Introduction

This guide provides information to help you choose a nursing home for yourself or a loved one. Nursing homes, sometimes called skilled nursing facilities, serve both long-term residents and people who come for a short period for rehabilitative care (usually after a hospital stay). Some nursing homes also provide respite care, which is when a person comes for a short stay, to give relief to a primary caregiver.

A nursing home can be a freestanding facility or it can be part of a continuing care retirement community (CCRC). A CCRC allows residents to move from one level of care to another, as needed, and can include independent living, an assisted living facility, and/or a nursing home. Additionally a hospital can have a skilled nursing unit which includes designated beds within the hospital that serve patients who need short-term care and rehabilitation services.

Topics Include:

Nursing Home Services

A nursing home provides 24-hour nursing and personal care to residents. Nursing care is provided by licensed practical nurses (LPNs) and registered nurses (RNs). Personal care is given by certified nursing assistants (CNAs) and can include help with bathing, dressing, eating, walking, and physical transfer (like moving from a bed to a chair). Nursing home services include, as needed:

• Nursing care 24-hours a day
• Help with personal care
• Nutritional meals and special diets
• Physical, occupational, speech, and respiratory therapy
• Case management, health monitoring, and supervision
• Social and creative activities
• Respite care

A nursing home might also provide services like dietary consultation, laboratory, x-ray, pharmacy services, laundry, and pet therapy visits. Some facilities may provide special services like dialysis, tracheotomy, or ventilator care as well as Alzheimer’s or hospice care, among others.

When you visit a nursing home, be sure to ask about all of the services that are available, and think about the services you need now as well as those you might need in the future.

What services will you need?

In order to enter a nursing home a doctor will need to write a medical order for nursing home care. When you (or your loved one) first arrive in the nursing home the staff will do an assessment of your condition. A registered nurse, along with other staff, will use the doctor’s order and the assessment to develop a care plan. The care plan will state what services you need; what health care professionals should provide this care and how often; what kind of medical equipment, supplies, or medicine you might need; and your health care goals.

You or someone acting on your behalf have the right to take part in planning your care, to meet with the care plan team, to review your care plan, and to be notified of any changes to your plan.

Finding and Choosing a Nursing Home

There are many things to consider in choosing a nursing home. How will you find the nursing home that offers the services you need and where you feel comfortable, that provides quality care, and is in a location convenient for visitors and for your needs outside of the nursing home (like your doctor, place of worship, etc.)?

There are tools available to find nursing homes in Florida and to compare them for quality of care, special services, lowest daily rate, payment forms accepted, and other measures. The following resources can help you begin to review and compare nursing homes:

Facility Locator: You can use Facility Locator on FloridaHealthFinder.gov to find a list of nursing homes in your area.

After you have a facility or a list of facilities, click on a facility name to find the address, phone number, and driving directions. This profile page also includes the names of the administrator and owner, the number and types of beds, and emergency and/or legal actions (where applicable).

The profile page includes links to inspection reports, the Florida Nursing Home Guide, and the Federal Nursing Home Compare website. It also displays the current daily room rate, payment forms accepted, languages spoken, special programs and services, and more.

If you are looking for a particular bed type, certain languages spoken, payment forms accepted, religious affiliations, nursing homes with a Gold Seal award, or special programs and services, you can choose these options on the first page of Facility Locator by clicking “Advanced Search” before clicking the Search button.

Following are descriptions of some of the options you will find under Advanced Search:

• The bed type includes pediatric beds, private rooms or rooms with multiple beds, sheltered retirement community beds (these are beds reserved for residents of a continuing care retirement community), and community beds (available to everyone).
• The Gold Seal is awarded for a two-year period and recognizes those nursing homes that demonstrate excellence in long-term care over a sustained period.
• Special Programs and Services include dialysis, tracheotomy, and ventilator care; 24 hour onsite registered nurse (RN) coverage; pediatric, Alzheimer’s, HIV, and hospice care; and others.
• You can choose to view nursing homes that have an emergency action. There are two types of emergency actions that can be imposed by the Agency for Health Care Administration (Agency) for poor performance by a nursing home: With a moratorium the facility can continue to operate, but cannot accept new residents until they correct their deficiencies. With a suspension the facility's license is suspended until the Agency takes further action.  The nursing home cannot operate during a suspension.

Florida Nursing Home Guide: Some of the information described above can also be found in the Florida Nursing Home Guide on FloridaHealthFinder.gov. On the Web page choose the “characteristics” link to look up nursing homes by a category of special services they offer, payment forms they accept, languages spoken as well as city or county location.

Florida Department of Elder Affairs: You can request a list of nursing homes in your local area by calling the Florida Department of Elder Affairs toll-free number (800) 963-5337.

From Your Hospital: If you are a patient in a hospital, ask the hospital’s discharge planner or social worker for a list of local nursing homes. The staff may also help you find an available bed.

Continuing Care Retirement Communities (CCRCs): To find a list of CCRCs (described earlier) go to FLOIR.com/CompanySearch and choose “Continuing Care Retirement Communities” in the Company Type box.

Questions You May Want to Ask

When you visit a nursing home you may want to ask some of the following questions, along with any other questions you might have. For your first visit, call and schedule an appointment to speak with the administrator and the director of nursing, and request a tour of the facility. You might also want to ask to speak with the dietitian, activities director, social worker, and others during this first visit or during a follow-up visit.

What are the fees and what services are provided?

By state law nursing homes are required to provide written and verbal information about the services they provide and their charges. The nursing home may have one fee for certain basic services provided to everyone and other fees for additional services you may want or need. Ask that these be clearly explained and request a printed copy of the fees and services. Think about additional services you might need in the future, not just your current needs.

If you are not covered by Medicare or Medicaid, ask if a cash deposit will be required, how much, and when it would be due. If you are covered by Medicare or Medicaid, the nursing home cannot ask for a cash deposit. They may ask you to pay your Medicare co-payment, but it is best to pay these charges when you are billed, not in advance.

Ask if there have been fee increases. How often and how much of an increase?

A nursing home is required by state law to provide written notification to residents in advance of changes in fees and services.

What types of payment are accepted?

Payment for a nursing home stay may be paid with private funds, Medicaid, long-term care insurance, health insurance for rehabilitative care, or Medicare under certain limited circumstances. If you are eligible for some government help or you are covered by long-term care insurance, or other types of assistance such as veterans’ benefits, ask the nursing home if these will be accepted. For more information check the Financial Resources section.

Is there a bed available or is there a waiting list?

If there is an available bed how soon could you move in? What do you need to do in order to become a resident? If there is a waiting list how long might the wait be? Is a deposit required to be on the waiting list? How much?

What paperwork will I need to complete?

Before choosing a nursing home, ask for printed information on the services and fees and any other paperwork you can take home with you. You can read these at home and write down questions you might have. You can also share the paperwork with a friend or family member.

Then make an appointment to discuss your questions and concerns. If possible, take a friend or family member with you, to help you gather information and help you think about your choices. If you ask a question, but do not understand the answer, ask that it be more clearly explained to you.

Before you sign any papers, read them carefully, make sure you understand them and that all of your questions have been answered. When you do sign paperwork, ask for a copy for your own records.

What activities are offered?

Ask to see a schedule of activities. Are there a variety of activities you or your loved one would enjoy? Is there transportation available to go to community activities that you choose? Are there planned trips? Are there activities for residents who are bedbound? Ask if you can attend an activity.

What meals and snacks are provided? Are special diets available?

Ask how many meals or snacks are provided. Are they provided at certain times of the day or can a resident make choices about when to eat? Is there a variety of food served? Are special meals or diets available, if needed? Ask if you can have lunch one day. Then you can sample the food and speak with residents.

What if I have a medical appointment?

Will the nursing home help make appointments for medical care and provide or arrange for transportation to medical appointments? Is there an extra cost for transportation services?

Does the facility provide a doctor who visits residents, as needed?

Can a resident continue to use his or her own doctor who can attend to them at the nursing home? If the nursing home has a doctor, what role do they play in resident care?

What if a resident needs hospital care or emergency care?

Can the resident choose the hospital for planned care and/or emergency care or does the nursing home use a particular hospital? How and when is a family member or friend contacted in an emergency or when the resident has a significant change in their condition?

What is the availability of other services?

Does the nursing home provide or help with access to a dentist, podiatrist, eye care, a beauty shop or barber, and other needed services you might have?

Are special services offered for persons with dementia (like Alzheimer’s disease)?

Ask what special services and activities are available for persons with dementia. Is the staff trained to handle the special needs of these residents or participants? Is there equipment to assure the person does not wander off?

What is the facility’s bed hold policy?

A bed hold policy is for when a resident is admitted to a hospital or some other type of health care facility for short-term care. If the resident is expected to return, the nursing home agrees in writing to reserve their bed for a designated period of time.

The resident will be required to continue to pay the monthly fee until the bed hold is ended, as described in the written agreement; or until the resident or their legal representative tells the nursing home in writing that the resident will not return; or if a medical condition prevents the resident from telling the nursing home and the resident has no legal representative to speak for them.

Is there a resident council and/or a family council? How often do they meet and what kinds of things do they do?

A Resident Council is a group of nursing home residents that meets to make suggestions on improving services, voice grievances, assure residents’ rights are observed, plan social activities, and other aspects of resident life.

A Family Council advocates for residents’ rights and quality of care and provides a way for family members and friends to voice concerns and request improvements.

Nursing homes certified for Medicare and Medicaid must provide a meeting space, cooperate with the council's activities, and respond to the group's concerns. The Long-Term Care Ombudsman Council (described later) advocates for residents’ rights and can provide information for resident and family councils.

Other questions might include:

• If I want a loved one notified of changes in my medical condition or any other changes, how and when are they notified?
• How often are care plan meetings held and how are the resident and family notified?
• Will I have a choice of rooms or is one assigned to me?
• Will I have my own room or share it with another person?
• Can I change rooms if my roommate and I don’t do well together?
• How is personal laundry handled?
• If you (or your loved one) speak a language other than English, how will language needs be met?
• Can my pet or pets reside with me? Can family or friends bring my pet or pets for a visit?
• How does the nursing home meet the religious and spiritual needs of the residents?
• To whom should I speak if I have concerns or problems?

If you see or hear things during your visit that concern you, ask the staff about it. If there is something you do not understand, ask that it be explained more clearly.

After your first visit:

After you have met with staff at the nursing home and have had a tour, you may want to return again unannounced and at a different time of the day, to get a feel for the place. Take time to talk with residents and staff. How does it compare to when you had an appointment and the staff knew you were coming?

You can visit a variety of times if you wish. Also, if you have additional questions after your initial and follow-up visits, make an appointment with the administrator and/or director of nursing to discuss your questions.

Checklist for Visiting a Nursing Home

The following checklist can help you think about what to look for when you visit a nursing home. Since there is a lot to view and to consider, you might want to take this list with you or write up your own checklist.

Residents

• Are residents appropriately dressed and well-groomed?
• Are residents alert and up and about or are they sitting in chairs for long periods or lying in bed? (Some residents may be bedbound due to their medical condition.)
• Are there organized activities and are residents participating?
• Is privacy respected? Do you see staff knock on doors before entering a resident’s room? If there are privacy curtains, are they drawn while care is given?

Staff

• Does the staff interact with residents? Are they friendly and respectful?
• Are the administrator, director of nursing, and other staff friendly and willing to answer your questions?

Residents Rooms

• Are the rooms pleasant, with good lighting, a window, and enough space?
• Do the rooms have storage space for each resident?
• Are rooms private or shared? How many residents are in each room?
• How many residents share a bathroom?
• Are there handrails and a call button in the bathrooms?
• Where does the resident shower or bathe?

Common Space

• Is the facility clean and free of strong odors?
• Are rooms and hallways neat, free of clutter, and easy to walk through?
• Are there handrails in the hallways?
• Is the temperature comfortable throughout?
• Are there common areas available for residents and their visitors?
• Are there outside areas for use by residents and visitors? Are they being used?
• Is furniture sturdy, comfortable, and clean?
• Is the kitchen clean and well-organized? Is the dining area clean and comfortable?

Meals

• Ask to see a menu. Is there variety and do residents have choices?
• Are nutritious snacks provided between meals and/or upon request?
• Visit during a meal. Does the food appear and smell appetizing? Does it include fresh foods or mostly canned or frozen? Do residents enjoy the meal?
• If staff are assisting some residents with eating, are they patient and attentive to the resident?

Financial Resources

Residency in a nursing home can be paid with private funds, long-term care insurance, or a person might qualify for help from government programs.

Often people do not know that Medicare does not pay for long-term residency in a nursing home. Medicare may cover a limited number of days, but only if you require some form of skilled care (nursing and/or rehabilitation), only after you have had at least a three day hospital stay, and other requirements. Depending on your length of stay you may be responsible for a co-payment. Speak with Medicare or the nursing home concerning these requirements. Additionally, if you are in a Medicare health plan you need to ask the health plan which nursing homes are in the plan and if you need to notify the health plan prior to admission. The nursing home has to be certified for Medicare and have Medicare beds available.

The Florida Medicaid Program does cover nursing home care for those who qualify for Medicaid coverage and who meet the criteria for nursing home care. A person may initially need to pay with their own funds, if the person does not qualify for Medicaid when they first enter a nursing home, or if they exhaust their coverage under Medicare or another form of insurance. When the person has spent down their own funds or no longer has another type of coverage, they might then qualify for Medicaid. The nursing home has to be certified for Medicaid and have Medicaid beds available.

If the person is married and the spouse continues to live in their home, Medicaid takes this into consideration in determining eligibility for the nursing home resident, to assure the independent spouse can continue to have funds for his or her living needs.

The following contacts can help you learn more about Medicare, Medicaid, and other possible resources:

Medicaid: The Florida Medicaid Program covers mostly seniors, disabled adults, children, and pregnant women who meet the eligibility requirements. The Florida Department of Children and Families takes applications and determines who is eligible for Medicaid. Call the toll-free number (866) 762-2237 or view MyFlorida.com/accessflorida.

Medicare: Medicare covers people 65 years or older, some disabled persons who meet the eligibility requirements, and people with end-stage kidney disease. For more information call the toll-free number (800) 633-4227 or TTY (877) 486-2048 or view Medicare.gov.

Long-term Care Insurance: Long-term care insurance is paid for with private funds. If you have a long-term care insurance policy, or are considering buying one, find out exactly what it covers, under what conditions you can receive coverage, any restrictions that might apply, and what you need to do when coverage is needed. The Florida Department of Financial Services regulates insurance in Florida. For questions or to request their consumer brochures, call the toll-free number (877) 693-5236 or (850) 413-3089 or view MyFloridaCFO.com.

Department of Veterans Affairs (VA): Veterans may qualify for care in a nursing home operated by the VA or in a nursing home that has a contract with the VA. For more information, call the Florida Department of Veterans’ Affairs at (727) 319-7400 or view FloridaVets.org. Or view the website for the U.S. Department of Veterans Affairs at VA.gov.

Health Insurance and Health Plans: Your health insurance or health plan may cover a stay in a nursing home. Contact your insurance provider to ask about the coverage they offer, under what circumstances a person can receive coverage, and for what length of time.

Workers’ Compensation: If you are injured on the job and need nursing home care it is possible workers’ compensation would provide some coverage. To learn more call the Florida Department of Financial Services toll-free number (877) 693-5236 or view MyFloridaCFO.com/WC.

SHINE Program: The SHINE Program serves seniors and people with disabilities and provides counseling on Medicare, Medicaid, long-term care insurance, prescription assistance programs, and other health insurance issues. To learn more call the Florida Department of Elder Affairs toll-free number (800) 963-5337 or view FloridaShine.org.

Prior to Admission

If you are a Medicaid recipient or have just applied for Medicaid, and need care in a nursing home, you will receive an assessment from the CARES program (Comprehensive Assessment and Review for Long-Term Care Services). CARES provides assessments for persons 21 years of age and older and evaluates a person’s ability to perform personal care (bathing, dressing, eating, walking, physical transfer) as well as their emotional, cognitive, medical, and psychosocial state. The program is to assure the person receives an appropriate placement and the level of care that is needed. Individuals not covered by Medicaid can request a CARES assessment at no charge.

For Medicaid recipients 20 years of age or younger, the appropriate level of care is determined by the Children’s Multidisciplinary Assessment Team. Children’s Medical Services at the Florida Department of Health administers this program for medically complex children. Children with medically complex conditions can receive this assessment even if they are not covered by Medicaid.

If you are moving into a nursing home that is Medicaid certified (whether you are covered by Medicaid or not) you will go through a Pre-Admission Screening and Resident Review (PASRR). This is a federally required screening performed prior to admission to a Medicaid certified nursing home. The screening is to check for mental illness and mental retardation to ensure appropriate placement in the least restrictive environment and to see if special services are needed. This screening is usually done by discharge planners and hospital staff prior to discharge from a hospital.

To learn more about the PASRR and CARES programs, call the Florida Department of Elder Affairs toll-free number (800) 963-5337 or view ElderAffairs.state.fl.us/doea/cares.php. For information on Children’s Medical Services and the Children’s Multidisciplinary Assessment Team click DOH.state.fl.us/AlternateSites/CMS-Kids and DOH.state.fl.us/AlternateSites/CMS-Kids/families/health_services/cmat.html or call (850) 245-4200. The Web pages include contact information for local CMS offices.

Moving into a Nursing Home

When you move into your new home you will be leaving behind the familiar and adjusting to new surroundings, new people, and new routines. You will also receive supportive services and care and have the opportunity to have daily contact with other residents and employees at the facility and to participate in activities.

You will need to make decisions about what to bring with you. If you have a favorite chair, lamp, TV, radio, or other items, ask the staff what you can bring with you. Before bringing items that are valuable, ask the staff how your personal belongings will be safeguarded. Ask if you can decorate your room.

If possible, take time to carefully go through your personal belongings. Decide what you want to take with you and if you want to store, sell, or give away anything. It may be helpful to temporarily store some of your personal belongings with a loved one or in a storage unit. Once you have moved in, you may want to bring additional things from storage or exchange items.

You may want to label the things you bring with you and, if your laundry is going to be done by the facility, ask if you need to label your clothing.

Ask friends or family members to help you with packing, moving, and setting up. Be sure it is clear what day you are moving in.

Nursing Home Admission

At the time of admission the nursing home is required to provide you with a copy of the residents’ bill of rights, the nursing home’s admission and discharge policies, and information on health care advance directives. Read the admission and discharge policies, if you haven’t already done so, to make sure you understand them.

You will also sign a contract with the nursing home. Read the contract carefully and if there is something you do not understand, ask that it be explained more clearly. Make sure you understand the contract, what services will be provided, and what the charges will be. You might want to request a copy of the contract prior to your day of admission to take it home for careful review. You can ask loved ones or even an attorney who specializes in elder law to review it with you.

The contract should also include a list of services and supplies not covered by the daily charge, but available to the resident along with the charges for those extra services. The contract will also include the nursing home’s bed reservation and refund policies.

This may take some time to read through everything, but do not feel rushed and make sure all of your questions and concerns are answered. If possible, have a loved one with you to help you to review everything. Keep a copy of the contract in case you want to refer to it in the future.

If you are helping a loved one: If you are helping a loved one with admission into a nursing home, if the person gives you permission, you can participate throughout the process. If your loved one is unable to make decisions or to understand the process, or they need a lot of help to do so, you may want to consider becoming the person’s health care surrogate or durable power of attorney. You can read more about this in our publication Health Care Advance Directives.

Discharge or transfer: If you are a resident in a Medicaid or Medicare certified nursing home you may challenge a decision by the facility to discharge or transfer you. The nursing home is required to give a 30 day written notice prior to a discharge or transfer. If you or a loved one receives such a notice, you can contact the Long-Term Care Ombudsman Council (listed below) to request a review and hearing.

An exception to the 30 day notice is if the change is necessary due to your health and welfare as recommended by your doctor or for the health or safety of other residents as indicated by your doctor or the medical director at the nursing home. You can speak with the Long-Term Care Ombudsman Council if you have questions or to ask for a review and hearing.

Important Phone Numbers and Websites

If you are concerned about the care or treatment you (or a loved one) are receiving in a nursing home, you can contact one or more of the following:

Agency for Health Care Administration – The Agency licenses and regulates nursing homes in Florida. To file a complaint against a nursing home call the toll-free number (888) 419-3456 or find a complaint form at AHCA.MyFlorida.com/contact/what_happens.shtml.

Disability Rights Florida – To report a health care facility that has not made reasonable accommodations to meet your needs due to a disability or has discriminated against you because of a disability, call the Disability Rights Florida toll-free number (800) 342-0823 or view DisabilityRightsFlorida.org.

Florida Abuse Hotline – To report abuse, neglect, or exploitation call the toll-free number (800) 962-2873 or TDD (800) 914-0004, or view www.myflfamilies.com/service-programs/abuse-hotline.

Long-Term Care Ombudsman Council – To get help with concerns about your stay in a nursing home, with discrimination in a nursing home, or for what might be an inappropriate transfer or discharge, call the toll-free number (888) 831-0404 or view Ombudsman.MyFlorida.com.

Alternatives to Nursing Home Care

The following consumer guides can help you look at alternatives to nursing home care. If nursing home care is not yet needed, or if the nursing home stay will be short-term for rehabilitative care and additional services might be needed after discharge, you might like to read Assisted Living in Florida and Home Health Care in Florida.

Additionally, to determine the level of care that you might need, you can request an assessment from the following: For adults contact the CARES Program and for children contact Children’s Medical Services and/or the Children’s Multidisciplinary Assessment Team mentioned earlier.

Additional Consumer Guides Include:

Note: This is not designed to offer medical or legal advice. Please talk with your doctor for medical advice and an attorney for legal advice.

Information is current as of August 2012.

This may be copied for public use. Please credit the Agency for Health Care Administration for its creation. If you have comments or suggestions, call (850) 412-3730.