In Choosing Care Home for Elderly, Good Senses Count

Muriel Greensaft has been in hundreds of residential homes for the elderly and knows they can run the gamut.

She recalled visiting one board-and-care home in a well-kept neighborhood of Mission Viejo, with a manicured front yard and a beautiful view of the mountains.

“And it was just as immaculate when you walked in,” said Greensaft, formerly the head of an ombudsman service overseeing care of the elderly. “There were no odors. It was furnished beautifully, and everyone was well dressed.” The residents were busy, not just “slumped over, watching TV.” At lunchtime, the table was set nicely, and the food was appetizing, she said.

Not far away, she recalled, was another home, also in an upscale Mission Viejo neighborhood. “But the front yard was run-down, and weeds were growing everywhere,” she said. Inside, a staff member wore a uniform “stained with everything.”

Relatives Can Help

The house was nearly bare of furniture, and curtains were hanging by a thread. The kitchen was filthy, and the refrigerator was nearly empty, she said.

“This place was a disaster, and you could see it the moment you drove up,” said Greensaft, who now works for a developer of senior citizen housing. “As a general rule, if the home is neglected, the people probably are, too.”

In the past few years, state agencies have stepped up investigations into allegations of abuse and neglect at board-and-care and nursing homes. The state Department of Social Services is holding hearings into alleged violations at two El Toro board-and-care homes, Love Haven I and II, which the state closed April 6. The owners have denied charges of abuse and neglect.

Despite their increased efforts, however, experts say it is unlikely that the watchdog agencies will ever be able to completely overcome abuses in board-and-care and nursing homes. But they add that there is much the public can do to ensure that the elderly receive good care, simply by checking out the homes thoroughly before placing relatives.

Keep Eyes, Ears Open

Inspection records of the facilities are open to the public and can reveal whether there have been complaints or citations for infractions, they said. But as important as checking out the paper work is checking out the home with open eyes and an unplugged nose.

“One of the things that tells you a lot is the smell,” said Jacqueline A. Lincer, district administrator for the Orange County office of the state Department of Health Services’ licensing and certification division, which oversees nursing homes. “You need to go take a tour and rely on your senses--what you see, hear and smell.”

“People should go and look at the physical structure, the sanitation, the menus that are posted,” said Fred Dumont, district manager of the Department of Social Services, which keeps tabs on board-and-care homes. “Do they have an activities program? Sometimes there’s one written on the wall, but often it’s just TV all day long. There should be a program to keep them active.”

One of the first things a person must do before placing an elderly patient in a home is determine what level of care is needed, authorities said. There is much confusion about the different types of facilities, which often get lumped together in the public’s minds as convalescent homes, convalescent hospitals or nursing homes.

A nursing home is a facility that offers just that--nursing. The homes are for patients with chronic conditions who must be monitored and have their medications administered, but who are not sick enough to need the services of a hospital.

Nursing homes, which are licensed and inspected by the state Department of Health Services, come in two types: the intermediate care facility, which offers eight hours of nursing a day, and the skilled nursing facility, which provides around-the-clock nursing care. There is one intermediate care facility in Orange County, and there are about 60 skilled nursing facilities, but many of the skilled nursing homes have wings set aside for intermediate care, Lincer said.

Board-and-care homes--also known as residential homes or community care facilities--are designed for people who need assistance in such daily activities as dressing, getting out of bed, eating and getting to and from the doctor’s office but who do not need constant medical monitoring. There are 326 licensed board-and-care homes in the county, which provide about 7,300 beds, Dumont said.

Role of Care Providers

The “care providers” at residential homes can store medicines and help the residents take their pills; they even can steady a diabetic’s hand for an insulin shot. But they cannot administer any injections. Any patient who requires ongoing medical attention should be in a nursing home, Dumont said. For example, board-and-care home operators cannot care for people with bedsores, he said.

When looking for a facility for an elderly relative, Greensaft said, one of the best places to start is with the patient’s doctor or hospital. Another source is the Long Term Care Ombudsman Service in Santa Ana, of which Greensaft is former director. The service, operated by the Orange County Council on Aging, acts as an independent patients’ rights advocate, makes regular unannounced visits to nursing and residential homes, investigates complaints and acts as a mediator in disagreements between home operators and patients.

For patients needing room and board, or nursing care because of Alzheimer’s disease, Greensaft recommended that relatives call the Alzheimer’s Disease Assn. of Orange County, which has information about facilities and day care especially for people suffering from the disease.

After learning the names of several facilities, do some research on them, the experts said. Call the appropriate state agency or the ombudsman service and check the public records, they advised. The records will show if there have been complaints and what the follow-up investigations revealed. They also will show when the last yearly licensing inspection occurred and where any citations were issued or disciplinary actions taken, Lincer said.

Then, the experts suggested, visit several homes.

Compliance Urged

“I would look at least three or four nursing homes. For board-and-care (homes), I would look at even more,” Greensaft said, explaining that nursing homes must comply with more state rules and are more strictly regulated.

“You just use all your senses, but mostly smell. Check to see if there are any odors,” Greensaft said. “An odor will tell you if the patients are being changed,” if they are lying in soiled bedclothes, she said. “You can tell the ones with no odors, and that’s a good indication that patients are being changed, and the staff is taking care of them.”

Greensaft cautioned, however, against jumping to any conclusions on an early-morning visit. Many patients soil their linens overnight, and the morning crew may have its hands full, changing beds and picking up the dirty laundry, she said.

Lincer recommended visiting in the late afternoon, around the dinner hour, to check on the food that is being served and to see how well patients are assisted in feeding. Some patients also will be getting bathed and ready for bed and will be having medications administered, she said. It can be one of the most hectic times at the nursing home, Lincer said, and the observer will be able to tell how well the staff can handle its most demanding duties.

In addition, listen to how staff members talk to the patients, said Joan Dowling, regional administrator for the state Department of Health Services. “If you’re just walking down a hallway and listening, you’ll hear how the staff speaks to the patients in their rooms, whether they’re courteous or curt.”

Greensaft recommended looking at how the patients are dressed. If they are wearing soiled clothes and are not well-groomed, it’s the staff’s doing, she said. “Grooming is important; it indicates caring,” she added.

Visits Needed

It also is important, the experts said, that a patient not be abandoned once he or she is placed in a residential or nursing home. Not only do the patients need visits by friends and relatives for their own mental happiness, but they’ll probably get better care from the staff if visitors are often around, they said.

“They (the staff) know when there is someone there to advocate for the patient,” Lincer said. Added Greensaft: “If people know there’s someone there who cares, they’ll make more effort.” The ombudsman service, she said, sends volunteers to homes just to visit with patients because “some people have nobody. They (the elderly) suffer tremendous losses. They may have lost their husband or wife, and maybe they have no children. Maybe they’ve lost their friends. So many are alone, and they welcome any volunteer’s visit.”

Also, if they find deficiencies, the visiting friends and relatives can lodge complaints, something the patients themselves may be too frail or confused to do.

The most common complaint, said overseers of nursing and residential homes, is about food. It may be that the food is fine, only that individual tastes vary, said Betty Mannes, field services coordinator for the ombudsman service. “But it (mealtime) is an important event of the day, when you’re in one of these facilities.”

Abuse complaints are relatively rare, said Lincer and Dumont, but they are vigorously investigated. More common, Greensaft said, is neglect.

The state Department of Health Services, following federal guidelines for the Medicare program, began stepped-up enforcement of nursing home regulations about two years ago, shifting away from inspections of the homes’ paper work and focusing instead on personal visits and interviews with patients, Lincer said. As a result, more homes have been cited, and more homes are improving their care, she said.

Inadequate Nursing Cited

Last year, 13 nursing homes in Orange County were warned that they would lose their certification to receive Medicare funding unless they made improvements, she said. The most common complaint, she said, was an inadequate nursing staff. Ten complied, but three temporarily lost their certificates until they improved their services, she said. All three were later recertified.

In addition, she said, the health department is empowered to issue three grades of citations that carry hefty fines--up to $25,000 for the most serious violations--for inadequate care that jeopardizes patients’ lives or well-being.

The state social services department likewise can impose fines if deficiencies are not corrected. In the event of more serious infractions, the department can attempt to suspend or revoke licenses. In the past year, the agency suspended or revoked licenses of about a dozen homes, district manager Dumont said.

Mannes, of the ombudsman service, gives good marks, overall, to the county’s nursing and board-and-care homes. “The people in the field are very caring overall, and they’re all trying very hard,” she said.

Lincer is a bit more cautious. “I would like to think they’re getting better,” she said of nursing homes.

Greensaft said the quality of care can vary vastly but that most home operators are doing a good job.

“There’s been some bad publicity, and in some cases it’s valid. In nursing homes, particularly, I think they’re trying to upgrade their image,” she said. “In board-and-care (homes), there are exceptions; but overall, they are run by caring people who really want to provide good care. It’s just a shame that the ones who aren’t are spoiling it for the others.”