You will probably tour three or four places before you choose, and most of them will look lovely. Fresh flowers, a piano in the lobby, a marketing director with a folder. None of that tells you what 3 a.m. is like on the memory care floor, which is what you most need to know.
This letter is the list I wish every family carried in with them: what the different kinds of places are, what to ask, what to watch for, and the one question most families forget.
First, know what you are looking at
The names are used loosely, and the differences matter.
- Assisted living is housing with help: meals, medications, some help with bathing and dressing. Many are not set up for someone who wanders, is up at night, or needs two people to help them move.
- Memory care is a secured unit or building for people living with dementia, sometimes inside an assisted living community. It usually has locked or alarmed exits, staff with dementia training, and a daily structure built around it, though what a place must provide to call itself “memory care” is set by each state and varies widely.
- A nursing home (skilled nursing facility) has licensed nurses around the clock and is built for heavier physical care: lifting, wounds, feeding, tubes and complex medications. Some have dedicated dementia units.
A useful rule of thumb: if the main problem is behavior and safety, memory care is often the right fit. If the main problem is physical care, look hard at nursing homes. Many people eventually need both, which is why the question further down this letter matters so much.
The money, plainly
Medicare does not pay for assisted living or memory care. Room, board, and help with daily care are paid privately, through long-term care insurance, or, in some states, through Medicaid programs that may cover the care services but cannot pay the room-and-board portion (some states help with that separately). Nursing home care can be covered by Medicaid for people who qualify financially, and the rules vary by state. Medicare covers only short skilled-nursing or rehab stays, not long-term nursing home care, though it still pays for doctor visits and hospice wherever your person lives. Ask every place, in writing, what is included in the monthly price and what costs extra. The base rate is rarely the bill. Many memory care communities add a “level of care” fee that rises as needs increase, so ask what the bill would be at each level, not just today’s.
You don’t have to build the shortlist alone
Honesty note: the link in this section is an affiliate link. If you use the service, this site may earn a referral fee, at no cost to you.
Free placement advisors can put together a shortlist of local memory care communities with openings in your price range. A Place for Mom is the largest such service. It charges families nothing directly because the communities on its list pay it a fee when someone moves in — which also means its list only includes communities that pay, and it is generally not set up for families who will rely on Medicaid. In 2024 the chair of the Senate Aging Committee questioned how neutral these recommendations are.
So treat it as a starting point, not the whole map, and check every name on it against the inspection records below. Expect calls from the advisor and from the communities once you register. Your Area Agency on Aging, reached through the Eldercare Locator at 1-800-677-1116, is the free public route and can tell you about options outside any network.
Before you visit: check the record
For nursing homes, look the building up on Medicare’s Care Compare. It shows inspection results, staffing, and quality measures, including the share of long-stay residents who receive antipsychotic medication. A high number is worth asking about.
For assisted living and memory care, there is no national rating. They are licensed by your state, and most state licensing agencies publish inspection reports or will send them on request. Search your state’s name with “assisted living inspection reports.” Read the actual findings, not just the count.
On the tour: what to watch
Go at the wrong time. The Sunday-morning tour shows you the building. A weekday visit in the late afternoon or early evening, when sundowning tends to peak, shows you the care. Ask what time shifts change, and try to see that too. Then drop in again, unannounced, at a mealtime.
Watch the staff, not the decor. Do they speak to residents at eye level, by name, and explain what they’re about to do? When a resident is upset, does someone go to them, or does everyone look busy? Are residents engaged in something, or parked in front of a television?
Use your nose and your eyes. A passing smell happens anywhere. A building that smells of urine all over, residents in soiled clothes, or call lights left ringing tells you about staffing.
Look at the doors and the outside. Exits should be secure without feeling like a prison. A safe garden or courtyard people can use freely is worth a great deal to someone who needs to walk.
Questions to ask a memory care community
- How many care staff are on the memory care unit during the day, the evening, and overnight, and how many residents?
- How much dementia-specific training do staff receive, and how often is it refreshed?
- What is your staff turnover? How often do you use agency staff?
- What do you do when a resident refuses a shower, becomes aggressive, or tries to leave?
- How often do you use antipsychotic or sedating medications, and who decides?
- What happens after a fall? When do you send someone to the emergency department, and do you call the family first?
- Is there a nurse on site, and at what hours? Which doctor or nurse practitioner sees residents, and how often?
- Do you work with hospice? Can residents stay here to the end of life?
The question most families forget
“What would make you ask us to leave?”
Many assisted living and memory care communities can discharge a resident whose needs grow beyond what they are licensed or staffed for: two-person transfers, certain behaviors, needing a feeding tube, or needing skilled nursing. Families usually learn this at the worst moment, often with about thirty days’ notice and sometimes less; the rules are set by each state, and your free Long-Term Care Ombudsman can help you respond. Ask for the answer in writing, and ask to see the discharge section of the contract before you sign. A place that can care for your person through the late stage and into hospice may spare them a second move, and second moves are hard on people living with dementia.
One practical thing for moving day: many homes ask for every item of clothing to be labeled. A pack of iron-on name labels (paid link) saves a lot of lost sweaters.
When a sudden change comes after the move
New confusion, a fall, or a sudden change in behavior in the first weeks is easy to put down to “settling in.” Settling in happens gradually. A sudden change is medical until proven otherwise — infection, pain, constipation, or a new medication — and it deserves the same phone call it would get at home. The rules are in when to call the doctor and when to go.
And for you
No place will do things exactly the way you did. That is not the test. The test is whether your person is safe, clean, comfortable, treated kindly, and noticed when something changes. If you find that, you have not handed over the caring. You have handed over the night shifts, and kept the part only you can do. If you are still deciding whether it is time at all, start with is it time for long-term care?