Ten Points to Consider When Selecting a Skilled Nursing Facility

By Christine J. Wilson, Esq. and Ruth Phelps, CELA

Our clients come to us for assistance with their estate planning, asset preservation and other questions in anticipation of long term care. What do we tell these family members who ask our advice on choosing where their loved ones will receive long term care?

In selecting a Skilled Nursing Facility (SNF) you are deciding how someone you love will live for the next few years. In our experience, the following points are important, if not crucial, to consider when selecting a SNF.

  1. Approach a prospective nursing facility with a positive attitude. Despite the horror stories that provide fodder for the evening news, most people who work in nursing facilities are professionals and proud of the work that they do. Of course, some facilities are better than others and that is why you are evaluating more than one.
  2. Do not confuse SNF care with assisted living. Do not be shocked or upset by the fact that you will see some nursing home residents who are very ill, often mentally as well as physically. You are looking for quality of care. If your family member is more alert and needs a quiet room, be sure to discuss this with the person showing you the facility. The residents in assisted living may look healthier but that kind of facility may not be able to provide the level of care and supervision by licensed nurses that is provided by a skilled nursing facility.
  3. Location, Location, Location. As with any place you live, location is crucial. A very important factor in receiving good SNF care is family involvement. Therefore, try first to find a facility that is convenient for family to visit.
  4. Conduct your own inspections. Find the three most convenient facilities and check each one three times as follows:

    First visit: Go in during business hours, tour the facility, meet the Administrator, Director of Nurses (DON) and social worker, read the survey report, and ask questions. If this is a short term admission for physical rehabilitation, talk to the therapy department as well. Find out how long key staff, such as the Administrator and the DON, have been working there. Ask about facility ownership. Find out how each shift is staffed (registered nurses, licensed vocational/practical nurses, certified nursing assistants (CNA), uncertified staff) so that you can compare among facilities. Although there is usually a specific regulatory requirement for nursing hours per day, (i.e., 3.5 hours per day of nursing care per patient) different facilities may allocate this differently between nursing shifts and some may exceed the minimum to a greater extent than others.

    Second visit: Go in during the evening meal and observe interactions between CNAs and residents. Pay particular attention to residents who need encouragement with meals. Are they receiving it? Are the patients dressed appropriately for the time and season?

    Third visit: Go in on the weekend. Talk to family members visiting other residents about their experiences with the facility. Look to see if there are activities. Ask to speak to the nurse in charge on the weekend and find out how long he or she has worked there. Get a general feeling for the place during a busy day shift when the higher level administrative staff people are not there. Are the staff members interacting with residents or talking over residents’ heads to each other?

  5. Will your loved one’s special needs be accommodated? If your family member is a fussy eater, ask about how often the dietician visits and how much flexibility is available with the planned menus. If he or she has Alzheimer’s, find out about any special programs as well as what safeguards are placed to prevent wandering. If your loved one speaks English as a second language, ask if there are any staff members who speak your family member’s primary language.
  6. Do not rely on reputation. A good facility can go downhill quickly and a bad reputation can haunt a facility for a long time even after a complete staffing change.
  7. Do not rely entirely on the survey report. It is merely a subjective snapshot of a particular 3 to 5 day period which focuses more on “paper compliance” than patient care. For example, surveyors look to see that CNAs are a charting whether or not a patient is repositioned every two hours to make a determination as to whether this is really being done. It is just as likely that the care is being provided but not documented as it is that the care is documented and not provided. So, if you see negatives on the survey, ask the administrator and DON about them and see what they say. When one author followed this advice with her best friend who needed to find a place for her father, she chose the facility with the WORST survey report because her own evaluation placed it #1. Her father was there for three years, received good care and his daughter continues to volunteer there even though her father is deceased.
  8. Who will follow your loved one’s care? Find out whether or not a physician who knows your family member will follow him or her to the nursing home. Most will not. Therefore, find out about the physician who will be following the care and contact him or her. If the physician is not receptive to this, find another. Sometimes a good choice is the facility medical director as he or she is often more accessible. However, remember that physicians usually only visit every 30 days and rely heavily on the eyes and ears of the nursing staff.
  9. Be sure to discuss financial issues. Be aware that Medicare or the HMO will pay only for a limited time. Does the facility accept Medicaid (MediCal in California) if long term care is needed? Unless your family member is wealthy enough to easily pay for care or clearly indigent enough to qualify for Medicaid, seek the advise of a competent elder law attorney before you make a costly mistake.
  10. You are not married to the SNF. Remember you can choose a new SNF if things don’t work out. Simply check out other facilities and move your loved one. The only down side is that Medicare/Medicaid will not pay for the cost of the transfer but if this is a long term situation then it is worth the money for medical transport if needed. Remember, many residents who need SNF care are still well enough to travel a short distance in a passenger automobile driven by a family member.

Authors: Christine J. Wilson, RN, JD, Tyler & Wilson, Los Angeles, CA & Ruth Phelps, JD, LLM (Taxation) CELA, Phelps, Schwarz, & Phelps Pasadena, CA. The authors encourage the readers to add to this list and provide it to clients. Reprinted with permission.

Contact us:


We're here to help!