For many frail older Americans, assisted living has become an increasingly popular alternative to remaining in their homes. You can live in a comfortable residence, receive the services that you need, such as help with bathing and dressing, as well as avoid the institutionalized setting of a nursing home.

But finding the right residence can be a daunting challenge. For starters, the cost is high—in 2017 the median fee for a private one-bedroom was $45,000 a year, according to Genworth, a long-term care insurer, with most residents paying out of pocket, though some qualify for Medicaid. (Medicare generally does not cover long-term care services.)

It's also difficult to judge the quality of care you will get. Two recent reports, which focused on Medicaid beneficiaries, highlight potential problems with some facilities.

More on Assisted Living

A study by the Government Accountability Office, published earlier this year, found significant gaps in the oversight of assisted living. Some 26 state Medicaid agencies were unable to report how many critical incidents, such as physical assault or emotional abuse, occurred in these facilities, often because the data was not tracked.

Another recent study by the U.S. Department of Health and Human Services found that money recovered by state Medicaid fraud units, which investigate and prosecute provider fraud and neglect, rose sharply, by more than 600 percent, in cases involving assisted living last year.  

The assisted living industry says these two reports actually show that there isn't a significant risk at the facilities.

“These recent government reports signal we can all do better—states, the feds, and providers—but they do not indicate widespread abuse or mismanagement,” says Rachel Reeves, a spokeswoman for the National Center for Assisted Living, a long-term-care provider trade group.

Even if those issues are not widespread, shortfalls in caregiving can be a problem for assisted living residents. A 2017 survey for Consumer Reports of state long-term-care ombudsmen, who monitor senior living facilities nationwide, found the most frequent complaints focused on understaffing and delays in response to calls for assistance. And ombudsman data show complaints about assisted living have risen 10 percent in recent years.

“Many more people going into assisted living facilities today have high care needs,” says Lori Smetanka, executive director of National Consumer Voice for Quality Long-Term Care, an advocacy group for state long-term-care ombudsmen. “But many of the facilities aren’t set up for high levels of care.”  

Instead, many assisted living providers prefer to showcase their amenities, such as restaurant-quality meals, lavish lobbies, and cultural event calendars, rather than the specifics of caregiving. That marketing practice reflects the roots of assisted living, which grew out of the hospitality industry, says David Grabowski, professor of health care policy at Harvard Medical School.

“The assisted living industry originally targeted healthier older adults with hotel-like services,” says Grabowski. “But given the level of chronic illness and medical complexity they’re now seeing in their residents, some in the industry are moving to a new paradigm that recognizes you have to deliver both health care and hospitality services.”

Smart Questions to Ask

For families seeking assisted living for a loved one, there are ways to find a facility that delivers quality care in a comfortable setting. The key is to do careful research, says Amy O'Rourke, an aging-life-care expert in Maitland, Fla.

Start by asking these five key questions:

1. What Kind of Help Do You Need?
“Think about what kind of help you or your family member needs now and in the future,” says Amy O’Rourke. Are you looking to help your loved one enjoy more social interaction, or get help with memory loss, or more medical care? Different facilities offer varying levels of care—not all have memory units, for example. The social activities vary as well, so check to see if the book clubs or trips to the symphony fit in with your loved one’s interests.

It’s also a good idea to have your family member evaluated by a physician to have a better understanding of the level of care required and how that might change. That way, you can judge whether the facility will meet your loved one’s needs over the long term.

2. What Is the Quality of Care?
Check into the residence’s licensing and inspection records to see if there are reasons for concern. Depending on your state, you may find this data online—a good starting point is your state Agency on Aging. You can also contact your state ombudsman about the facility’s complaint record. (Go to ltcombudsman.org; use the map tool to find links for your state.

You should also ask if the facility has a registered nurse on staff.  “If the facility doesn’t have one, your loved one may end up going to the ER more frequently,” says Bobbi Kolonay, an aging-life-care expert in Allison Park, Pa.

To get a feel for the quality of life, make multiple visits to the facility. Go for meals and during the weekends, when fewer staff are on duty. And speak with residents and their families about their experiences.

3. What Are the Real Costs of Care?
As noted above, the typical cost of care is high. And add-on fees could push those costs even higher, which will stretch, or exceed, many retirees' budgets. (Read this story for tips on affording assisted living care.)

Be sure to get a written list of fees and charges from the residence, and check to see that they’re included in the contract. While some facilities have all-in costs for room, board, and a particular level of care, others have a point system or charge à la carte. Find out what circumstances might lead to more fees, such as needing help walking to meals or falling ill for a week or so.

Given the high costs involved, it can be a prudent move to hire an elder law attorney who is familiar with local facilities to review the terms of the contract.  

4. Can Your Loved One Age in Place?
One of the biggest risks for assisted living residents is involuntary discharge, or eviction, which can happen through lack of payment or when the care required exceeds the facility’s ability to provide services. These circumstances might include cognitive decline, lack of mobility, or complex medical needs.

Find out what situations might trigger a discharge, and whether you could hire private aides if more care is needed. Also ask what assistance the facility would be able to provide if a move is required, says Kolonay.

Some nonprofit facilities, for example, may help a resident running low on funds to qualify for Medicaid, which could pay for nursing home care, or funds that may help your loved one stay in place.

5. Will Your Family Member Have an Advocate?
Once you’ve found a residence for your loved one, it’s important to have family and friends drop by regularly. That way, you will be able to spot any lapses in care quickly, which is especially important if your family member is ill or confused and cannot advocate for herself.

If you or your family are not able to visit regularly, consider hiring an aging-life-care expert or asking a friend living nearby to check in on your family member. Spotting issues early may help prevent more costly problems later. And if the assisted living management knows you’re keeping a close eye on your loved one, that can help ensure the quality of care.