Residents have the right to participate in care planning meetings.
   
    
3. When a resident experiences any deterioration in health, or when a physician wishes to change the resident's treatment, the facility must inform the resident, and the resident's physician, legal representative or interested family member.
   
    
4. The resident has the right to gain access to all his or her records within one business day, and a right to copies of those records at a cost that is reasonable in that community. The facility must explain how to examine these records, or how to transfer the authority to obtain records to another person.
   
    
5. The facility must provide a written description of legal rights, explaining state laws regarding living wills, durable powers of attorney for health care and other advance directives, along with the facility's policy on carrying out these directives.
   
    
6. At the time of admission and during the stay, nursing homes must fully inform residents of the services available in the facility, and of related charges. Nursing homes may charge for services and items in addition to the basic daily rate, but only if they already have disclosed which services and items will incur an additional charge, and how much that charge will be.
   
    
7. The resident has a right to privacy, which is a right that extends to all aspects of care, including care for personal needs, visits with family and friends, and communication with others through telephone and mail. Residents thus must have areas for receiving private calls or visitors so that no one may intrude and to preserve the privacy of their roommates
   
    
8. Residents have the right to share a room with a spouse, gather with other residents without staff present, and meet state and local nursing home ombudsperson or any other agency representatives. They may leave the nursing home, or belong to any church or social group. Within the home, residents have a right to manage their own financial affairs, free of any requirement that they deposit personal funds with the facility.
   
    
9. Residents also can get up and go to bed when they choose, eat a variety of snacks outside meal times, decide what to wear, choose activities, and decide how to spend their time. The nursing home must offer a choice at main meals, because individual tastes and needs vary. Residents, not staff, determine their hours of sleep and visits to the bathroom. Residents may self-administer medication.
   
    
10. Residents may bring personal possessions to the nursing home such as clothing, furnishings and jewelry. Residents may expect staff to take responsibility for assisting in the protection of items or locating lost items, and should inquire about facility policies for replacing missing items. Residents should expect kind, courteous, and professional behavior from staff. Staff should treat residents like adults.
    
     
11. Nursing home residents may not be moved to a different room, a different nursing home, a hospital, back home or anywhere else without advance notice, an opportunity for appeal and a showing that such a move is in the best interest of the resident or necessary for the health of other nursing home residents.
    
     
12. The resident has a right to be free of interference, coercion, discrimination, and reprisal in exercising his or her rights. Being assertive and identifying problems usually brings good results, and nursing homes have a responsibility not only to assist residents in raising individual concerns, but also to respond promptly to those concerns.

Disagreements with a nursing home can come up regarding any number of topics, and almost none is trivial because they involve the day-to-day life of the resident. Among other issues, disputes can arise about the quality of food, the level of assistance in feeding, troublesome roommates, disrespect or lack of privacy, insufficient occupational therapy, or a level and quality of activities that doesn't match what was promised.

The nursing homes that live up to the ideal of what we would want for our parents or ourselves are few and far between. The question is how far you can push them towards that ideal; what steps should be taken in such process; and at what stage does the care become not only less than ideal, but so inadequate as to require legal or other intervention. This can be a hard determination to make and in some cases needs the involvement of a geriatric care manager who can make an independent evaluation of the resident and who has a sufficient knowledge of nursing homes to know whether the one in question is meeting the appropriate standard of care.

Following is a list of the interventions a family member may take, in ascending order of degree. Move down the list as the severity of the problem increases or the facility does not respond to the less drastic actions you take. In all cases, take detailed notes of your contacts with facility staff and descriptions of your family member and his or her care. Always note the date and the full name of the person with whom you communicate.

1. Talk to staff. Let them know what you expect, what you care about and what your family member cares about. This may easily solve the problem.
   
    
2. Talk to a supervisor, such as the nursing chief or an administrator. Explain the problem as you see it. Do it with the expectation that the issue will be favorably resolved, and it may well be.
   
    
3. Hold a meeting with the appropriate nursing home personnel. This can be a regularly scheduled care planning meeting or you can ask for a special meeting to resolve a problem that wasn't resolved more informally.
   
    
4. Contact the ombudsperson assigned to the nursing home. He or she should be able to intervene and get an appropriate result. Contact information for the Ombudsman Program in your state can be found at: www.ltcombudsman.org
   
    
5. If the problem constitutes a violation of the resident rights described above, report it to the state licensing agency. This should put necessary pressure on the facility.
   
    
6. Hire a geriatric care manager to intervene. An advocate for you who is not as personally involved as you and who understands how nursing homes function as institutions can help you determine what is possible to accomplish and can teach the facility to make the necessary changes.
   
    
7. Hire a lawyer. While a lawyer may be necessary to assert the resident's rights, the involvement of an attorney may also escalate the dispute to a point where it is more difficult to resolve. This is why we have listed this as the second-to-last option. But when all else fails, a lawyer has the tools to make the facility obey the law.
   
    
8. Move your relative. If nothing else works, move your family member to a better facility. This may be difficult, depending on the situation, but it may be the only solution. It does not prevent you from pursuing legal compensation for any harm inflicted on the nursing home resident while at the earlier facility.

Myths and Realities