How can nursing home aides keep a constant eye on someone with dementia who needs help with most ADLs?

I'm going to tell you plainly and honestly here. There is no nursing home the world over where your grandmother or any other resident is going to have a CNA keeping a constant eye on her. That is not how life and care work in a nursing home. No one is going to be her "shadow" there next to her every second of the day to serve her every need and anticipate possible future needs and take care of them in advance.
She will get this from you. She will not get this in a nursing home.
After your grandmother is placed the facility will probably ask you not to visit for a couple of weeks. This is so grandmother can get acclimated to her new surroundings. Do what they say.
Also be prepared that things will be different. You will likely see her at times wearing another resident's clothes. This happens often in nursing homes and MC. It doesn't mean she isn't getting care. Teeth and eyeglasses go missing all the time too. Other residents take them. The patient themselves lose them too.
Nobody is going to style her hair, or put on make-up, or paint her nails. Don't be alarmed.
Here's what to look for when you visit. If she appears clean and her hair and clothes are then she's being decently cared for. Take her into the bathroom to use the toilet and have a look at her bottom and surrounding areas. If you don't see any rashes, redness, or skin blanching then she is being changed and toileted regularly and they're keeping up on her hygiene.
This is what to look for when a person with dementia gets placed.
She will not have her own private aide who works only for her. If you want that, keep her home and hire private-pay caregivers 24 hours a day. Look for what I told you after she's there and that's how to tell if she's getting good care in a facility.

If you are expecting your LO to get one on one attention 24/7 in any managed care facility, you have unrealistic expectations, period. Keep your LO home if you want them to get 'constant assistance' and to be shadowed at all times, to your own detriment and expense, of course. That's the trade off.

My mother lived in Memory Care AL for nearly 3 years where she got an excellent level of care by truly devoted caregivers who loved her. Did they wait on her hand & foot 24/7? Of course not. Which is not to say that her needs weren't met, that she wasn't toileted when she needed to be, and that her social needs weren't seen to and exceeded, actually. They were. Her MC had no more than 23 residents at any given time, and the CG to resident ratio was 5:1, which meant the caregivers were able TO give the residents great attention. My mother was a gigantic handful, too, requiring a LOT of care which she did get. She was incontinent, wheelchair bound, fell 55x in under 3 years, needed help with ALL ADLs, etc., and she was helped with everything at all times. She fell b/c she forgot she couldn't walk, which nobody can prevent from happening; whether it's at home or in managed care.

So do your homework if you want your LO in managed care. Find a SNF or an Memory Care AL that has great reviews, a good caregiver to resident ratio, is clean and well organized, and then be your LOs advocate all the time. Be there to check up on them and to make sure the facility is giving them good care.

Best of luck!

IMO a MC is just a step up from AL. There ratio of aides to residents is only slightly better. They are changed on schedule or when they smell. Its very disciplined. Morning shift, up toileted, teeth brushed or put in, dressed and taken to the dining room. And Mom is not the only resident a particular aide has. Like said, most residents are kept in a common area where they eat and have activities. Taken outside when the weather is nice. Those who are bedridden get brought out for some social time. I had no problem in the care Mom received. She seemed as happy as she was able to be. I also had a daughter who worked Nursing facilities that told me what to expect.

My mom is aware but forgetful. She doesn’t do self care (showering, brushing teeth). After finding out that the extra money I was paying for her to have more assistance (showering, escorting to meals, lotions applied for her skin) AND she was refusing those services, I got her a daily carer that I hired privately. She bonded with the 5 day a week lady and puts up with the 2 day a week lady. Both are wonderfully kind to mom. I have them work 2-6 p.m. so she can get exercise walks, go to events, get showers, watch tv and escorted to dinner. Breakfast and lunch I have delivered to her apartment. Mom can get around, loves her bed so the afternoon caregiving works the best for her. At this point, I am paying about the same amount monthly that I would pay if she was in memory care. If she ends up in memory care (due to falling risk mostly-where she is checked hourly), I will still have the caregiver come in-maybe not daily but at least 3 days a week. The personal care has helped mom so much and she cannot refuse because I am the hirer. I was terribly disappointed to find that even though I was paying for additional care through the facility, the facility did not inform me when mom refused care EVEN though I had documented doctor notes that she is unable to make decisions. I felt robbed! I was in contact with the facility often and no one told me of mom refusing and mom sure didn’t tell me. That is the crazy thing about dementia-at some level they know how to be sneaky. ;) I am glad you asked this question because I am learning from the answers. Thank you.

My mom needed that kind of care. She was independent in walking but advanced dementia (can't dress herself, needs directions to find the bathroom, no sense of time, can talk but not coherently express any needs. If a memory care unit has 15 people they have 2 staff on and a med tech if you are lucky. My mom's unit was an upscale boutique facility with 9 residents (15 max) and she had 9 falls, bathroom accidents daily, wasn't given fluids (because she couldn't ask), and she was anxious and afraid all the time because no one was there to help her navigate her time and space. It is IMPOSSIBLE no matter what any facility tells you to have 2 workers on for 15 + memory care residents who all have varying needs for care, meds, food, activities, etc. I had cameras in my moms room (approved) and what I saw was absolutely horrific. My moms loneliness and isolation was painful as were many's during covid. She had times that she fell and hours went by before someone checked on her. I believe that anyone with a loved one in memory no matter what the facility is telling you, they can't provide adequate care and you should have a camera. Your loved one needs an advocate when they have dementia and you cannot rely on the facility to know what is going on with them accurately. It is sad, but it is the reality of the system that is broken and needs more regulation.

My mother is in a nursing facility and needs help with everything. She even needs a lift to get out of bed. I have no expectation that she gets her needs meet 100% of the time in the way she would if she had her own carer. However, I do know that she has all the medical care she needs, social interaction, and help with her ADL's.

If I wanted to provide the same level of support I would need to move, invest in a significant amount of medical equipment, quit my job which would significantly impact my financial future, not provide my own kids with the support they need, give up vacations and destroy my relationship with my husband. If I wanted to provide a level of support where her needs were met 100% of the time in a timely manner, I would need to add the loss of my sanity to that list.

Even if providing care at home, many people don't get all of their needs met as it is so difficult to deliver that level of care! In reality, this expectation is unrealistic and results in extreme stress, guilt, and anger.

I am grateful that my mother is in a facility as it allows me to live my life while ensuring she is safe and cared for. Every person I have met is very kind and my mother seems happy. It is outrageously expensive and I know that it isn't the same level of care she had when my Dad was providing 24-hour care, but I also know it is the only option if I want a life.

You place them in a memory care, not a nursing home (skilled nursing or assisted Living).

My mom's place had great systems in place. There were two levels of care -- though all were there for memory care -- and those who could dress themselves or use the bathroom on their own were supervised as needed, but those who required more help like my mom (incontinent, wheelchair-bound, mostly blind, stone deaf, crabby) were handled by a couple of caregivers in the mornings and evenings. Everyone was up, dressed and in the dining room by 7:30, then those who needed bathroom help were taken to the bathroom or changed on two-hour schedules.

Everyone spent most of the day in the common room doing activities under supervision, and those who could take themselves to and from their rooms were free to do so to take a nap or watch TV, etc. They were checked on by their assigned caregivers if they were gone for more than a half-hour or so.

I'd advise you to ask the places you're considering what a typical day is like. They should have their activities on their website, so look it up and see what they do all day. Obviously take a tour, too. Avoid places that park residents in front of the TV for hours at a time, and if possible, find ones that have multiple levels of care. You don't want someone with mild dementia being forced to hang out with those who are barely cognitive. My mom's place had a huge common room, and one side was used by those who needed the most help (lots of music therapy there and caregivers talking to them) and one was for those who could play bingo and trivia games and move around better. The TV was turned on for 30 minutes after dinner, and then the bedtime routine started. Everyone was ready for bed by 8:45.

My mom did better in the memory care than she had at home, because there were things to see and hear and do. People always talked to her when they walked by, and she didn't take a nap during the day until the last six months of her life. Before going to the MC she slept around 18 hours a day because she was bored and my dad couldn't engage with her while doing everything else he did to keep the household running.

@Nokonoko

You ask how we change the system of care. Here's how. Nursing homes and care facilities are allowed to charge whatever they want. The sky's the limit with these places.
If they are forced to treat their help better, they will. If they are forced to clean up their acts and business practices, they will.
If Medicaid refuses to pay unless they meet the standards they could set for them, they would meet those standards.
All nursing homes, MC, assisted living, hospitals, clinics, and homecare agencies should be non-profits. No shareholders they have to make and keep rich and no out-of-control salaries that have to be paid. Watch how fast patient and resident care improves.

Memory care PLUS daily visits and a camera (if allowed) . Cultivate relationship with staff and know their names and shifts. Document and photograph any problems mostly for primary cate provider to alert for any health developments. Prepare for the point of “refusing food and care”. Consider medication alternatives. Pack a “go bag” for the ER for eventual falls. Visit skilled nursing facilities in the area BEFORE your LO might need one.

If you are worried about one-to-one care then best quit your job and become a full time caregiver. You will not get the level of care you are expected anywhere, even in higher end private facilities trust me I know we looked into that option for my sister. Upscale ones where the cost is upwards of 20k, our family still would have had to pay privately for a one-to-one.

It was cheaper to keep sis home and just hire a private aides.