You get a call from a neighbor saying she went to check on your mom and found her on the floor and your mom is on the way to the hospital. Once you get there, the doctor informs you that your mom has broken her arm.  He says she hasn’t been eating well, is unsteady on her feet and probably will fall again. And, he adds, she has some dementia.

Her physician recommends she move into a senior living community.

You hadn’t planned for this kind of news.

Great! Now what?

Many adult children find themselves in a crisis when a loved one’s health deteriorates. Do they need to look at assisted living or a skilled nursing community?

What’s the difference? Actually, a lot.

Well, for instance, sixty years ago the only choice for someone who needed healthcare was a nursing home and you really didn’t want to be caught dead in one!

Most nursing homes at that time were at best primarily designed for people further along in their aging or illness and at worst plagued by issues of neglect or mistreatment. Nursing home abuses of the last century gave the whole care industry a bad name.

In the 50s, I remember going with my mom to visit a neighbor lady who was in a nursing home. It left a lasting impression on me and I’m sure anyone who ever stepped foot in one. Disgusting! They were little more than warehouses holding people hostage who probably wished they were dead instead of (barely) living there. The first thing I saw was a nurse’s station shaped liked a horseshoe surrounded by wheelchairs. Some folks were slumped in them, drooling and sleeping, while others staring blankly into space. And the smell … the place reeked of urine!  Food was bland, high in salt and not freshly prepared. Forget activities because there weren’t many, if any. I couldn’t get out of there fast enough.

So during my many years as a sales director for numerous senior living communities, I have seen the faces of fear on elderly people who had this image of a “nursing home.” They were horrified at the thought that they will be stuck in a place like that to die.

Thank heaven things have changed. I think the baby boomer generation, who will be the next group to need healthcare communities, have said “you’re not putting me in a place like that.”

Beginning in 1979 to 1985, motivated by distaste of nursing home care, a shift occurred in senior housing. Today, the term “nursing home” has been generally replaced by the words “skilled nursing” or “long-term care. Many skilled nursing communities offer rehabilitation therapy services so Medicare covers nursing home services for 100 days for people who need skilled nursing care or rehab service if they have been in a hospital for three consecutive days.

Today, due to older adults living longer, eruption of chronic illnesses, and the exploding boomer market, assisted living is reorganizing and examining its standards and how it provides care. The appeal of these facilities in comparison to skilled nursing is obvious. They offer considerably more privacy.

Skilled Nursing (Long-Term Care)

Private rooms are less common in skilled nursing and they do sometimes have a more institutional feel, which accounts for a lot of the resistance to choosing skilled nursing over assisted living, even when it may be the more appropriate choice for a senior’s needs.

Skilled nursing, in contrast, make medical care a central component of what they offer. They are required to have medical staff available at all times and are subject to laws and regulations from the government on the quality of care provided. Those who are bed ridden require skilled nursing. Skilled nursing residents require fully staffed, skilled nursing medical attention on a daily basis, while assisted living residents are more stable and do not need ongoing medical attention. Skilled nursing have licensed practical nurses on duty 24 hours a day, and a registered nurse on duty at least 8 hours every day.

Assisted Living

Assisted living residents typically live in a studio apartment, one-bedroom or even two-bedroom apartments. Many assisted living communities allow small dogs and cats as long the resident can provide care for them. For obvious reasons, no one in skilled nursing can have a pet.

Services like meals, housekeeping, transportation and help with basic activities of daily living like getting dressed and bathing and make autonomous decisions about their day. What they don’t provide is 24-hour care or medical supervision. While assisted living homes typically have registered nurses and/or doctors come in for visits to check on residents, they’re not required to have staff members with medical licenses. And they’re not regulated by the federal government.

What they do offer is a higher level of independence for seniors.

Assisted living is often less expensive then home health care or skilled nursing care. A lot of assisted livings offer meals and light housekeeping. They offer minor medical supervision, personal care assistance, 24 hour supervision, social activities, security and emergency call systems. Arranged transportation to doctor’s appointments and to fun outings are provided.

There are many assisted living facilities that offer dedicated Alzheimer’s memory care programs for residents which are designed to decrease agitation and improve their quality of life. Generally residents with early stage Alzheimer’s or dementia can live among the regular population of assisted living residents, but when the condition becomes advanced, residents are then transitioned to the memory care area of the assisted living community. Memory care is considered to be specialized assisted living that is secure to protect residents, and also has staff specially trained to care for those with the disease.


Medicare never pays for skilled or assisted living and most assisted living and the majority of skilled nursing communities are private pay. However, there are some assisted living that will take a limited number of Medicaid residents. Most states have flexible income guidelines for Medicaid reimbursement for long-term care. Medicaid requires you to contribute most of your income to your long-term care when

you are living in skilled nursing. You are allowed to keep a small fixed amount of money as a “personal needs allowance” to pay for uncovered medical expenses

Before a healthcare crisis hits you need to shop around and see what best fits the needs of your loved, the care provided and how long you can afford to keep them in a community.