I Promised Mom I’d Never Put Her in a Nursing Home

These promises are hard to keep, especially if Mom starts failing and living in her own home is no longer a safe option.

But what are your alternatives and how do you get the best information to make the right decision? Families everywhere are facing these dilemmas as more and more older people are simply living longer.

Monte Levinson, MD, FACP, a Certified Medical Director and Vice President of Medical Affairs (and Medical Director) of the Presbyterian Homes in Evanston, Illinois, talked about the issues. He is the former President of the American Medical Directors Association.

“The nursing home industry has done nothing to clear up the confusion about which living arrangement may be the right place for mother,” Dr. Levinson said.

Assisted living was a marketing creation to respond to those of us who say, “I promised Mom I would never put her in a nursing home.” The assisted living arrangement provides “sheltered care with a chandelier” with minimal staffing, he said.

The concept of aging in place

Mom may be frail physically (unable to dress or cook or walk) or have cognitive needs (be forgetful, confused or unable to make decisions), but it’s usually a combination of both that start Mom down the path toward living with assistance.

Our elders age in place, a term Dr. Levinson used to describe the process that goes on wherever Mom may be living. She may fall, become confused, leave the stove on, the phone off the hook, and progressively require a blend of services to assist her as she ages.

Because care will become progressive, he recommends that you seek a continuum of care options. Look across the entire spectrum of what is being offered in the facilities you visit.

A continuing care retirement community (CCRC) is usually an all-encompassing facility with independent to terminal care on one campus. At first, Mom may need simply retirement living, where the snow is shoveled and grass is cut. Or she may need a place where a little help is given. Or a lot. You want her to be in a place that can provide a continuum of care for her as she ages in place.

How does the family know when “it’s time”?

The best place to grow old is in your own home, but we cannot turn this country into a nation of single-bed nursing homes,” Dr. Levinson said. Those who try these arrangements realize how difficult it is to get reliable and consistent caregivers to provide in-home assistance.

Moving Mom out of her home is a difficult decision. And it’s different for every family. Consider if family members are close by and how involved (or not involved because of work or other obligations) they are with Mom right now. Care often falls to a daughter or daughter-in-law, Dr. Levinson has observed, and that’s not always a good thing. These are complex issues, and the problem of caregiver stress is very real.

Long-distance caregiving is also difficult. Consider the scenario if you phone Mom at home and there is no answer. The phone could be off the hook. Or she could actually have fallen and not be able to get to the phone. Your imagination makes the situation even worse. Or she could simply be at the neighbor’s. You’re 800 miles away. What do you do?

The decision to find a place for Mom must be made with the family and the potential resident along with the person involved in their health care, Dr. Levinson advised. But don’t jump the gun:

  • Mom may have physical or cognitive impairments because she isn’t taking her medication properly. The solution may be as simple as providing a medication box with each day’s dose in each compartment. The problem of possible overmedication must also be considered. Talk to her doctor about these issues.

(Mom may be depressed. This is a vastly overlooked condition among the elderly. It’s understandable why they might have depressive symptoms. They can no longer do the things they used to do. You’d be depressed too. Depression can be treated, but first it must be diagnosed.) 

  • Mom may not be eating well. Arranging for Meals on Wheels may solve that issue.


  • Is the home safe? Once things such as throw rugs are removed and handrails installed, get Mom an emergency call device to wear around her neck and encourage her to use it whenever it is necessary.

  • Sometimes by arranging for a visiting nurse to come by a few times a week, you can keep Mom in her home—at least for now. It does take a village, Dr. Levinson acknowledged, and the lonely elderly can do well in their homes if they have interested, friendly visitors who keep them from becoming socially isolated.

  • Consider using a care manager. Care managers are social workers or nurses who have educated views on which facilities are good and which are not. National and local organizations of care managers can sometimes be found on the Internet. Look in the phone book under care managers (or sometimes referred to as case managers).

When it’s time

As you begin your search for a place for Mom, talk with her doctor or the doctor’s nurse. Ask this question: In your experience, what facility would you want to put your loved one in? The health care professionals may have ideas; they work with these facilities and residents of them in their practice.

Then talk with friends and relatives about places. Narrow your search to 3 places. The good ones will surface.

  • Check to see that the facilities have proper accreditation through the Joint Commission  (www.JointCommission.org) or the Commission on Accreditation of Rehabilitation Facilities (www.carf.org).
    Accreditation doesn’t mean they’re perfect, but it gives them a leg up.

  • The American Association of Homes and Services for the Aging provides helpful information online (www.aahsa.org).

  • Also check on violations through Medicare (www.medicare.gov/NHCompare/home.asp).
    Again, just because a place may have a violation doesn’t mean it’s a bad place.

  • Your state’s department of public health is another source for information.

www.aginginfousa.com Here we have provided all the background checks and references for you. All our resources on our site ARE ALREADY APPROVED.

Are staffing ratios important? “Numbers don’t mean everything. You must focus on finding good care,” Dr. Levinson said. You’re looking for RNs to be on staff, but this depends on levels of care. The sicker people require more skilled staff. The range can be from one staff member for every 7 to 13 residents. Expect fewer staff on duty at night.

Make your first visit

Show up unannounced. Walk around until somebody says, “May I help you?” advised Dr. Levinson. Use your senses, he said. Look, smell and feel.

Do you see residents parked in wheelchairs in front of TVs? Are they dressed in their own clothes or in hospital-style pajamas? What do you observe about the interactions with staff? Is it warm and friendly? Even with profound cross-cultural differences, the caregiving can be warm. Are residents responding to the people entrusted to care for them? If so, you’ve found a good place.

He prefers private rooms with carpeted floors, so falls may not be so serious. The hospital-looking institutional model with long corridors is less preferable than a cluster of rooms in which people spend their days together, sharing stories and memories, and getting to know one another.

Be prepared, Dr. Levinson said. “Mom will never like it.” She has been experiencing a series of losses. Her living space is shrinking, she has lost friends and income, and now she is losing a measure of her independence. She is experiencing loss of physical abilities and intellectual sharpness.

“You’re looking for a place where Mom can function at the highest level, psychologically and emotionally, that she can,” Dr. Levinson said. If activities are too simple, that would be a disservice to her. Food should be presented in an appetizing and appropriate way so it almost “smells like home.”

States set specific rules for determining what services are provided for residents at each level of care (from sheltered care to assisted living to skilled nursing), and the facilities will continually assess their ability to perform activities of daily living: bathing, toileting, dressing, transferring weight (from a wheelchair, for example, to bed), and eating.

Moving Mom is always difficult, Dr. Levinson acknowledged, “Families are riddled with guilt. They want everything to be perfect in the facility. Add to that the guilt they feel that they should be caring for Mom at home.”

Who’s in charge?

Families are entering this process loaded with information, Dr. Levinson has observed. They are reading books and surfing the Internet to become well informed. It’s the children who are far away who are sometimes the least knowledgeable and least understanding. The closest child is doing his or her best in managing Mom’s care. This strife can break families apart at a time when everyone should be pulling together.

Should Mom live near a family member? And which one? This is not an easy decision. A child who gives the most support (financially or emotionally) may not be in a stable job situation and could be transferred. It’s unrealistic to think that Mom would move happily in these cases. But if Mom has outlived her friends and relatives, she may be more open to moving closer to a child who can supply support. E-mail is changing the picture, and plenty of seniors are online and loving it. So physical closeness may not be as important as long as Mom has visitors once or twice a month.

Check out your options before a crisis arises,” advised Leslie Knight, Regional Vice President of the American Association of Homes and Services for the Aging. “Otherwise, you may be forced to make hard decisions quickly during an emotionally distressing time.” Be prepared, proactively.

Look for a care community that provides a continuum of care as higher levels of care are needed,” she said. “Your parent may be just fine in a living arrangement right now, but can that facility ramp up their services your loved one may need a year from now?”

[In this article, we use “MOM” to refer to any elderly family member or friend who requires care.]

About Sue Salach

Sue has a Master's degree in Gerontology and has worked with the elderly and their families for over 30 years and is the Author of "Along Comes Grandpa", a caregiving resource guide, and the novel "If I Walked in Her Shoes". As an ElderCare Expert and Keynote Speaker, Sue employs her comprehensive experience and passion, to educate and promote self-care values to family caregivers and the community at large.
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