There are numerous research tools on the Internet for "grading" facilities, i.e., http://facilityquality.dhs.state.tx.us. For Nursing Homes, you can also check www.medicare.gov/NHcompare/home.asp. These are useful tools and generally only as valid as the information collected. Your best resource is a combination of all sources, especially on-site visits to the homes. Narrow your choices and revisit three or four times, after hours and on weekends. Utilize the questions each time you visit. You will find your answers may vary from visit to visit. Contemplate on all data collected and go with your best gut feeling.

Other good sources for information are:

• Hospital Discharge Planners
• Physicians who serve seniors
• Geriatric case managers
• Clergy
• Friends and family of residents in assisted living facilities within your area

REMAIN IN CURRENT RESIDENCE

A recent study showed that the majority of seniors (85%) would prefer to remain in their own homes if at all possible. Being in your own home with your own belongings, your own memories, and being near your friends is truly ideal. A healthy, secure, and independent lifestyle is the goal of each senior, but sometimes to reach that goal they need a little help.

One of the ways you can get that extra help is by contracting with a Home Health Care Agency for a "certified nurse aide" or a "homemaker". The difference between the two individuals is that the Home Health Aide is able to do the "hands on" tasks such as dressing, bathing, assisting with walking, and assistance getting in and out of bed. The homemaker could prepare meals, remind you to take your medications, help with errands and shopping, do light housekeeping, but is not to do actual physical care. Both provide companionship and friendly conversation.

You could also privately recruit a certified nurse aide or homemaker through the local newspaper or perhaps find an individual or couple that would trade room and board for doing the activities we have mentioned. No matter how you recruit, you need to make every effort to ensure the individual is an honest, caring individual. Careful, close screening, with as many personal references you can get, is certainly a must.

Now if a health crisis occurs and the individual has been in the hospital and has a "skilled need", i.e., a dressing needs changing, blood pressure must be monitored, or the individual is receiving physical therapy, then the doctor could order Home Health Care under Medicare. While the individual caregiver will take care of the skilled needs, the other needs, such as bathing, dressing, toileting, and skin/hair care, can also be accomplished. However, the visit will only be as long as necessary to complete the assigned tasks and only for as long as there is a "skilled nursing need". Therefore, it is not a long-term solution. If the need is long term, then you may be able to obtain help through the Texas Department of Human Services (TDHS) Community Care for the Aged and Disabled Program. This service is based on "need" and there are certain income and resource criteria that must be met. It is best to talk to TDHS about this program.

Another TDHS program designed to allow one to "Age in Place" is called Community Based Alternative (CBA) Medicaid Program. This program provides at-home and community based services in Medicaid licensed assisted living facilities to the aged 60+ adults in lieu of nursing home placement. This program also has specific income and resource criterion. In 2003, it was an income of no more than $1,656 a month and $2,000 in resources for an individual, $3,313 for a couple with less than $3,000 in resources, plus the medical necessity for skilled care. TDHS should be contacted if you feel this may be an option. They will assign a case manager to first determine eligibility and, if approved for the program, develop an Individual Plan of Care. If you feel you may qualify for CBA Medicaid, contact the caseworker for your county. The phone numbers are:

You might combine the CBA or the nurse aide help with a move to the residence of a family member. The option of moving in with another family member has much in common with remaining in the current residence. You can use the CBA program, Adult Day Care, or the Home Health Care Agency to assist you with meeting identified needs. However, you must factor in the size of the home or apartment, the health needs of the other family member(s), their work schedules, size of their family, their financial commitments, etc., before making this decision.

In summary, the pluses of the aforementioned options are:

• friendly surroundings
• close to neighbors and friends
• enhances personal freedom
• retains dignity
• allows independent lifestyle

If you are generally healthy and only need to be reminded to take medications, then a workweek, daytime solution might be Adult Day Care, which will be covered next.

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ADULT DAY CARE

Licensed Adult Day Care are licensed as Type C facilities. An Adult Day Care Center provides a safe, secure, and stimulating environment for older adults. Many are specially equipped to help individuals who may need assistance with daily living skills, but do not require nursing care.

Individuals at a day care center enjoy being with their peers and may participate in many activities that make the day-out an enjoyable experience. Hours for centers vary, but they usually are open from 7:00 A.M. to 6:00 P.M. each weekday. Some may even offer weekend or overnight stays for respite care. Respite means taking a break from caregiving just to recharge those batteries for a few hours, a day, or longer.

Some Adult Day Care Centers are stand alone licensed facilities. Others may be services offered as part of an Assisted Living or Nursing Facility. All will offer nutritional meals and a wide range of activities like exercise, arts and crafts, field trips, games, shopping trips, etc.

The costs vary depending upon the amenities, number of hours/ days utilized, etc. Some centers may even have a sliding scale of charges depending on the income range of the member. Be sure to check them all out and compare the services with the costs, the training of the staff, and the overall professionalism.

In summary, the pluses of Adult Day Care are:

• enhances emotional and mental being of the members and their caregivers
• helps the member remain self-sufficient
• gives respite to the caregiver.

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ASSISTED LIVING FACILITIES

Assisted Living Facilities are designed to meet the needs of the individuals who require some assistance in their daily lives, such as meal preparation, medication monitoring, laundry, maid service, and help with bathing and dressing. An Assisted Living facility can give you the best of both worlds - the independence you truly want and the support you really need.

Assisted living facilities emphasize independence and choice as vital to their philosophy. They also have rules and procedures designed to protect residents from harm. It is important to match the residents' ability with the extent of choices and opportunities offered by the facility, as well as the limitations it will impose on the resident. Facilities vary with regard to the extent of protection they offer residents and may use negotiated risk agreements when issues of safety and choice arise. Because each facility may define the terms differently, use a different term, or not believe in using such agreements, ask the facility whether it uses any form of negotiated risk agreement. If they do, have the Administrator clearly explain what is meant by the terms that they use and how they use such agreements in practice at the facility.

The services and activities provided or arranged for in assisted living facilities generally include:

• 24-hour supervision;
• Three meals a day in a group dining room;
• Personal care services, (help with eating, bathing, dressing, etc.);
• Social Services;
• Supervision and assistance for persons with Alzheimer's or other dementias and disabilities;
• Medication management, or assistance with self -administration of medication;
• Social and religious activities;
• Exercise and recreational activities;
• Arrangements for transportation;
• Laundry and linen service; and
• Housekeeping and maintenance.

Assisted Living Facilities may be stand-alone facilities, part of a retirement community, or part of a nursing facility. Some may be designed as one room with shared bathrooms (dorm style) or full apartments. Some apartments may be set up with a kitchenette while others may offer full kitchen options. Additionally, they may be residential type settings where an individual has modified a home to accommodate several residents. All Assisted Living Facilities must be licensed if they have 4 or more residents in the facility. What sets an assisted living residence apart from a nursing home is that assisted living does not provide continuous skilled nursing care. The regulations affecting assisted living settings are quite diverse and constantly changing. Basically, most assisted living residences have met local building and fire safety regulations. Some states require special certification or education for key management personnel.

Licensed facilities are designated as "Small" (up to 16 residents) and "Large" (17 + residents), Type A or Type B. There is also a Type C, which are licensed as adult foster day care facilities.

In a Type A facility:

• The resident must be physically and mentally capable of evacuating the facility unassisted in the event of an emergency. This may include the mobile nonambulatory, i.e., persons in wheelchairs or electric carts having the capacity to transfer and evacuate themselves in an emergency.
• The resident does not require routine attendance during nighttime sleeping hours.
• The resident must be capable of following directions under emergency conditions.
• The night shift staff in a small facility must be immediately available. In a large facility, the staff must be immediately available and awake.

In a Type B facility:

• The resident may require staff assistance to evacuate.
• The resident may be incapable of following directions under emergency conditions.
• The resident may require attendance during nighttime sleeping hours.
• The resident may not be permanently bedfast, but may require assistance in transferring to and from a wheelchair.
• The night shift staff must be immediately available and awake.

Assisted Living Facilities that have a Certified Alzheimer Unit attached would be licensed as a Type B. There are some Assisted Living Facilities that have "Memory Units", which are not Certified Alzheimer Units, but are under the general licensure.

Certified Alzheimer Facilities

• Licensed Type B
• Special Disclosure Statement
• Activity plan must address cognitive, recreational, and ADLs - specifically
• Person designated to plan activities (less than 17 beds)
• Must employ activity director 20 hours weekly (17+ beds)
• All staff must receive 4 hours of dementia-specific orientation prior to assuming any job responsibilities
• Direct care staff must receive 16 hours of on-the-job supervision and training within the first 16 hours of employment
• Direct care staff must annually complete 12 hours of in-service education regarding Alzheimer disease

Type C - Adult Foster Care (AFC) provides 24-hour living arrangement with supervision for persons who, because of physical, mental, or emotional limitations, are unable to continue independent functioning in their own homes. Providers of AFC homes must live in the household and share a common living area with the clients. Services may include minimal help with personal care, activities of daily living, and provision of, or arrangement for, transportation.

Type E - Residents require only medication supervision and general supervision of safety and welfare. Facility may not provide substantial assistance with activities of daily living. Residents must be physically and mentally capable of evacuating the facility unassisted, must not require routine attendance during nighttime sleeping hours, and must be capable of following directions under emergency conditions.

An unlicensed facility of less than four residents, referred to as a Personal Care Home, can be a very fine facility and should be included in your sampling. There is nothing inherently wrong if a facility does not want to be licensed. There are fees, some modification costs, and some governmental oversight involved with being licensed that some owners just may not want to be involved with. These smaller facilities are generally modified residences. Some will be on quiet residential streets, while others may be in the country with a "farm like" atmosphere.

Once again, you will need to spend some time "shopping around". You will want to be sure that the care is good, the facility is safe, and that your needs can be fully met. The homelike setting may offer more privacy, space and dignity than other options.

The pluses of an Assisted Living Facility is the fact that someone is always on duty to provide for the security of the residents. Further, the staff ensures medication is taken at the right time in the right dosage. It a health crisis develops, the facility will follow the same procedures as one would in their own home, i.e., 911 will be called and the resident taken to the hospital. However , those facilities that are part of a Nursing Facility will have more caregivers; available for an emergency due to physical proximity.

Costs for Assisted Living Facilities vary based upon the amenities that are provided. In fact, it may be even more expensive than a Nursing Facility. Be sure to understand what the charges include or do not include. For example, some facilities include medication administration in their rates, and some charge additional fees for this service. Some contracts discuss level of care and others mention additional costs. Review carefully how these are defined, or which services are provided at each level, who determines which level or additional services the resident will receive, when a resident will need to change levels, who is consulted when a change is necessary, and whether the resident can appeal a decision regarding a level change. If a resident slips and falls once, does this constitute a "fall hazard" increasing the level of care costs? Does the contract state whether assistance is available around the clock or only during specified hours? Read the contract closely to be sure everything is clear to you. The contract is a legal, binding document not to be taken lightly. Take it home and read it carefully before signing. Ask for clarification on anything you do not understand. Take it to an attorney specializing in Elder Law for review.

Under what conditions may a contract be terminated? Under what conditions are deposits refunded if a resident chooses to leave the facility? Is there an appeal process? Some facilities state that they allow residents to "age in place". What does this entail? How does the facility assist a resident being discharged?

There are four basic ways which assisted living costs can be financed.

 

Personal Resources:

Generally, the cost of room and board plus personal care is paid for out of personal resources. On average, assisted living in costs $1,807 monthly for basic room and board. There may be additional charges based upon amenities and services. Some facilities require entrance fees or deposits. Ask if the fees are refundable and under what circumstances you would be entitled to a refund.

 

Private Insurance:

Long-term care insurance is on the rise with more insurance companies offering insurance plans to cover assisted living/residential care. The details of coverage depend on the insurance policy. Some pay only for nursing home care and do not cover assisted living care. It is a good idea to have an Elder Law Attorney look over any policies before you sign them..

 

Medicaid:

Medicaid is funded by both state and federal sources and is health insurance for eligible low-income individuals. Medicaid may pay for some services or room and board. The assisted living residence must be licensed by the state. Refer to the County/telephone chart under "Remain in Current Residence" to contact an intake person for CBA (Medicaid) payment.

 

Medicare:

Medicare (Part A) will not pay for assisted living room and board. Medicare may cover certain health services provided within the assisted living setting, such as physical or occupational therapy, in specific circumstances.

The first step in your search for an assisted living facility would be to call all the facilities you may be interested in and ask specific, but general questions such as:

• Do they have a vacancy?
• Are there any restrictions on the type of resident they admit?
• What is provided for in the basic daily rate?
• What services cost extra?
• Are residents required to purchase renter's insurance for their individual units?
• Is there a deposit required? Is it refundable?
• What happens when funds are depleted and full payment can no longer be made?
• How much training does direct care staff receive?
• How do you provide for on-going training?

Checklist for Choosing an Assisted Living or Continuing Care Facility

The following checklist is reprinted from The American Bar Association Legal Guide for Older Americans by Charles P. Sabatino, et al., Times Books, © 1998 by the American Bar Association and is made available with permission, from the www.elderlawanswers.com

These questions will help you to evaluate and compare just about any kind of supportive housing arrangement.

Questions Regarding the Solvency and Expertise of the Provider

1. What is the provider's background and experience? The provider is the person or entity legally and financially responsible for providing the housing. Some facilities advertise that they are "sponsored" by nonprofit groups or churches that in reality have no legal control or financial responsibility. Be wary if such illusory sponsorship is trumpeted.


2. Is the provider financially sound? Ask a professional to review the facility's financial, actuarial, and operating statements. Does it have sufficient financial reserves?


3. Are all levels of care licensed or certified by the state? Check with the state office on aging and with the state licensing agency.


4. How does the facility ensure the quality of its care and services? Is it accredited by any recognized private accrediting organization?

Questions Regarding Fees and Accommodations

5. If there is an entrance fee, how much is it, and can you get a refund of all or part of it? The facility should provide a formula for a pro rata refund, based on the resident's length of stay, regardless of whether the facility or the resident initiates the termination. Some facilities offer fully refundable entrance fees.


6. What is the monthly fee? When and how much can it be increased? What happens if you cannot afford higher fees? Some facilities give residents financial help if they become unable to pay.


7. Do the fees change when the resident's living arrangements or level-of-care needs change?


8. How much say do you have in choosing where you live? How large is the living unit? Can you change or redecorate it?


9. What if your marital status changes? Will your payments change, or will you be asked to move, if you marry, divorce, become widowed or have a friend or family member move into the unit?


10. What if spouses require different levels of care?

Questions Regarding Services and Health Care

11. What services are included in my regular fees? Ask about coverage, limitations (based on cost, time, or number of visits), and special charges for the following matters:

Supportive/Social/Recreational Services

• Meal services: Is the schedule reasonable? Is it flexible?


• Special diets/tray service: e.g., What is the policy on eating in your room?


• Utilities: Are they included in the monthly fee?


• Cable television: Is it available? Who pays?


• Furnishings: Can you bring your own?


• Unit maintenance: Who is responsible for repairs?


• Linens/personal laundry: Is there an extra charge for laundry?


• Housekeeping: Is it included in the fees? What are the options?


• Recreational/cultural activities: What is available? What is on-site?


• Transportation: To where? Is there a limit on the number of trips?


• Safety: What kind of security systems and policies are in place? Is there a fire emergency plan?

Health and personal care

• Assessment and plan of care: What kind of assessment is done to determine your needs and a plan for meeting those needs? What are the qualifications of the person doing the assessment? Is a detailed plan of care developed? When and how is it reviewed?


• Physician services: Can you choose your own doctor?


• Medications: Who gives medications? How is it coordinated with your physician?


• Nursing care facility services: Are they on-site? Who pays?


• Nursing services outside a nursing unit: Is assistance with medications provided?


• Private duty nursing: Is it available? Are there limits"


• Dental and eye care: Is it included in fees? Available on-site?


• Personal care services: What if you need assistance with eating, dressing, bathing, toileting, etc.?


• Homemaker/companion services: Are they available? Is there a limit?


• Drugs, medication and medical equipment/supplies: Who pays?


• Emergency call system: Is it available? Who pays?

12. Are additional services always guaranteed? If the facility provides a nursing unit, what happens if a bed is not available when you need it?


13. Can services be changed? To what extent does the facility have the right to cut back, change, or eliminate services, or change fees?


14. What about preexisting conditions? Does the facility limit its responsibility for certain health conditions or preexisting conditions? Can the facility ask you to move if you become too sick or impaired to be cared for by the facility?


15. Who pays for health care? Can you receive Medicare and Medicaid coverage in the facility? Does the facility require residents to buy private insurance or participate in a special group insurance program for residents?


16. Who decides that you need more care, and on what grounds? What are the criteria and procedures for determining when a resident needs to be transferred from independent living to assisted living, or to a nursing care unit, or to an entirely different facility? Who is involved in these decisions?


17. What are the staffing levels? What are the professional qualifications of the staff? Nursing homes are regulated, but assisted living and other supervised care may not be. Make sure that staff is professionally equipped to do their jobs. What kind of emergencies are staff expected to handle and how are they trained for them?

Questions Regarding the Rights of Residents

18. Can residents participate in facility management and decision making? What input do you have in activity and meal planning and in house rules? Is there a resident council? How are complaints and disputes handled?


19. What if you want an exception to a policy or to routine scheduling?


20. What are the grounds for eviction? Is there a right to appeal?


21. Are the general operating rules reasonable? What rules cover the facility's day-to-day operation? Are they reasonable? What happens if you break a rule? Can you appeal?


22. What happens if you are injured? Does the contract release the facility from liability for injury resulting from negligence? Avoid such waivers.

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Now you are ready to visit the selected facilities.

Evaluate each facility and decide which facility you want to visit. Call the Administrator or Admissions Coordinator to schedule an appointment for a tour. Visiting the residence is essential to gathering information. It will give you the opportunity to meet with administration, chat with other residents, view the condition of the residence, watch the staff in action, and feel the atmosphere. If you are seeking placement for a loved one, as much as possible, involve that person in the decision making process. They may not be happy in the placement if they are not allowed a choice.

Ask questions that are most important to your specific needs. Ask for a copy of the contract. If you are visiting with a family member, does staff speak only to them or do they direct questions and comments to you, the client? While visiting, it is important to remember that the most important consideration is your specific situation. It is important to properly assess your needs as they are now and ask how the facility might accommodate any changes over time. Under what condition are individual's asked to move if there is a change in health status? If you hope to preclude having to move again, take into consideration future care needs, i.e., incontinence, mental health, supervision, or dementia. Do not hesitate to ask questions. Each resident has different needs, preferences, and desires that should be taken into account in choosing an appropriate residence. Although the value you place on any question is up to you, remember that you cannot change the resident to fit the facility, and definitely not the facility to fit the individual. Select the facility that best meets your needs and those of your family. Visits are important! Is the facility convenient for frequent visits by family and friends?

It is imperative to examine your finances and ask about costs. What happens if you exhaust your finances? Monthly rate and fee structures vary. Is there a security deposit? What is the refund policy? How are service agreements and/or contracts amended or modified? Because contracts often do not spell out in detail the scope of services provided, it is important to know which are covered and which require extra payment, i.e., cable and telephone. Does housekeeping include only light dusting and vacuuming? Does this include the bathroom, floors, windows, and emptying of the trash, or do these cost extra? How frequent is the cleaning? Are towels and bed linens provided? Are linens just laundered or are they removed and beds re-made? How often is laundry done? Is personal laundry included, or can you have access to the washer/dryer? What measures are in place to prevent lost laundry?

Can you access your physician of choice? How are medical emergencies handled? If you temporarily need hospital or nursing home care, is the assisted living room held? What are the associated fees? Is there a discount for unused services, i.e., medication management or meals, while you are away? If private health care insurance is used, can you obtain prescription medications on a three-month basis through mail order? Ask for a copy of the resident agreement outlining, at a minimum, services, prices, extra charges, admission/discharge criteria, staffing, and facility rules.

What are the complaint/grievance procedures? Who is the primary contact person and what is their phone number?

There are several mandated postings, i.e., the Residents' Bill of Rights, the Provider Bill of Rights, information on the Ombudsman Program, the current staffing pattern (now is a good time to ask about the current resident population), and the latest Survey report. This is a good time to review the Survey and ask what course of action was taken to correct the deficiencies. Keep in mind that viewing a facility through a surveyor's eyes is limited only to the regulations that a facility must meet. These regulations are, at best, minimal requirements for licensure. If you are looking at an assisted living facility connected to a nursing home, ask to see the inspection report (Survey) for the nursing home. It may shed light on how the organization is administered. Do you feel comfortable with the response given for the Survey deficiencies? Does the Administrator seem sincere with the response? Keep in mind that this is the person you will deal with for any concerns you may have in the future. Is this a workable relationship? How long has this Administrator been at this facility? In the long-term care setting? Does the Administrator belong to professional associations? Which ones and how are they related to the care of residents?

What is the emergency evacuation plan, and is it among the postings? How, and how often, are drills managed? Does the facility provide ample security? Do windows have security locks? Are exit doors alarmed or monitored?

Each facility will have a unique operational and admission policy. Each operational and admission policy must contain certain elements:

• Type of residents accepted
• Services provided
• Refund policy
• Responsibilities of facility and residents
• Other rules and regulations

These operational policies must be furnished to residents and/or the residents' responsible party at the time of admission. If families feel the need to have their own copies, ask the facility to provide an extra set. These should remain with the resident for reference.

The facility's admission policy must include the requirement that each resident have a health examination by a physician performed within 30 days prior to admission or within 14 days after admission.

Prior to admittance into an assisted living facility, a service agreement is developed to coordinate the delivery of services to each resident. The agreement, which includes an assessment or evaluation of the resident's physical and psychological needs, is reviewed and updated regularly by the staff, and as the resident's condition indicates. Ask the facility how resident and family members are notified of assessments and who is involved, i.e., a doctor, a nurse, and staff members. More information about the Care Plan can be found under Nursing Facilities - Questions to Consider About the Care Plan. The resident, family, or responsible party should play an active role in the development of the service agreement, and should be provided a copy of each agreement. What procedure should be taken if the resident or family disagrees with the facility's plan of care?

The facility will assist in arranging the appropriate medical, health, and dental care services for each resident. The physician of your choice generally provides for the health care of each resident. Residents who experience periods of incapacity due to illness, injury, or recuperation from surgery can remain in the facility, or be readmitted from a hospital if appropriate services can be provided by the facility.

By now you have a feel for the management of the facility and can perhaps narrow your selection to 2 or 3. This is the time to visit the facilities again after normal business hours and/or the weekend. Compare the tour guides comments with what you actually see, hear and feel. Do you like the outward appearance? Is the décor attractive and homelike? Did you receive a warm greeting from staff? Do residents appear happy and comfortable? How do residents feel about their home/staff? Is staff appropriately dressed? Does staff treat each other professionally?

Medication assistance should be provided by a skilled staff member. Is self-administration of medications allowed? What procedures are followed to ensure the resident is taking medication appropriately? Health and minor nursing services should be available. Whose role is it to note changes in a residents' condition and report them to a doctor and/or family member? How are staff trained and supervised? If the resident requires around-the-clock medication, is this available? To what extent will the facility monitor the residents' health? Is there a Registered Nurse on staff? What hours does the RN work? Who is responsible when the RN is not available? What safeguards are in place to ensure the resident gets the appropriate medications on time and in the correct dosage? If the resident refuses the medication, how is this handled? Is another attempt made to offer the medication? Is the residents' doctor or family notified? Does the facility use a pharmacy that provides delivery, consultation, and review of medication? Do I have to use the facility pharmacy? Are residents closely monitored when new medications are added, or when old medications are removed?

Transportation - Contracts generally state transportation is available. Sometimes this is an added cost. How far in advance must a resident schedule for transportation and with whom? Is transportation available at anytime, evenings and weekends, and to what destinations? Is transportation available if the resident wants to go to an event alone or with another resident? Is there a staff member available to coordinate or assist with transportation for doctor visits, therapists, or other health care professionals? Is the vehicle equipped to accommodate residents with varying degrees of physical mobility? Can a resident have their personal vehicle and is there a parking fee? Is the facility convenient to public transportation? Will the facility assist in obtaining other transportation services?

Dining Service - Review a copy of the menu, which should be posted near the dining room. Does it look appealing? How often do menus rotate? Are residents involved in menu planning? Are residents allowed to invite guests for meals? Is there a separate guest dining room available for family parties or family gatherings? Is the meal being served consistent with what is on the menu for that day? Does the food smell and look appetizing? Is the wait staff sufficient for the residents being served? Does the wait staff appear friendly or rushed? Are residents socializing or do they appear impatient?

The facility should provide 3 nutritious meals daily. Most will encourage residents to eat in the dining room for socialization. What is the normal waiting time for the meal to be served? Are beverages or an appetizer being offered while waiting for the entrée? If the resident is ill, what is the procedure for getting a meal tray delivered to the room? Is there an additional charge? Is it possible to get a meal at any time during the day? What happens if the resident is late, misses a meal, or refuses a meal? Is the answer different if the resident is confused? If the resident does not care for a food item, what is the procedure, or can the resident get something else? Are dietary preferences honored? Are there diabetic or no salt/low fat diets available? Are nutritious between meal and bedtime snacks offered or available? Does a nutritionist or dietician review meals? How often?

Living Space - Do community areas appear to be adequate for the number of residents? Are the open areas clean, neat, and temperature comfortable? How is the temperature controlled? Do all areas have good natural and artificial lighting? What is the overall atmosphere? Are there any obvious safety hazards, such as throw rugs or dark hallways? Is the furniture attractive, comfortable and safe? What is the policy for overnight guests? Are guestrooms available and at what cost? Does the residence meet the rules for people with disabilities? Are patios/courtyards inviting and furnishings in good repair? Are pets allowed to reside in the residents' room? What are the additional fees/costs/deposits? If so, how many pets, and what kind, are currently in the facility? Who is responsible for the care of pets? If not, are pets allowed to visit? What is the smoking policy?

Personal Quarters - Are all rooms private or does the facility have some share rooms? If sharing a room, does the resident have a choice of roommates? Are the living quarters comfortable, clean and have a window to the outside? Are residents allowed to lock the doors to their rooms? Who has passkeys? What safety measures are in place to keep personal property from being stolen or lost? Are phones available in every room or is there a private telephone available to residents and accessible by wheelchair? How does the resident call for assistance at night? How does the staff help the resident maintain their abilities to care for themselves, especially in regard to toileting, dressing, and eating? What if the resident does not like the staff person assigned to them?

Do the bathrooms have solid grab bars at toilets and bathing areas? Do the bathing areas have non-slip surfaces? How many residents share the same bathroom? How is cross-contamination avoided? How does the facility tailor the schedule for bathing and dressing to accommodate the preferences of the resident? How are incontinence needs handled? Are there call lights in each room and bathroom? How often are they checked to be sure they are working properly?

Activities - Observe staff and resident interaction. Are they positive? Courteous? Are residents addressed by name? Does it appear that resident requests are being handled timely? Does the Administrator practice an "open door" policy? Do residents appear to be "involved" or merely sitting around with nothing to do? Does there appear to be adequate staff for the needs of the residents? Is it sufficient to assist with bathing, dressing, mobility, feeding, shopping, laundry, etc.? Are residents clean and dressed appropriately for the climate? Do the residents appear well cared for and content? Does the direct care staff speak the residents' native language clearly? What is the staff turnover rate? Keep in mind the posted staffing pattern and the total number of residents in the facility, which was discussed with the tour guide.

What kinds of group/individual recreational activities are offered? Is there an appropriate area provided for activities? Are there supplies for social activities or hobbies? Is there involvement with community events? Are residents active in planning events and activities? Are the activities posted actually being initiated? Who is responsible for developing activities? What training does this person receive? What religious/spiritual activity is offered? Can the resident walk on the grounds? Are there protected walking areas for residents with dementia?

Resident Council - Each facility is required to have a Resident Council. This enables residents to have some choice in their daily lives. When does the council meet? How does the facility encourage residents to become actively involved? Volunteer activities are sometimes encouraged through the council. If not, the facility may have a volunteer program. If so, find out what types of activities are offered, i.e., computer training for residents, gardening, raising and lowering the flag, etc.

Family Council - Is there an active Family Council? If not, what is the Administrator's feeling for Family Councils? All families should become involved in some way.

If you have more questions than answers after the subsequent visits, call the Administrator for a second appointment to ask the questions. How does the Administrator deal with your questions?

After you have narrowed your choice, arrange to stay overnight or a weekend in the first choice facility. There is no better way of determining the likelihood of your future satisfaction. Choose the facility that comes closest to your needs, remembering that nothing is perfect.

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