9 Questions to Ask When Choosing a Care Facility

Placing a loved one into a care facility can be a gut-wrenching decision

Doctor talking to elderly woman
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Caregivers struggle to find a balance between meeting their loved one’s needs and meeting their own. It’s like walking on the ridge with the needs of a loved one on one side and those of the caregiver on the other. Rarely is the balancing act maintained for long periods of time—the caregiver often slides down one to slope or the other. When caregivers sacrifice their well-being resentment may develop.

When caregivers take care of their own needs, they may experience guilt.

Often the balance between one’s needs and a loved one’s involves painful choices, including giving up a fulfilling life filled with professional accolades or placing more importance on preserving a family’s structure and one’s sanity, rather than meeting every need of a loved one. But caregiving does not have to be a “zero-sum” game, where if one person has her needs met, the other doesn’t.

When Is It Time to Pull-Back?

As a bedside volunteer for more than eight years, I sat with dying patients and their families once or twice a week for up to four continuous hours. Sometimes I’d stayed overnight with patients when I was asked to do a vigil (when a patient is close to death). Regardless of how demanding my responsibilities, I knew that, when I left the bedside, I’d have three to six days to “recover.” It was a time to prepare myself for the next week’s activities, which might range from cooking a meal to witnessing a friend’s active dying.

It was a luxury many caregivers didn’t have.

Psychological Readiness

There may come a time when, despite your wanting to care for your loved one, it may not be possible. Either you’re physically unable, or the emotional strain on you has become unbearable. You may need outside help to come into your home, or you may need to place a loved one in a care facility.

It’s a difficult decision, especially when a loved one pleads to remain at home or be cared for only by you. But doing either might endanger him and be so punishing for you that you are no longer able to serve him competently.

The decision whether or not to place a loved one in a care facility often has more to do with emotions rather than practical issues. Two of the most critical are memories of a loved one prior to the illness and issues of abandonment.


Caregivers will often feel guilty even thinking about placing a loved one in a care facility. The guilt comes from feeling they are abandoning a loved one who has been a significant part of their life. The reasoning goes, “How can I place him now in a facility when he has contributed so much to my life?”


We often look at present situations as a continuation of the past. For example, “My husband loved having conversations about politics before his illness, so I try to have them now.” One thing we know about caregiving and illness is that nothing is static. You can’t assume what was important before his illness remains a high value, nor the personality of your loved ones is stable.

Holding on to the past often is an attempt not to lose the person for whom you are caring.

Even in the presence of this “new person,” you may be clinging to what he was prior to the illness.

Before Selecting a Facility

While it can never be too early to investigate facilities, there are strategies that can be used as a mid-point to placement: these are the use of senior centers and the development of criteria for placement.

Senior Centers not only offer caregivers needed breaks but also can be stimulating to loved ones and prepare the loved one for placement. Almost every community has a senior center. Some are affiliated with national organizations, while others are local.

The range of services they provide varies greatly.

Obviously, for someone confined to bed, senior center services may not be appropriate. Some senior centers have programs for those with specific illness, such as dementia. And others will pick up individuals in the morning and bring them home later in the day. The amount of time offered for day care varies greatly.

Some loved ones may be reluctant to go to senior centers. They may not want to leave the house or may fear trying something new. You’ll likely find that as your loved one’s illness advances and he becomes more dependent on you, he will display increasing reluctance to separate. One strategy is to start using a senior center while you loved one is feeling more independent.

Another strategy to make the transition easier is to go with him on the first day, or even on subsequent days, and stay until he feels comfortable. And a third strategy is to have him take something along from home that has produced a sense of familiarity or calmness in the past, such as a favorite hat or shirt, or maybe a picture of you.

What you want to help him avoid is the feeling that he is going from a safe, stable environment to one where the structure is unknown. You’ll also need to assume that, just as your loved one’s illness is progressing, so are the illnesses of other clients at the senior center, and the stability your loved one encountered yesterday at the center may change today. As the condition of the other seniors change, they may no longer by physically able to spend time at the center.

Developing Criteria for Placement

There are no hard and fast rules for when placement should occur. I’ve counseled caregivers who had decided no matter what they needed to sacrifice they would never put a loved on in a care facility. The decision often came with terrible consequences the caregiver never imagined could occur. For others, their sacrifices felt justified.

Think in terms of thresholds—yours and your loved one.  What will you need, psychologically and physically to continued home care for your loved one? What will your loved one psychologically and physically need to remain safely in your home?

Once you know the thresholds, you can either make the decision for placement when they are crossed or use various strategies (e.g., senior centers, additional paid help, stress-reducing activities, etc.) to avoid crossing the thresholds.

Selecting a Care Facility

I’ve often heard the phrase, “I’ll never put her in a nursing home” as a generic condemnation of all care facilities. While many facilities deserve the terrible reputations they have, other provide wonderful care.

Many people believe that the more expensive the facility, the greater the likelihood care will be outstanding. However, the cost of services is not always an indication of their quality.  I served a woman at a small, inexpensive nursing home with staff so caring that I would have felt comfortable being placed there. I’ve also been in expensive assisted living facilities where the selection of staff didn’t match the scrutiny given to choosing furniture.

So how to you decide on a facility? Recommendations are always helpful but are often based on limited knowledge. A friend’s loved one may have had a wonderful experience in a certain nursing home ten years earlier. But the likelihood that the same staff members are still there is remote.

There are two different approaches you can use for selecting a facility. The first involves the thought “I want the very best there is for my love one, regardless of the cost.” For someone with substantial financial resources or a generous insurance coverage, this is an appropriate guiding principle. But for most people, the cost of an “ideal” care facility can be out of reach, especially if their funds or Medicare reimbursements are limited. For them, the quest is “Of all the facilities I can afford, which offers the best care for my loved one?”

Below are nine questions you should feel free to ask any facility manager or owner.

  1. Are you licensed by the state and/or a national association?

  2. Are your employees bonded?

  3. Has a background check been run on every employee?

  4. Can I see the background check of the person(s) who will be assigned to my loved one?

  5. How much training do your caregivers have?

  6. Have there been any complaints against your agency or employees, and if so, how ere they resolved? (This information is available from your state licensing agency.)

  7. Are your employees required to seek continuing education?

  8. What services can my loved one expect, and how often will they be given?

  9. What is the total monthly cost?

A reluctance to answer a few of the questions may involve legal obligations. But if the facility administrator won’t answer many of them, it may be an indication that a potential problem exists.


The placement of a loved one into a facility may be one of the most gut-wrenching decisions a caregiver can make. It’s one that often involves more psychological issues, such as guilt, rather than physical needs. Unfortunately, most of us delay even thinking about the decision until it’s past the point that our loved one requires a placement. By waiting until placement is needed, options are reduced or irreparable damage is done to relationships and the psychological well-being of both the caregiver and the loved one.

At some point, you may become a midwife for your loved one. Just as a midwife gently helps a newborn into the world, you can gently aide your loved one’s passage at the other end of the continuum. Caregiving often involves choosing between two less than perfect options. Although you may wish the choices were greater or the ones presented to you better, we often have to choose between the lesser of imperfect options. 

Remember, you are doing the best you can given the circumstances of your life.

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