Last Updated: April 2, 2013
My 88-year-old mother has been in an assisted living community
near me for the past two years. She has been declining slightly,
almost imperceptibly, over the years. Recently she had a fall in
her room and couldn't get up or reach the call cord. When a staff
person noticed she had missed dinner, mom was found after three
hours on the floor, but with no problems other than general
The administrator called me the next day and said it was time
for mom to move to "skilled care," i.e. nursing home care, for her
What are my options? My mother loves her apartment and her
community, plus, she has many strong friendships there. Her doctor
says she may have had some small strokes over the years and has
osteoporosis, which is successfully treated with medication. She
doesn't seem forgetful or have any other major complaints; she's
just feeling the years. I want her to be safe, of course, but she
actually burst into tears when I suggested that we visit the
nursing home and now she refuses to even discuss the issue.
Can the facility actually force her to move? Is she better off
being safer receiving nursing home care, or will she have optimum
physical and mental health in a community she knows and loves?
Sincerely, at my wit's end,
Your concerns are complex and unfortunately common. You are
asking all the right questions and several more are in order:
- What kind of contractual agreement does your mother have with
the retirement community? For example, most free-standing assisted living facilities have
month-to-month rental agreements, which often state that a person
can be required to move if the community is not able to provide
needed care, such as skilled nursing
home care or 24-hour supervision. Assisted living varies widely
in different states, and indeed even within the same state. One
community will provide services right up through hospice care,
while another can ask a resident to leave if he or she is unable to
manage medications independently.
- If it is a
continuing care retirement community (CCRC), it is often
stipulated in the contractual agreement that a nurse's assessment
will determine the location and level of care. It is more difficult
for staff to provide services all over a large community and easier
if all the people needing care such as medication and continence
management are in the same building or on the same floor.
- Would your mother's quality of life decline in a different
setting? This, of course, is difficult to judge. Much depends on
both the individual and on the type of nursing home care available.
Some people find the additional attention and complete services in
a nursing home desirable. Others find the lack of privacy and
choice in a standard nursing home too restrictive. Because the
level of cognitive ability will usually be much lower in a nursing
home than in assisted living, it may be more difficult for your mom
to find other people with whom she feels compatible.
Some possible interventions might postpone or preclude a move to
nursing home care:
- Many older people benefit dramatically from physical therapy
and exercise. With appropriate guidance and strength training from
a well-trained professional, she may get stronger and also learn
how to get up from a fall unassisted.
- Arrange additional help from an outside source, such as an in-home
care agency that can offer trained companions, nursing care,
- If feasible, increase your own involvement and perhaps that of
other family members as well. If the staff knows that you are
visiting on a daily basis, they will have fewer concerns about
- Because we live in a litigious society, the facility may have
liability concerns. Some communities allow a negotiated risk
agreement or a "hold harmless" contract, where your family would
basically promise not to sue if there is an adverse event.
Other factors might also influence this decision to move or to
stay. Is nursing home care more expensive? Usually it is. Will it
be harder for you and family member to visit your mother if she is
in a higher care setting? It might be farther away. In addition,
some people find visiting a nursing home depressing or even
distasteful. Please note that this is not the norm; many facilities
are homey, helpful, and family oriented, especially those with the
"culture change model" (see www.pioneernetwork.org).
If your mother had a progressive condition such as Alzheimer's,
congestive heart failure, or
Parkinson's disease, a move early in the disease process could
be easier in the long run. It would give her an opportunity to
master her new environment and make new friends while she is still
As with any important decision, it could be useful to get other
professional opinions. Have her physician do a checkup and suggest
the best level of care. Also, all US counties have some type of
senior information and assistance phone line and you could consider
asking for their help locating a geriatric social worker to do an
assessment. They may also be able to recommend some types of
communities other than a nursing home,
such as an adult family home or an assisted living facility that
provides more oversight and care.
Lastly, work with your mom to minimize her need for assistance.
Sometimes it might be the most troublesome resident who is asked to
move-not the most medically needy. Most assisted living facilities
will work hard to keep the friendly, easy to please, personable
residents in the community.