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I'm going to go back and look through all the paperwork from my mother's admission to her assisted living facility, but I do not really feel that she was assessed and I did not receive any detailed care plan for her. Initially one of the administrators or health director (or whatever) made an appointment to go to my mother's home to "assess" her. That appointment was cancelled however, and the person said she would just assess my mother after she moved in. I've never seen this assessment or any kind of care plan. When I've asked if we can meet regarding her care I've generally been asked what I want to talk about or what I'm concerned about and no one is available to even discuss scheduling a specific time to meet. I really feel like staff have avoided this topic and do not get back to me. They really have not acknowledged that something like a care plan meeting even exists, or should happen. I feel like I've been negligent in not pressing the issue but I also feel like I deal with enough on a daily basis and sometimes just want a break from mom's issues. Caregiving was overwhelming prior to the move to assisted living.


Since the move to assisted living I've pretty much discovered that the facility is low on residents and as a result very low on staff. I don't think anyone gets assistance with much unless they are together enough to ask for help on a regular basis. Please let me know what others are experiencing.

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My in-laws were in a place just like where you have your mom! We chose it for the same reasons you did. Rather than going for a formal care meeting, you should become well acquainted with the house manager for moms house and as many of the staff as possible. Talk to the house manager about your concerns-her not coming out to meals-and say that rather than taking her meal to her you’d really appreciate it if they could bring her to the meal. Older people often lose track of time. If the meal times are sometimes affected by staff preferences and/or resident care that may put them behind schedule, then it is more imperative that the staff know it’s important to go tell the residents it’s time to come eat. We really courted the good graces of the house manager and the overnight staff as that’s where we seemed to have the most needs.
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cskrno Jun 2022
Thanks for taking the time to respond. I do try to talk directly to the care staff as much as possible. My mother's "house" does not have a house manager, maybe because only 4 of the 12 apartments are occupied at this time. Direct care staff are spread pretty thin and go between several houses. I did in fact schedule a meeting with the administrator then was rescheduled with the health director. She at least showed me the care plan. She didn't give me much time but gave me a copy and asked that I make notes about any areas of concern. She did note that they had my mother sign the plan since I wasn't yet guardian at the time it was written. Nevermind my mother is legally blind and has no recollection of any discussion. A step at a time. Right now the daytime caregiver is very caring and seems to do her job well. I'm still hoping this facility will become what it has the potential to be.
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I was curious so I went to the Nevada Dept of Health's website to read their regulations. Deciphering ancient Egyptian hieroglyphics was a lot easier! That being said and all states being different, I think your Mother must have a care plan in place (it's required in NJ) and it should have been a requirement for her admission (how do they know if they are meeting her needs if they didn't assess them?).

If the Administrator is balks at the meeting your are requesting, you can always mention you are thinking of call the Nevada state Ombudsman's office (I assume they have one.......... I got so lost in the website.... I couldn't tell but I think that might be a requirement). That frequently works wonders in getting folks attention.
If that doesn't work.... you may want to consider moving your Mom to a different facility that is more responsive and that has more residents and possibly more staff. Be aware that staffing is an issue at most healthcare facilities post covid and that more residents unfortunately doesn't necessarily mean more staff.
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cskrno Jun 2022
It was EXTREMELY hard for me to find the regulations in any user-friendly format!
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So your mom is in AL? Not Memory Care or a Nursing Home but AL?

By & large ime an AL does not do or provide staff for a detailed care plan. That level of care is done in a NH (& sometimes MC) and are required to do a care plan and do an initial one and thereafter every 90 days. It’s required as NH as they provide skilled nursing services and get paid in some way by Medicare (Medicare not Medicaid) for those services and there’s also a MD that is medical director of the NH services who also bills to Medicare. MediCARE requires care plans and there’s reporting forms that must be submitted to Medicare.

If she is in the usual AL, she is fully expected to be able to do the majority of her ADLs on her own and perhaps some with staff support. Like to help her do a back zipper or help her get into the van that takes them shopping. She should be able to transition herself from bed or chair to the bathroom on her own. She should be able to set her own clothes out, get dressed & down to the dining room at the appropriate time, dine & be civil. It’s unfortunate that a needs assessment wasn’t done on her in her old living environment ahead of ever moving into AL.

If she cannot then an AL can offer a list of services that staff can do for a resident and the AL can charge for those. Probably the most common is “medication management” so AL has an CNA come around with residents RXs and mini water bottles and oversees them taking their pills OR it’s done electronically from a central area at the AL which staff monitors. $300-$600 a mo fee added to their mo rent.

So right now if you were to go to the AL and spend the entire day, can your mom do what 90% of the other residents physically can do? Can your mom do mentally what 70-80% of the other residents can do? Like this could be getting up and dressed appropriately then off to the dining room or activities at the scheduled time; can recognize what a fire bell is and understand where to go to outside for a fire drill.

I’m going to guess that she cannot and if so, this is why you are not yet getting your calls & emails answered. That the AL is working up her assessment and it will be a timeline on all the inabilities she has and why she needs a higher level of care beyond what this AL can ever provide. AL will do a “we love your mom but….30 Day needs to move Notice”. Really, If you can easily see that your mom cannot so what the others do, be proactive in speaking with admissions as to what facilities other residents have moved to for MC or NH. If your mom needs to have her medical history beefed up to show she’s “at need” for skilled nursing care and mom doesn’t have a gerontologist ask the AL what docs their residents see. Should mom not have the $ to private pay for care, that means she will need to file for LTC Medicaid and by&large for most states that requires “at need” medically for skilled nursing care in a NH facility (rarely do AL participate in LTC Medicaid) and “at need” financially for whatever income / asset limits your States LTC Medicaid program has set. Tends to be 2k for assets & $2200 for income. Good luck in all this.
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cskrno May 2022
First, I appreciate the time you took to respond and you sound very knowledgeable, but I'm not familiar with a lot of your abbreviations NH, MC, LTC Medicaid. The assisted living facility my mom is in has a flat fee for residents which was one of the reasons I selected this facility. Though they didn't do an assessment with her, I did spend a lot of time discussing mom's abilities and difficulties in regard to ADLs and indicated that I wanted to be sure the care level there was appropriate and adequate for her. She seems pretty similar to most of the residents that I've met and spent some time with (I go there at least every other day and for some events). Some are more capable and independent but some clearly have higher needs than my mother. It was important to me that I try to find an appropriate facility and not have to move her more than once if at all possible. Most of us don't do this more than once or maybe twice in our lives so we do our best. I will add that my father spent time in skilled nursing so I have some experience with that setting and do understand that assisted living is different.
This facility has "houses" with 12 studio apartments per house and supposedly offers family style meals within each house. It seemed like a nice setting with more social opportunities than a group home but less overwhelming than the really large facilities that seemed more like big hotels. I would at least like her to be invited to go to meals and some planned social activities. Most often staff take her meals to her room which leaves her isolated in her room most of the time. She is capable of getting to the dining room herself but mealtimes aren't very regular. Census is WAY down apparently and there seem to be only 4-5 people in her house.
To me, your description sounds more like what I would think of as independent living. I visited some facilities that started pricing at that level and then increased the price for every minute of assistance needed, like med management added $500/mo. I guess that is common. I had to do a lot of digging to find the information but I believe an individual care plan is required for assisted living facilities in Nevada. I will be inquiring further about this with the administrator. I certainly want to know if her needs exceed their program and capabilities so I can start looking for a better placement if that is necessary.
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We were definitely given an intake assessment and regularly scheduled progress meetings. I was their 5-6 days or week so could see for myself and discuss her care almost daily. We were blessed to have my mother, who passed away on Easter Sunday after 8 years there, in a loving as well as caring environment. Whether it's a law or not, I would insist on regular updates Tell them that is the reason. It's a logical reason and their responsibility to you. They're paid to do that. I'd get my updates if I had to camp out outside someone's office! Frankly, and I'm sorry to be so blunt, but it sounds like you have your parent in the wrong facility.
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cskrno May 2022
Thanks for your reply. I was really given the big sell when I toured this place and met with administrative staff. I am worried that it might be the wrong facility but still hoping that issues can be resolved and not have to do another move. She likes her apartment and says that overall people are nice to her. It was tremendously difficult to make this move from living on her own in her own home. It is good to hear that you had a very positive experience.
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First let me tell you this is old news. I have to imagine things have changed dramatically since Covid started however in Sept 2018 when my parents went into LTC together I could not have asked for a more supportive team. Sixty days after they had arrived I had a meeting with a team comprised of the doctor, a nurse, dietician (and the lead in the kitchen) head of PT, the Life Enhancement Director and 2 PSWs.) Mom was in late stage dementia and Dad had a number of health matters so my meeting with their team was very productive and I was able to assist them by providing some insight to their dynamics as a married couple ie, Dad was very easygoing but not very helpful. Mom by then could not be away from him without fretting. They knew in advance some of the special days in the year when my parents might be more emotional (family birthdays and such) After the first meeting they were annual and altho Mom passed within 6 months of arrival, the team were unbelievable as they ferried Dad through his grief and also later when he diminished (I lost him in Jan 2021 to Covid)

FWIW prior to each meeting I was asked what I wanted to discuss (personally I thought they asked so that the appropriate team members were available at the meeting) and I did not receive a written assessment or care plan although I made notes during each meeting. I also received calls from the nurses any time there was a change be it meds, diet, mobility and later a tumble and fall.

Oddly, I suspect the fact that I lived 500 miles away aided me. The team certainly gave me more latitude during the Covid visits than other families were offered but I was careful to never abuse the situation and by all standards Dad was a happy go lucky soul right up to the end, always with a kind word to the staff, a please, a thank you (not always the case with other residents so I heard).

Some people may think it was sucking up but in my mind the staff was caring for two of the most important people in my life so it was important to me to think of all of us as a team...my brothers and sisters in arms as I referred to them. Not sure if this helps but I'm wishing you the best.
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There may be some confusing terminology from time to time. Assistive Living is NOT necessarily regulated by the Federal Government via Medicare and Medicaid.

So first question to ask, is your mom's AL actually Medicare and Medicaid qualified? IF NOT, then the AL is state regulated. ONLY Medicare and Medicaid qualified facilities [which may have AL wing but also have SNF (skilled nursing facility aka nursing home), Rehab (qualified Medicare Rehab - post acute care treatment), qualified Medicaid-covered long term and/or memory care] have a federal law requiring "a care plan" that is reviewed no less than every 90 days.

Those Medicare and Medicaid qualified facilities, also have a myriad of other requirements such so many RNs per patient load. And, in such facilities there would be a physician on-point for her care (could be a contract MD, rather than on staff but a physician you can speak with). And there would be a social worker assigned to her, a lead floor RN too; all of whom you should be able to contact and speak with about her care (not that you call them every day or week, but certainly more often when just arriving).

If you mom's AL is not Medicare/Medicaid approved then any "care plan" or "care plan meetings" may be required by state law, but each state is totally different. You may want to contact your Area Agency on Aging for assistant too or start with the Ombudsman as others have suggested. But if the AL is only state regulated, some states are a "hot mess" in how they regulate these facilities.

Good luck, this is not a fun journey.
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cskrno May 2022
This is not a Medicare or Medicaid regulated facility and is totally private pay. They do have a physician that sees all the residents though that is paid through her Medicare the same as if she were leaving the facility to see her primary care physician. There are no nurses though I think the Health Director is a nurse. I sure hope I am correct in thinking there is some agency that regulates this type of facility.
I really can't tell you how many agencies, social workers etc etc I spoke with in the course of trying to find a safe place for my mother to be appropriately cared for. The circle kept coming back to the agencies providing therapies and caregiving on an hourly basis. I do think Covid has changed EVERYTHING. I couldn't even find a local caregiver support group which I wanted desperately just to try to find out how other people/families had dealt with these issues.
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Here you are, if you go to this webpage you will find more information and some links/helpline numbers but this is what it's about:

https://adsd.nv.gov/Programs/Seniors/LTCOmbudsman/LTCOmbudsProg/

Ombudsman Services:
Assist resident with concerns related to day-to-day care, health, safety, and personal preferences.
Provide information to the community regarding long term care in Nevada;
Provide education to residents, families, facility staff and others on a variety of issues related to aging, long term care and resident rights; and
Provide in-service training for long term care professionals regarding trends and best practices to improve the quality of care for residents

Who Can Make a Report to the Ombudsman Program?
All residents of long term care facilities;
Friends and relatives of persons living in long term care facilities;  
Health care professionals; and
Long term care facility staff members.

*****************************************

In my service we work to a support plan, and I can't quite imagine how we would work without one - okay, we'd still look after people but there would be no consistency, no agreed standard, and no actual plan for each call. It would be chaos.

Speaking just for myself I often find that a support plan and the daily notes that depend on it are not necessarily as professional or as detailed or as accurate as might be ideal. But they're always (almost always) *there* (there was one occasion when there wasn't any plan or any client information, all we had was the name and address; but that was an urgent and very unusual situation which took three days to sort out).

This facility sounds as if it might be struggling. That's not necessarily a reason to move, but it's a very good reason to push constructively for this basic routine to be carried out properly.
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cskrno May 2022
Thank you so much for this information. I do think this facility is struggling and I want to think they have good intent. I also don't want to ask for or expect care that is above and beyond reasonable. I do think there should be an agreed upon plan for my mother's care and they should strive to adhere to that plan. I'm still learning what I can and can't expect but I have learned that I need to have this more specifically laid out for me. I've copied your answer and will look into your information further. I thought I was pretty good at navigating our health system etc but it is so difficult.
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Good Morning,

Assisted living is real estate...

Folks in my neck of the woods in Assisted Living there is no assistance. Basically, everything is a la carte. You get a room, which is a usually a studio and a fancy menu. After about the 3rd day (just like being on a cruise ship) the resident wants soup and a sandwich or oatmeal. The fine dining wears off.

In my experiences of touring these facilities, everything is an add-on. You have to have your mother's primary care doctor or specialist assess your mother and write orders for care for your mother at the Assisted Living facility (ex. physical therapy, occupational therapy, CNA to dress Mom, shower, walk to and from the dining room). In my opinion, I always thought that you pretty much had to be mobile, if you are not up to par (if you break a hip) basically you're out of luck.

Another thing is in my neck of the woods they don't allow bed rails on the bed, which concerned me. The people they have filling prescriptions only have to train for about six weeks, that's it.

The fancy brochures and lobbies are attractive but it doesn't sound like they are meeting your mother's needs. Read your contract and you may have to start looking around. Be sure you know beforehand what is going to transpire.

I understand that when someone is frail and elderly you need to place them because you need immediate care. But from what you wrote it sounds like they are not delivering. A lot of these places have new hires after the Pandemic. There is no one to train them properly and they are run by a Board. There are signs on every street corner in my neighborhood for CNA, RN, LPN, etc. p/t, f/t with sign on bonus.

You need to contact a Social Worker and your mother's Primary Care doc and tell them what services you think your mother needs. You know your mother best. Don't let the Assisted Living be your mother's mouthpiece because it sounds like too much grass is growing under their feet. It's really not their role.

Remember, it's real estate, there is no assistance. These are (2) separate issues. It's up to you to bring in the medical services. Contact your mother's insurance company and sign up for the PCP portal so you can know what's going on and sit in on the assessment.

I rather tell you the truth because I have learned all of this over many years. You are paying for room and board and perhaps a nurse for too many residents. The fees can add up. For example I was told if they fill (10) or more prescriptions and dispense prescriptions, that would be $495 per month.

You probably felt a relief when your mother was placed but there are some loose ends. I hope this helped. A lot of it is probably what you didn't want to hear but I was surprised too to learn how little assistance is offered for that kind of $$$.

Knowledge is power and the Primary Care Doctor and Nurse Manager can guide you. You are in my prayers...
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igloo572 May 2022
Omfg, “assisted living is real estate” that is so accurate. This should be hands down winner of bumper sticker of the year for anyone dealing with facility placement.
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Is it that they don’t have a nurse on staff right now? Maybe that’s why they’re avoiding voiding it? Definitely needs to be done. With my mother from Arizona to here, they had the nurse in Arizona to her assessment for them and then the nurse at the memory care reviewed it. Funny they missed the fact that she was incontinent, but I saw in the plan she was noted to be continent! Ha ha had that changed. I don’t mean ha ha and funny but you know.

I noticed your note about a new administrator… my mother was at her memory care eight or nine months, first administrator was let go , the assistant administrator was promoted to temporary, they hired someone for that position, and fired the person they promoted temporary, and about six weeks before my mother passed they promoted one of the caregivers to the administrator position. Good help is hard to fine…. They are also on the third nurse that they are hiring.
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cskrno May 2022
Staff changes seem to be constant. I think they really try hard to keep the resident to caregiver ratio at the lowest level allowed so they are always letting people go and then they hire new people.
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My Mom was assessed by the RN who was in charge of the staff. She asked me what could Mom do and not do. Her likes and dislikes. Got her prescription list and doctor info. There were 4 levels and Mom was #4. She needed help with all her ADLs. Three months after her admittance, I had her first actual care meeting.

Its been a month since your last post and I can't believe there has been no interaction. Just read you are her guardian so no reason not to talk to you. Did you give them a copy of your paperwork? Not sure if your State Ombudsman covers ALs but I would call and ask. A call from the state will get some results.
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There should definitely be a care plan for your mother in AL! How else will they know what services she needs? Medication administration, bathing, help with dressing/undressing, etc? There should be care levels at the AL as well, based on how much help she needs, which are charged accordingly. At my folks' place, the care was based on a point system, and 12 points were included in the monthly rent. So, for 12 points, mom could get 3 'free' services (each service cost 4 points). So it sounds ludicrous to me that nobody has met with you to discuss your mom's needs and their plan to address them.

I would call the Executive Director immediately and demand a meeting with him or her in person so you can address these concerns. And if there are few residents who live in this AL and fewer caregivers, that sounds like a big red flag to me! See what the ED has to say about that, and what the plan is to hire people and get the ball rolling here. Otherwise, you may have to move mom to a different ALF that's been established for a long time & has good reviews from satisfied residents.

You are not out of line for expecting a care plan for your mom; THEY are out of line for not having one in force for her by the time she moved in, and for not having assessed her prior to her move in date. A big part of why you moved her into AL to begin with was to relinquish your duties as her caregiver and move them over to a staff of others to deal with. If that's not going to happen, what is she paying for? 3 meals a day? Come on folks, that's ridiculous!

Good luck getting the answers you seek!
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cskrno May 2022
Thanks for your response. I do plan to ask the NEW administrator to meet with me this week. It's pretty amazing how skilled everyone in the office is at avoiding my requests for this meeting. I might also add that it was very hard for me to find any specific information about Nevada guidelines for assisted living aside from the actual very long detailed actual laws in tiny print that no one could wade through. I have to admit that I do worry some that my complaints could result in poorer care for my parent. Wish me luck.
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