On your first tour, they’ll want to show you their renovated patient bedrooms and their glitzy activities calendars. They will want you to see the art room and hear about the visiting music therapist. They’ll make sure you notice the flower bedecked reception area and the nicely appointed dining room. They might even cite the amount of training their aides receive. Of course, all these things are positives, but administrators of senior living communities may not encourage you to examine the nuts and bolts.

To make a true assessment of the standard of care a facility provides and the residents’ “joy” levels (yes, that’s what I said: JOY), you need to take some time out of your busy schedule as a caregiver and put in the work to investigate. You also need to use a more evidence-based method of assessing the quality of board and care your loved one will receive in a home that may cost anywhere from $4,000 to $12,000 each month.

When you take a tour of a prospective assisted living facility, memory care unit or nursing home, your guide is likely to direct your attention to superficialities or things that are no longer relevant to your family member. This is especially true for a loved one who has declined physically or cognitively. (Smart TVs, anyone?)

So, what do you look for specifically to judge the quality of the facility? Below is a list of features that are essential for your family member’s happiness and physical wellbeing. Look for them. These are the minimum, no-frills tests that a prospective long-term care home should be able to pass.

Deal Breakers for Assessing Senior Living Care Quality

  1. The Wheelchair Test: Even if your loved one is still ambulatory, when you visit a home, take a good look at the footrests and frames of all the wheelchairs you see. Are they clean? If not, other unseen areas may be neglected and unsanitary. Are there footrests attached to the wheelchairs? Sometimes a resident can benefit from “paddling” along with their feet as they move because it helps strengthen ankle and leg muscles. But, if you see residents being wheeled around uncomfortably without footrests, this may signal minimal attention to detail from aides and inadequate monitoring by nursing supervisors.
  2. The Bathroom Linen Test: Are there clean washcloths and towels in the bathrooms? Towel shortages are a perennial problem in care homes. If you ask your guide or the management about this, they will probably tell you that they have plenty on the premises, but the residents hide them. This is sometimes the case, especially in settings for patients with cognitive issues. But sometimes the real problem is that there aren’t enough towels to go around, or that there are not enough laundry workers to ensure clean towels are always available.
    Every medical authority tells us that proper hand-washing with warm water is the best barrier to the spread of infection in care homes and hospitals. How can patients, staff and visitors comply with this mandate if clean bathroom linens aren’t available? Ask to visit a few residents’ rooms to see if they have adequate linens. If the tour guide discourages you from seeing occupied rooms due to “privacy rights,” strike up a friendly conversation with a resident and ask if you can take a peek in his/her room. This will nearly always gain you access.
  3. The Warm Water Test: As mentioned, medical authorities mandate hand-washing with warm water for infection control. Certified Nursing Assistants (CNAs) like myself are expected to wash their hands with soap and warm water frequently throughout the day. We are also expected to wash residents’ hands whenever necessary.
    When you visit a patient’s private bathroom, check out the sinks. Do the warm-water controls actually function? How long does it take to get hot water? If you are unable to enter a resident’s room, try the same tests on bathrooms in the common areas or wherever you can find a sink that should have hot running water. The water may warm up after a few minutes, but when an aide has only five or 10 minutes to get a resident washed and dressed in the morning, they might not have an extra two minutes to spare. Your family member might get a cold face cloth first thing in the morning. Not only is it unpleasant, but it also means that a basic infection control measure, warm water, is MIA.
  4. The Bathroom Temperature Test: Visit the bathrooms and/or shower room. Is it warm enough? Older residents get cold easily and usually are more comfortable in warmer rooms when bathing. When they leave the bath or shower, they shouldn’t shiver and shudder.
  5. The Call-Button Test: On your tour, do you hear annoying call bells or even verbal requests that go unanswered? How long does it take an aide to attend to the person calling for assistance? If these things distract from the tour or annoy you, imagine how they affect someone who feels anxious and may be confused.
  6. The Chair-Alarm Test: Look carefully at the residents’ beds, wheelchairs and other seating to see if there are chair alarms on them. Virtually every group with an interest in improving the lives of residents in long-term care settings, including the Centers for Medicare and Medicaid Services (CMS), recommend eliminating the use of bed and chair alarms. Supervisors will likely tell you that these measures keep residents safe, but evidence suggests that they actually lead to less attentive care from staff and more falls. (Google it!)
  7. The Noise Test: Alarms aren’t the only things that can distress residents. If aides routinely shout down the hall to each other, or music or televisions are allowed at higher volumes, this can be upsetting and contribute to anxiety and confusion.
  8. The Dining Room Test: The best way to get a feel for the meals that your loved one will be enjoying in their new home is to eat a few there yourself. How is the noise level in the dining area? Is hot food served deliciously warm as intended? Are residents offered condiments (salt, pepper, sugar, mustard, ketchup, etc.) that they would have used at home? Are the aides attentive to residents, or do they converse mostly amongst themselves during mealtimes as if they are extra breaks? For those who can no longer use a knife, is the food served in bite-sized portions or as finger foods that the person can comfortably chew? Are residents offered refills of drinks? Getting an aging loved one to eat enough and stay hydrated can be a struggle both at home and in a senior living environment. You want to see staff encouraging and enabling residents to eat and drink.
  9. The Calendar Test: From independent living to high-level nursing home care, every senior living setting creates a monthly calendar of activities and social events that is then posted prominently throughout the facility. Pay attention to the type of activities offered, how often the calendar matches what is happening in real time, and whether residents seem engaged while attending these sessions. Pay special attention to activities that you know your loved one would enjoy. How frequently are these sessions held each month? Are these classes appropriate for your loved one’s physical and/or mental capabilities, or can they be adapted?
  10. The Family Council Test: In elder care homes, a family council is one of the best ways we have of monitoring the care provided and advocating for changes or improvements for our loved ones. Many facilities do have resident councils, but frail elderly residents, especially those with dementia, can have trouble remembering their rights and expressing their needs, preferences and criticisms. They often rely on us, their family and friends, to be their eyes, ears and mouths. Once they needed you as a hands-on caregiver, and you did that lovingly. Now they need you to be their advocate. So, ask whether the home has a family council. It will make ensuring your loved one is well cared for much easier.
  11. The Staff-to-Resident Ratio Test: You want your family member to get the level of attention and care they need. That is why a family makes the difficult decision to place a loved one in the first place. If you ask the supervisor about staffing levels, you’ll probably hear something like, “We meet all the state’s requirements for the number of staff on each shift.” And they probably do. The issue isn’t that the home isn’t staffed according to state standards. It’s that the current standards do not meet today’s needs.
    Our expectations for care are higher today and residents’ needs are also greater. Many have cognitive as well as physical disabilities. In some homes, there is one aide assigned for every eight or 10 residents (sometimes more, depending on the state). If an aide calls out sick or has a family emergency at the last minute, the ratio could be instantly much worse and therefore the quality of care residents receive suffers.
    Although you may not find an ideal staff-to-resident ratio anywhere, at least ask whether census (the number of residents) or acuity (the level of care these residents require) determines the staffing levels. Ask how the facility assesses resident acuity, and, if applicable, whether dementia symptoms are factored into these assessments.
  12. The Supervisor Test: Who is responsible for monitoring care standards of the unit your family member will live in? Where is that person’s office located? It is within the unit or in some distant corner of the home? An effective manager will go out of their way to interact with their employees, residents and visitors. They will spend time close to the “action” so that they are knowledgeable about their employees’ duties and performance, the residents’ wellbeing and how their area of the home functions. This allows them to be proactive and informed when it comes to making changes and handling complaints. Ask to see the supervisor’s job description to get an idea of what their responsibilities are. After all, you’re paying their salary!
  13. The Aide-Engagement Test: Last, but certainly not least, do the aides smile and make eye contact when they engage with residents? Do they seem to know and respect the residents’ schedules, needs and preferences? When a resident calls out for something, like a snack, an answer to a question or a simple greeting, how do the aides respond? This may be the most important quality marker to look for on a visit.
    To get a truer picture of aide engagement, you’ll need to visit several times to observe different staff members on each shift. This includes visits on weekends and at different times of the day or evening, such as midmorning, during mealtimes and even after supper. Try to visit during a change of shift, too. Are the aides still available to pay attention to residents during shift changes?

When you’re evaluating long-term care providers, don’t be overly swayed by the charm and marketing initiatives of the administrative staff. Instead, use this checklist to observe the conditions your family member may live with day in and day out. There is more work and attention to detail involved in assessing and achieving excellence of care, but these concrete items can clue you in to the subtler indicators of a quality community. If those in charge aren’t getting even these basics right, are they really committed to the loftier goals they claim to have?