Assisted living includes a wide variety of settings and services. In some facilities, services are limited to meal preparation, housekeeping, medication reminders and minimal assistance. In others, more intensive services, including help with medication, on-site nurses, and regular assistance with daily activities such as bathing and dressing, are available for frail or confused older adults. Choosing an assisted living facility for yourself, a relative, a friend, or a client can be challenging and confusing and takes significant time and effort.
These questions were developed by CCAL - Advancing Person-Centered Living to help make the process easier. The questions can be used when visiting any assisted living facility and are directed to the person who will be moving into an assisted living facility. However they are useful to any interested person looking for a facility. (relatives, friends, and professionals)
The first step in making a good choice of a facility is to conduct an accurate and honest assessment of your physical, financial and lifestyle needs. If you need help with this assessment, or with finding a facility, consider consulting a private geriatric care manager, a professional trained in the field of human services, experienced in assessment and knowledgeable about assisted living alternatives. The National Association of Professional Geriatric Care Managers can provide referrals.
Visit as many facilities as you can to get a sense of the choices. Consider the proximity to those who will visit you; the closer the facility, the more likely that visits will be more frequent. During the first visit, take the tour and listen to the formal presentation. Ask the questions that are most important to you.
When you have narrowed your selection to the top three choices, return to those facilities and ask questions from the list below. Talk with residents. What do they like or dislike about the facility? Talk with staff. Are they friendly and knowledgeable? Eat a meal. Is the food good? Compare your answers from the different facilities.
Ask for a copy of the contract. Take it home and read it carefully. Ask for clarification about anything you don't understand. Take it to an attorney specializing in elder law for review.
Ask to read the licensing inspection report. If the facility had deficiencies, have they been corrected? If you are looking at an assisted living facility connected to a nursing home, ask to see the inspection report of the nursing home. It may shed light on how the organization is administered.
Visit the Eldercare Locator website or call 1-800-677-1116 to reach a local program. Call the Long Term Care Ombudsman program through your local Agency on Aging and ask about the nature of complaints about the facility and how they were resolved.
Consider making an unannounced visit to the facility. Also, arrange to stay overnight in your first choice facility before making the final decision. If you can arrange to stay for a week, or even a month, there's no better way of determining the likelihood of your future satisfaction with the decision.
Choose the facility that comes closest to your needs, remembering that nothing is perfect.
Costs and Contracts
The contract is a legal document, obligating you to potentially pay very large sums of money for care. CCAL encourages you to consult with an elder law attorney before signing the document.
- What is the baseline fee?
- What services are provided for that fee?
- What are the additional charges for services/products?
- What initial payments are required? Is any of it refundable?
- If I am away from the facility for an extended period of time, (in the hospital or temporarily in a nursing home) what fees continue to apply?
- When, how often, and why can the fees be changed?
- When fees are changed, who is informed? How much advanced warning is provided?
- What happens if funds run out? Is there any financial assistance?
- Is renter insurance required?
- What happens if there is a spill or accident that destroys property - mine or the facility's? Who is responsible for cleaning/repairing, payment or replacement?
Examine the contract. Is the print large enough for you to read? If not ask for a copy that is. Does the contract clearly describe:
- Monthly fees and extra charges including charges to hold a bed during an absence?
- A refund policy in cases of transfers, discharges, changes in ownership, or closing?
- Responsibilities of the resident and of the facility?
- Behaviors conditions, or other circumstances that may result in termination of services and an explanation of discharge policies?
- Rights of residents?
- Grievance procedure and alternatives if you are not satisfied with the grievance procedure?
In addition to the questions below, ask the facility to specifically describe how it will meet your known care needs, e.g., incontinence, mental health, supervision or dementia. If you hope to preclude having to move again, take into consideration that you may need more care in the future. Ask questions that don't apply to you now, but may in the future.
Meeting Individual Needs
- What criteria does the facility use to determine whether this facility is appropriate for my needs?
- What kind of assessment is done to determine my needs?
- What are the qualifications of the person conducting the assessment?
- How often is the assessment done?
- What happens if my needs change - I need more help, become incontinent, become confused?
- How does the facility tailor the schedule for bathing and dressing to accommodate the preferences of residents? Can changes be made?
- How does the facility help residents maintain their abilities to care for themselves, especially in regard to toileting, dressing, and eating?
- If a resident displays a difficult behavior, what steps will the facility take?
- How often is the room cleaned?
- Is there a schedule for staff to check on a resident's whereabouts and well-being?
- How many staff are there for each shift?
- What are their responsibilities?
- What is the training/certification of the people who care for residents?
- What are the trainer's qualifications?
- How many residents are assigned to each direct care staff person?
- What other duties do direct care staff have during these hours?
- Are there direct care staff who speak English (or my native language) clearly?
- Is there special training for staff about dementia and Alzheimer's disease? How long is the training?
- Are staff trained to deal with aggressive individuals? Wanderers?
- What if I don't like the staff person assigned to me?
- What is the staff turnover rate?
- Who decides whether to call 911?
- Are there written policies about how that decision is made?
- What kind of emergencies are staff expected to handle and how are they trained for them?
While assisted living facilities are not designed to provide medical care, the facility should be able to meet the medical needs of their residents, especially if the facility has an aging in place philosophy. This philosophy allows residents to remain in the facility if they become more infirm, and to receive more care as needed. It is important to evaluate the facility's capacity to manage health care needs even if you are healthy now, because you may need more help in the future. Also, although many seniors are basically healthy, many take a variety of medications, requiring assistance or supervision.
- Does the facility prepare a written plan describing how it will care for me?
- How often is it revised?
- What professionals/staff are involved in the development of this plan?
- How will I and my family be involved?
- What involvement does a confused resident have?
- What if I do not agree with the facility's plan of care?
Provision of Care
- To what extent will the facility monitor my health?
- Is there a nurse on staff?
- What are the nurse's hours and responsibilities?
- Who is responsible when the nurse is not on duty?
- If a nurse is not on staff, are there regularly scheduled visits by a nurse or other health provider?
- Does the nurse or provider see residents regularly?
- If I don't feel well, how quickly and to what extent will I receive medical attention?
- What health services are available on site: e.g. lab work, physical therapy, wound care, hospice, social work, podiatrist, etc.?
- What does the facility provide, and what can outside agencies provide?
- What are the costs?
- Under what circumstances and when does the facility call the family? The doctor?
- What safeguards are in place to ensure that I get the appropriate medications on time and in the correct dosage?
- How are prescriptions filled?
- Must I use the facility pharmacy?
- What are the costs?
- Who gives out medications? If not a nurse, how are staff trained and supervised?
- Who reviews medication procedures and how frequently?
- Is transportation to health appointments available?
- Are there any limitations?
- Is transportation available if I want to go to an event by myself or with a friend?
- What are the fees associated with using the facility's transportation?
- Is transportation wheelchair accessible?
Activities and Socializing
When looking at the activities a facility offers, think about your preferences. Some people enjoy scheduled activities, such as current events discussions, crafts, bingo, card games, etc. Others have never been "activities people" and won't care to participate. They would rather read a book or go for walks. A third group may want to spend a lot of time at cultural or community events such as museums, theaters and concerts. The last group will be more concerned about location of the facility and whether transportation is available, its cost, and who goes on these trips. Look at a monthly activity schedule. Do the activities appeal to you?
- How often are activities in the community scheduled?
- What staff are included?
- Can I walk on the grounds?
- Are there protected/enclosed walking areas for residents with dementia?
- How are religious/spiritual needs met?
- Is there transportation to my church or synagogue?
- Is there room and arrangements for worship programs in the facility?
- Who develops and supervises recreational activities?
- What is this person's background?
- How do residents have input into activities offered?
Meals are important to many residents of assisted living. Sample a few meals. How does the food taste? If you have special dietary needs, describe them and ask how those needs can be met. Ask to see a printed menu for the month. Does it look appealing?
- What times are meals served?
- What happens if I am late, miss a meal, or refuse a meal?
- Is the answer different if a resident is confused?
- What if I want to skip a meal regularly? Is the answer different if a resident is confused?
- Can I request to have a tray delivered to my room? Is there an additional charge?
- If I don't like a meal, what are the alternatives?
- Are snacks available at any time?
- What kind of snacks are available?
- Does a nutritionist or dietitian review meals and special diets? If yes, how often?
Assisted living facilities emphasize independence and choice as vital to their philosophy. They also have rules and procedures designed to protect residents from harm. It is important to match your ability with the extent of choices and opportunities offered by the facility, as well as the limitations it will impose upon you. Facilities vary with regard to the extent of protection they offer residents and may use negotiated risk agreements or contracts when issues of safety and choice arise. Because each facility may define the terms differently, use a different term, or not believe in using such agreements, CCAL urges you to ask the facility whether it uses any form of negotiated risk agreements. If they do, they should clearly explain what they mean by the terms that they use and how they use such agreements in practice at the facility.
- What safety measures are in place to protect residents from wandering away? Personal property being stolen?
- What if I want an exception to a policy, e.g. signing in and out, smoking, or eating foods that are not on a prescribed diet? Is the answer different if a resident is confused?
- Are background checks performed on all staff? What kind?
- Which doors of the facility are locked and when?
- When doors are locked, how does one access the home?
- Are exit doors alarmed?
- Are there safety locks on the windows?
- Are there call bells in each room and bathroom? How often are they checked to be sure they are working correctly?
- Is there a fire emergency plan? Are there fire drills? Are emergency plans publicly displayed?
- Is the floor covering of the facility made of a nonskid material?
Facility Initiated Discharge
Answers to these questions will help you clarify a facility's ability to care for people with health and behavior conditions that are more difficult to manage. It will also help you determine if you have recourse if you are asked to leave.
- What are reasons for discharge?
- Is there an internal appeal process? What is it?
- How many days notice is given and to whom?
- How does the facility assist you if they proceed with discharge?
Are hallways, doorways, bathrooms and common areas fully accessible to people in wheelchairs? If it is a multi-floor facility, what are the safety arrangements for escape in case of fire for people in wheelchairs?
Special Care Units
This section is directed to family members or other interested persons, because it would be unusual for the person who needs a special care unit to be asking these questions. These questions should be asked in addition to previous questions.
- Is there a separate area specifically for people with dementia?
- How do services in the special care unit differ from services in the rest of the facility?
- What is the difference in staff training? The staff-to-resident ratio?
- Do residents go out of doors regularly? How often? Where do they go?
- How do you ensure that the resident is getting proper nutrition?
- Are finger foods available?
- Do you offer decaffeinated drinks throughout the day?
- Look at a calendar of activities. Do they appear appropriate for the resident?
- Do the residents on the unit seem as disabled as the prospective resident?
- What is the facility's policy on restraints, both chemical and physical?
- Is there space to walk around on the unit?
- What are the room arrangements?
- If there will be a roommate, does he/she have any habits or mannerisms that would be difficult for the prospective resident to handle, e.g. staying up late at night, yelling, going through personal possessions of others?
- When rooms are shared, what does the facility do if problems such as those in the previous question arise?
- What is the cost difference between special care and regular units?
Source: CCAL – Advancing Person-Centered Living