Thinking about turning the care of an elderly or disabled relative over to a skilled nursing facility?

Do your homework and choose carefully. Slick brochures showing smiling senior faces don't tell the whole story.

And Texas, which has more than 1,000 nursing homes, ranks among the worst states on several quality measures – including use of restraints, staffing and housekeeping – according to figures from the U.S. Department of Health and Human Services.

Texas ranks fifth in the nation for the percent of nursing home residents who are restrained in bed with rails or other devices. One of every five residents is regularly restrained on a daily basis – more than twice the rate for all U.S. nursing home residents.

Federal law allows restraints only when they are necessary to treat a medical condition and are prescribed by a physician. They may not be used for staff convenience. Research shows that using restraints does not decrease incidents of falling. And residents who are restrained daily can become weak – or develop pressure sores and other medical complications.

High rates of physical restraints often are linked to staffing shortfalls. Texas ranks low on several staffing measures. It is one of six states with the lowest number of hours per resident of registered nursing care.

More than 35 percent of Texas nursing homes in 2005 had violations in housekeeping and facility maintenance.

But Texas did do better than the national average in some areas, including the percent of facilities with residents having accidents, pressure sores and weight loss. It also ranked better than average on the availability of activities, according to HHS figures.

The Center for Personal Assistant Services at the University of California, San Francisco, produced a report last fall on these and other nursing home statistics, which is available online at www.pascenter.org.

In addition to visiting facilities in person at different times of the day, you should check their inspection records.

You can check out nursing homes in Texas by going to the Texas Department of Aging and Disability Services' Web site, www.dads.state.tx.us. DADS is the agency charged with regulating nursing homes in Texas.

The federal Centers for Medicare and Medicaid Services also maintains a searchable database of nursing home inspections and violations on its Web site, www.medicare.gov.

Keep in mind that a nursing home may not be your only option.

Traditionally, nursing homes were the only service option for disabled and elderly individuals, particularly those receiving Medicaid or Medicare. But in 1999, the U.S. Supreme Court ruled – in what is known as the Olmstead Decision – that institutionalizing people with disabilities who wanted to live at home was unconstitutional. Following that decision, the federal government required states to make that happen. Most were slow on the uptake, and many are still forming their plans.

Texas is ahead of the curve when it comes to implementation of Olmstead. It was among the first states to develop a plan so that individuals in nursing homes who wanted to move out on their own could do so. State budget rules allow money from one fund (nursing home care) to follow a person to another fund (home and community-based services).

The process is not automatic however. Getting funding and services lined up takes time.

The biggest hurdle for nursing home residents who want to live on their own is the lack of affordable housing. The Texas Department of Housing and Community Affairs provides federally funded Section 8 housing vouchers to people with disabilities who move out of nursing homes, but getting one can take years.

Individuals also must have an attendant or nursing care. Those receiving Medicaid can go through a home health-care agency or hire their own attendant. You also can check out home health-care agencies on the DADS and CMS Web sites.

For more information about home- and community-based services, contact your local Center for Independent Living or Area Agency on Aging. In Dallas-Fort Worth, contact REACH (Rehabilitation, Education, and Advocacy for Citizens with Handicaps) through www.reachcils.org or the Dallas Area Agency on Aging through www.ccgd.org/daaa/daaa.html.