When the family home seems too big, too hard to manage, with too many steps or too much yard, the question becomes where to go next. It is advisable to do some preliminary work by asking friends for recommendations before a crisis arises. Many families must make these decisions within a few days of an unexpected hospital stay.

SOmetimes family members are concerned by the inability of the older adult to care for his/herself, even with assistance. This is called self-neglect and raises health and safety issues. When the worsening condition of an older adult who chose to remain at home, with or without additional help, requires a move to an assisted living facility or nursing home, a physician and/or a family caregiver may be the one to initiate this discussion. This can be a very traumatic occasion for the older adult, but the facility’s staff has been trained to handle these
transitions and can be helpful.

Cultural and Ethnic Diversity in Long-Term Care

America is more diverse now than ever before; this is especially evident in the people needing long-term care and the people who provide that care. Whether services are provided in a home or in a facility, your loved one will be interacting with people of different lifestyles, races, cultures, economic backgrounds, and religions, perhaps for the first time.This includes both agency and/or facility staff members and other residents.

It is a good idea to ask about religious practices and tolerance, food, activities, language and even the music played, to judge whether your loved one will be comfortable in the facility. The level of formality at a facility can also affect how satisfied he/she will be. If your loved one is physically frail but mentally alert, you’ll need to ask about the functioning levels of other residents and how they interact with each other.

Senior Housing Definitions

  • Independent Living: A residential setting for olderadults that may or may not provide supportive services. Under this living arrangement, the older adult leads an independent lifestyle that requires minimal or no extra assistance. In some settings units are owned; in others, they are rented. Generally referred to as elderly housing in the government subsidized environment, independent living may also include rental assisted or market rate apartments or cottages, where residents
    usually have complete choice in whether to participate in a facility’s services or programs.
  • Continuing Care Retirement Community: A continuing care retirement community (CCRC) offers several levels of housing and services that may include independent living, assisted living, and/or nursing home care. A CCRC offers independent living in an apartment or duplex with an array of supportive services such as transportation, meals, housekeeping services, and exercise classes, as well as access to healthcare in adjoining assisted living and nursing home facilities. A CCRC is different from other housing and care facilities for older adults because it usually entails a written agreement or contract between the resident (frequently lasting the term of the resident’s lifetime) and the community, which provides the continuum of housing, services, and a healthcare system, commonly all on one campus or site. Depending
    on the level of assistance needed, an individual may move throughout the community. It is best to make the decision to enter a CCRC while one is still healthy and active. Waiting for an “event” to happen may make it difficult for a new resident to adjust and/or feel happy in the new surroundings. Most important, a CCRC offers companionship and the social support
    of a variety of people. When and if the time comes for more care, the older adult is still part of the same community.
  • Assisted Care Living Facilities: A licensed residential setting that offers a variety of support services such as meals, housekeeping, activities, transportation, and assistance with bathing, dressing, and medication. Be sure the services provided meet the specific needs of the resident. This is a broad category of housing, and not every assisted living facility provides all of the services. In Tennessee, there is another category of licensed housing called Homes for the Aged that, unlike ACLFs, are not required to offer licensed medical care.
  • Nursing Home (sometimes called Healthcare Centers): Patients generally rely on assistance for most or all daily living activities (such as bathing, dressing, and toileting). Provides 24-hour licensed skilled nursing care (Level II) for the more acute patients. Intermediate care (Level I) is a less intensive level of care than skilled nursing care and may also be offered.
    Nursing homes may provide care by nurses, physical therapists, speech therapists, or occupational therapists. Some facilities have secure units and special care for individuals who are memory-impaired.

Senior Housing Shopping Guidelines

If you are seeking a residence for someone who cannot visit the residence personally, it is important to respect his/her needs and wishes by including the older adult in the process as much as possible. The result will be greater

The following are shopping guidelines for reviewing important services in assisted living communities. Many apply to nursing homes and continuing care retirement communities also. Make several visits at various times of
day to each residence you are considering.


  • As you tour the residence, is the décor attractive and homelike?
  • Did you receive a warm greeting from staff welcoming you to the residence?
  • Does the administrator/staff call residents by name and interact warmly with them as you tour the residence?
  • Do residents socialize with each other and appear happy and comfortable?
  • Are you able to talk with residents about how they like the residence and staff?
  • Would the residents seem to be appropriate housemates for your loved one?
  • Are staff members appropriately dressed, personable, and outgoing?
  • Do the staff members treat each other in a professional manner?
  • Are visits with the resident welcomed at any time?

Physical Features

  • Is the community well designed for residents’ needs?
  • Are doorways, hallways, and rooms accommodating to wheelchairs and walkers?
  • Are handrails available to aid in walking?
  • Are cupboards and shelves easy to reach?
  • Are floors of a non-skid material and carpets firm for safe walking?
  • Does the residence have good natural and artificial lighting?
  • Is the residence clean, free of odors and appropriately heated/cooled?
  • Does the residence meet local and/or state licensing requirements?
  • Does the residence have sprinklers and clearly marked exits?
  • Does the residence have a means of security if a resident wanders?

Needs Assessments, Contrcts, Costs and Finances

  • Is a contractual agreement available that discloses healthcare and supportive services, all fees, as well as admission and discharge provisions?
  • Is there a written plan for the care of each resident?
  • Does the residence have a process for assessing a potential resident’s need for services, and are those needs addressed periodically?
  • Does this process include the resident, the family, and facility staff along with the potential resident’s physician?
  • When may a contract be terminated, and what are refund policies?
  • Are additional services available if the resident’s needs change?
  • Is there a procedure to pay for additional services, like nursing care, when the services are needed on a temporary basis?
  • Are there different costs for various levels or categories of services?
  • Are residents required to purchase renters’ insurance for their personal property?
  • Is staff available to meet scheduled and unscheduled needs?
  • Is there an appeals process for dissatisfied residents?

Medication and Health Care

  • Does the residence have specific policies regarding storage of medication, assistance with medications, training and supervision of staff, and record keeping?
  • Is self-administration of medication allowed?
  • Is there a staff person to coordinate visits from a nurse, physical therapist, occupational therapist, etc. if needed?
  • Are staff members available to assist residents who experience memory, orientation, or judgment losses?
  • Does a physician, nurse practitioner, or nurse visit regularly for medical checkups?
  • Does the residence have a clearly-stated procedure for responding to a resident’s medical emergency?
  • To what extent are medical services available and how are they provided?


  • Is staff available to provide 24-hour assistance with activities of daily living (ADLs) if needed? ADLs include: dressing, eating, mobility, hygiene, grooming, bathing, toileting, incontinence care, using the telephone, shopping, and laundry.
  • Does the residence provide housekeeping services in residents’ units?
  • Does the residence provide transportation to doctors’ offices, the hairdresser, shopping, and other activities desired by residents?
  • Can residents arrange for transportation on fairly short notice?
  • Are pharmacy, barber/beautician and/or therapy services offered on‑site?

Individual Unit Features

  • Are units for single and double occupancy available?
  • Do residents have their own lockable doors?
  • Is a 24-hour emergency response system accessible from the unit?
  • Are bathrooms private, and are they accessible for wheelchairs and walkers?
  • Are residents able to bring their own furnishings for their unit, and what may they bring? What is provided?
  • Do all units have a telephone and cable TV, and how is billing handled?
  • Is a kitchen area/unit provided with a refrigerator, sink, and cooking element?
  • May residents keep food in their units?
  • May residents smoke in their units? In public areas?
  • May residents decorate their own units?

Social and Recreational Actitivies

  • Is there evidence of an organized activities program, such as a posted daily schedule, events in progress, reading materials, visitors, etc.?
  • Do residents participate in activities outside of the residence in the neighboring community?
  • Do volunteers come into the residence to help with or conduct programs?
  • Does the residence create a sense of community by requiring residents to participate in certain activities or to perform simple chores for the group as a whole?
  • Are residents’ pets allowed in the residence? Who is responsible for their care?
  • Are any religious services available at the residence?

Food Service

  • Does the residence provide three nutritionally balanced meals a day, seven days a week?
  • Are snacks available? Is water or juice offered several times in between meals?
  • May residents request special foods?
  • Are common dining areas available?
  • May residents eat meals in their units?
  • May meals be provided at a time a resident likes, or are there set times for meals?
  • Ask about having a meal at the residence. Is the food tasty? Do the residents seem to enjoy mealtime? Are there a variety of choices?

—Source: AFLA Web Site 2002

Questions to ask an Administrator/Social Worker

When you visit a facility, ask to see the state survey results. This inspection report must be made available to those who ask. Other tips:

  • Ask about the staffing ratio.
  • Ask if the administrator is licensed as well as the facility.
  • Ask about smoke detectors, sprinklers, and fire and other emergency drills.
  • Ask about the residents council, how often it meets and what it does.
  • Ask if the nursing home is Medicare-certified and Medicaid-certified.
  • Ask how many residents each CNA (certified nursing assistant) works with.
  • Ask if the facility has corrected all deficiencies from its last inspection report.
  • Ask how many staff members are on duty for each shift.
  • Ask to see the facility’s Resident Bill of Rights.