Choosing Assisted Living

Most assisted living communities offer a variety of care levels to cater to individual resident needs.

Portrait of smiling healthcare worker walking and talking with senior woman. Happy elder woman gets help from nurse for a walk through nursing home.

In the 1970’s, what were then known as nursing homes gained a notorious reputation for extinguishing the personal dignity of residents. Keren Brown Wilson, whose mother would soon be considering her senior care options, came to the conclusion that moving into a nursing home had as much in common with being “committed” as it did with being taken care of.

She went on to pioneer the assisted living model, opening the nation’s first such facility in Portland, Oregon in 1981. Her solution was to combine what she called “the three Hs: health, housing and hospitality.” The state of Oregon adopted a care philosophy that proclaims, “Assisted living…promotes resident self-direction and participation in decisions that emphasize choice, dignity, privacy, individuality, independence and homelike surroundings.” Today, there are around 40,000 assisted living facilities (ALs). These have become increasingly important in providing the lifestyles desired by longer-living seniors.

But as with any burgeoning field, the number of options, though a boon, can feel like a burden when trying to make informed choices. An expansive definition of senior care includes a wide range of options, including independent living, senior communities, assisted living facilities, and long-term or memory-care facilities. Given the options and the gravity of the decision, experts recommend beginning the search at least 6 months, if not a year, before the target move date. Of course, it’s often the case people don’t know they’ll need to move until they really need to—a period the industry refers to as a “Time of Crisis.”

In the 1950s, Dr. Sidney Katz developed a framework still in use today, which is helpful for assessing care needs. This framework indexes what are known as activities of daily living, or ADLs. Basic ADLs include functional mobility, bathing, dressing, eating, going to the bathroom and taking care of one’s hygiene. The inability to manage even one or two of these makes living independently extremely difficult, if not impossible. There are also Instrumental ADLs (IADLs), which include shopping, housekeeping, accounting, food preparation/meds, and telephone/transport. Oftentimes those needing help with IADLs can supplement independent living with periodic homemaker services or in-home care.

How these and other needs are addressed at an assisted living facility determines the level of care for each resident. Harriet Amonette, Director of Marketing for NHC Farragut, notes that many seniors in assisted living facilities progress through a number of levels of care as their needs increase. NHC Place Assisted Living offers six levels of care, progressing from the most independent residents, who live on campus for the security of 24-hour nursing on-site, to those with mild cognitive impairment who are not yet ready for a long-term care or full-time memory-care facility.

NHC staff go through a meticulous assessment process with each potential resident, says Amonette. The staff guides the individual through a twelve-page assessment in order to evaluate what kind of care they will need and how often they will receive it. For example, if a resident were mostly independent but needed some help with daily medications and bathing a few times a week, that person might need a care level two or three.

Those looking for eldercare need to be honest with themselves and their loved ones, not just about current needs, but also those likely to crop up in the near future. Knoxville-native Andrew Scruggs opened an in-home care business—Always Best Care—in 1996 after his family’s experience illustrated the need for it. He says “these facilities are not one size fits all. Each family has its own unique criteria… Some are in denial about various issues while others have a much better grasp of their loved-one’s needs.” Exercise as much foresight as possible, and be realistic. If the last year or two has been a roller coaster, consider a place offering more care.

Conversely, a senior-care facility may not be the immediate best option. Scruggs adds, “Most seniors are most comfortable in their own home and want to age-in-place. This allows them more independence and control over their circumstances. I believe this is the best setting for seniors, so long as they remain safe.”

Atmosphere and Service

If you do need facility-level care, what’s the next step? Lynette Edwards is the Long-term Care Ombudsman for the East Tennessee District, which covers 16 counties in East Tennessee. Her mission, as part of the East Tennessee Human Resource Agency (ETHRA), “is to improve the quality of life, and to protect the rights of people living in long-term care facilities.” She says, “There is absolutely nothing more important than actually visiting an AL multiple times. You must get a sense of the atmosphere….”

Each visit gives you a snapshot of the atmosphere, the people, and the customer service. Your goal should be to get as many and as varied snapshots as possible. Go in the morning, the afternoon, the evening, peak hours, off-peak hours, during activities, and while nothing is scheduled. Schedule a tour the first time you go, but show up unannounced several times afterwards. Only with a variety of these snapshots can you assemble a realistic picture of the place.

Cleanliness and Materials

To some extent, you can follow your nose. Are there unpleasant odors, or does the smell of cleaning chemicals singe your nose hair? Is the place clean? This is also a good time to note the building materials. Is the flooring grippy or slick? Are there railings where there should be? Is smoking allowed anywhere in the vicinity? If so, do people follow the rules? Make sure they do.

Appropriate Staffing

Are there plenty of people there to help, or does it always seem to be a skeleton crew? It’s a bad sign if you ever get the deer-in-the-headlights look, or if someone appears to be looking around for help that never comes. Of course, your expectations should be based on the type of facility you’re visiting. Facilities that claim to provide more care should have more staff to provide it.

Activities and Events

Ms. Edwards highlights another important question: “Are there activities going on? Or is it overly quiet and boring with no activities?” Most if not all facilities offer activities and events. Take a look at the calendar and find out if any of these appeal to you or your loved one. Ask if you can meet the person who coordinates them, and get a feel for his or her personality. Is he or she open to suggestions? It’s also great if some of the activities offered have a physical component. For body as for mind, if you don’t use it, you lose it.

If you’re looking into facilities in Tennessee, ask if or how often they host H.A.B.I.T. volunteers. H.A.B.I.T., short for Human Animal Bond in Tennessee, is a group of volunteers from the University of Tennessee College of Veterinary Medicine, the community, and local veterinary offices. They visit ALs with healthy, well-behaved pets. Bonding with animals is emotionally and physiologically beneficial—a loving dog can make anyone smile!


If it sounds shallow when I say that almost nothing is as important as the quality of the food, then don’t listen to me—listen to your district Ombudsman. “Do other residents enjoy the meals? Definitely eat more than one meal in the dining room,” she insists. Beyond that, find out how often the menu changes. Ask a resident’s opinion. Long-term care should not entail long-term dietary boredom.


Training should meet or exceed the level of care you are shopping for. Even basic skills require cultivation to ensure the safety and dignity of those being cared for. As Scruggs puts it, “It’s one thing to watch a video about changing the sheets on a bed while the client is in it. It’s another to actually do it.” That’s why the offices at Always Best Care host a hospital bed, full-size dummy, and a sling lift—an interesting contraption that uses hydraulic power to hoist a person up from a bed and place them gently into a wheelchair.

If you’re placing a loved one with Alzheimer’s or dementia, it’s important that staff understand the disease and know how to compassionately care for sufferers. You could also search for an Alzheimer’s special care unit or memory care facility. Ask what kind of training and experience the staff gets. ALs do not have these facilities, though some offer these kinds of advanced care on campus. NHC is breaking ground on its own memory-care facility this year.


Before she was the Long-term Care Ombudsman, Lynette Edwards served as an attorney for ETHRA’s Legal Assistance for the Elderly Program for 11 years. Her cautionary advice is this: “Be aware that when you sign the pages in the admission packet, you are signing a contract—READ IT!!! Make sure you understand all the charges, fees, and extra charges.”

How are you planning on paying for it? Some resort to “cashing in” a life insurance policy or setting up a reverse mortgage on their home. Nowadays, financial experts often advise clients to purchase long-term care insurance around age 50 as part of their retirement plan. Of course, you can hold off longer, but the price goes up as you get older. Keep in mind that most policies won’t pay out until the policyholder requires assistance in at least two ADLs. Veterans may also qualify for assisted living benefits through their pension, though many overlook this.

Gut Check

When several facilities meet every requirement on your list, return to how each makes you feel. It’s great if you’re impressed by one or two outstanding individuals, but keep in mind that those people may move on to other jobs. Choose a facility that only hires great people, that is committed to ongoing improvement, and makes you feel home, sweet home.

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