Finding a nursing home quickly is one of the most difficult things you will ever have to do as a caregiver. It usually happens when a hospital says it is time for your elder to be discharged, and going home or into an assisted living facility is not an option. Finding a good nursing home takes time and research, neither of which you will have, and the Medicare "star" ratings won't be very helpful.

More than half of nursing home admissions come directly from hospitals. Most hospital social workers and discharge planners do not really know much about the nursing homes where they discharge their patients. It's unusual for hospital staff to have ever set foot into these facilities. For that reason, they will rarely "recommend" a nursing home for either rehabilitation or long-term care unless it's a rehabilitation area within their own hospital. More commonly, they will hand you a list of facilities and suggest that you make a choice, preferably by the next day.

You can sometimes delay your loved one's discharge by a day or two. However, you will be under the gun to make a choice. If you don't, the hospital will discharge their patient to a nursing home or rehabilitation center of their choosing. It may not be at all what you would have wanted.

Keep in mind that you do not always know whether a nursing home stay will be temporary - for rehabilitation before going home - or permanent, if rehabilitation is not ultimately successful. You will want to look at every potential facility as if it will be your elder's long-term home. If rehabilitation is successful, you haven't lost anything by taking this approach. If leaving nursing care turns out not to be an option, you will have chosen the best long-term facility available.

Many hospitals will hand you a free booklet or directory of all the local nursing facilities. Many of these booklets are professionally produced, and costs are covered by the facilities appearing in them. Essentially they are an advertising vehicle, or a "yellow pages" of the local facilities. Because the descriptions are written by the facilities themselves, we recommend that you use these booklets as an address and phone directory only. They will at least give you a list of what's local, but not much more.

This is the time when the assistance of a geriatric care manager can be invaluable. A good care manager has been in all the local facilities, knows the good from the bad, and almost always has heard the latest about which facilities have had important changes in management or ownership (very important to know). A good care manager can accomplish in an hour or two what would take you many hours and even days to do if you had all the information at your fingertips, which you do not.

If you don't have quick access to a care manager, the Medicare website is a good place to start.

Medicare continually collects data on every nursing home in the country that receives Medicare or Medicaid funding: approximately 15,000 facilities. They utilize health inspection data collected by "surveyors" in each state, as well as staffing and quality measures reported by each facility to arrive at a "star" rating system. 5 Stars is the best rating a facility can receive, and one star is the lowest.

This health inspection data is a "snapshot" only. Much of the data is self-reported, which means that it may or may not be accurate. Although they have  specific guidelines to follow, the individual state inspectors who actually visit these facilities are only human. They have good days and bad days, as we all do. Each surveyor's evaluations may be more or less strict than those of another inspector from the same agency.

Medicare uses a curve to grade nursing homes in each state. No more than 10% of all nursing homes in any state may receive 5 stars. This means that a 4-star rated nursing home may have missed receiving a 5-star rating by only 1%. The bottom 20% of all nursing homes in each state MUST receive only one star. This means that some one-star nursing homes might have just barely missed receiving two stars.

Taking this to the extreme, if all the nursing homes in a given state were pitiful, 10% would still receive 5 stars, and only 20% would receive one star.

Medicare doesn't compare nursing homes between states. If you are close to a state border, 5-star rated nursing homes in one state may be quite a bit better, or quite a bit worse, than in a neighboring state.

So, have some healthy scepticism as you review the Medicare.gov nursing home ratings. Use them to help you decide which nursing homes to visit in person.

Telephone the three nursing homes that look the best to you. This will save you immense time. Ask first for the admissions coordinator so that you can inquire about whether they have a vacancy - for rehabilitation or for long-term care, whichever is appropriate to your situation. If the answer is, "Yes," then put them on your list. Don't schedule a visit yet. When you have three that look like they are worth a visit, place a call to your local long-term care ombudsman. The ombudsman has the skinny on these nursing homes, and can be very helpful in telling you the good and the not-so-good about each one. Take his or her recommendations seriously, as there is no business relationship to influence what they say. Then, and only then, will you be armed to make visits to the top two or three.

When you visit, be sure to ask for the most recent inspection report and use a simple paper and pencil checklist. This will help you keep information from running together in your head and will remind you about the most important questions to ask. Remember that chandeliers don't give care, people do. The presence or absence of fancy decor is something you'll notice, but won't make much difference to the experience your elder will have in any facility. Speaking to one or two aides and a visiting family member or two if you can will give you much more important information about the care provided and family/patient satisfaction.

If you are facing a short time deadline, this is about all you will have the time to do before you have to make a selection. Tell the discharge planner or social worker which facility you have selected and they will take it from there, including arranging for medical transportation if necessary.

Be prepared to visit regularly and to keep a watchful eye after your loved one is admitted. There will inevitably be things that could be better, even in the best five-star facility.