Last Updated: April 2, 2015
One of the most common questions families ask A Place for Mom is
"how do we know when it's time to move from assisted living to a
nursing home?" We received the following question from
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 weakness.
The administrator called me the next
day and said it was time for mom to move to "skilled care," i.e. a
skilled nursing home, for her own safety.
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?
Margaret's concerns are complex and unfortunately common. If
you're in a similar situation, ask the following questions:
- What kind of contractual agreement do you 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.
- Will your loved one'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
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 loved one has 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.