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Safety in Assisted Living

Feeling overwhelmed during the "evaluation" visit of a facility? Do you know what signs to look for that tell you it is safe or to RUN? Most people feel lost at the early, appraisal stage. That's why organizations like The Joint Commission and the Agency for Healthcare Research and Quality make serious and widespread efforts to improve health care quality.

Most state governments recognize the Joint Commission accreditation is a major condition of licensure for the receipt of Medicaid reimbursement.

The Joint Commission defined a series of incremental changes applied to hospitals that help them progress toward high reliability.

The Joint Commission changes involve:

  1. Leadership's commitment to achieving zero patient harm
  2. Fully functional culture of safety throughout the organization
  3. Widespread deployment of highly effective process improvement tools

It appears that the safety culture interventions used in hospitals associated with improved safety practices and outcomes make a big difference in patient care.

That was about hospital care safety.

Past studies in nursing homes report a poorly developed safety culture. The voluntary accreditation by the Joint Commission used for nursing homes provides a structure for organizing care processes and is known to stimulate continuous quality improvement in organizational safety culture.

Safety Culture shift in Long-Term Care Facilities

Long Term Care Culture
Long Term Care Culture

The Agency for Healthcare Research and Quality wanted to know if a culture shift in long-term care facilities, similar to the one in hospitals, could improve residential safety too. So, it used a similar approach that involved many facilities accredited by the Joint Commission (specifically nursing homes) to see if strict endorsement factors play a part.

Here is the Agency for Healthcare Research and Quality study on nursing homes, "Safety Culture - Relationship Between Nursing Home Safety Culture and Joint Commission Accreditation"

Even though you're evaluating assisted living, not nursing homes, keep in mind that same factors apply to safety, no matter what type of facility you call home.

Nursing Home Survey on Resident Safety Culture Results

The instrument designed by Westat under contract with the Agency for Healthcare Research and Quality measures the culture of resident safety in nursing homes. They targeted 6,000 Medicare and Medicaid accredited nursing homes for the study.

Of the 6,000 facilities, 523 were from Joint Commission-accredited nursing homes and 3,485 were from non-accredited nursing homes.

From the study, the Agency for Healthcare Research and Quality used the following factors to evaluate the resident safety culture. The nursing home administrators and directors of nursing completed the survey.

Using data from the study helps you, the consumer, be a smarter shopper when searching for good care at a facility.

The list is not a questionnaire nor does it list out what to ask during the visit. Instead, it's a robust set of qualifiers that impacts resident safety.

The take away is to train your brain on the things that enhance a facility's safety - it's what the experts use. And don't you want to use the same safety measures and criteria that healthcare experts use?

Resident Safety Culture

Safety Culture Checklist
Safety Culture Checklist


  • Resident safety is never sacrificed to get more work done
  • Procedures and systems are good at preventing errors from happening
  • When someone gets really busy, other staff helps out


  • We have enough staff to handle the workload
  • Staff has to hurry because they have too much work to do
  • Residents' needs met during shift changes
  • It is hard to keep residents safe here because so many staff members quit their jobs

Compliance with Procedures

  • Staff members follow standard procedures to care for residents.
  • Staff members use shortcuts to get their work done faster.
  • To make work easier, staff often ignores procedures

Training and Skills

  • Staff members get the training they need in this nursing home/facility
  • Staff members have enough training on how to handle difficult residents
  • Staff members understand the training they get in this nursing home

Non-punitive Response to Mistakes

  • Staff members' blamed when a resident's harmed
  • Staff members are afraid to report their mistakes
  • Staff members treated fairly when they make mistakes
  • Staff members feel safe reporting their mistakes


  • Staff's told what they need to know before taking care of a resident for the first time
  • Staff's told right away when there is a change in a resident's care plan
  • We have all the information we need when residents transfer from the hospital
  • Staff is given all the information they need to care for residents

Feedback and Communication about Incidents

  • When staff reports something that could harm a resident, someone takes care of it
  • In this nursing home, we talk about ways to keep incidents from happening again
  • Staff tells someone if they see something that might harm a resident
  • In this nursing home, we discuss ways to keep residents safe from harm

Communication Openness

  • Are Staff ideas and suggestions valued?
  • Are Staff opinions ignored?
  • It is easy for staff to speak up about problems in this nursing home

Overall Perceptions of Resident Safety

  • Residents are well cared for in this nursing home
  • This nursing home does a good job keeping residents safe
  • This nursing home is a safe place for residents

Management Support for Resident Safety

  • Management asks staff how the nursing home can improve resident safety
  • Management listens to staff ideas and suggestions to improve resident safety
  • Management often walks around the nursing home to check on resident care

Organizational Learning

  • This nursing home lets the same mistakes happen again and again
  • It is easy to make changes to improve resident safety in this nursing home
  • This nursing home is always doing things to improve resident safety

Characteristics of Administrators and Directors of Nursing

  • Tenure (in months)
  • Nursing home administrator education
  • High school or associate degree
  • Baccalaureate degree
  • Master's or higher degree
  • Director of nursing education
  • Diploma or associate degree
  • Baccalaureate or higher degree
  • Age (in years)
  • Race
  • Sex (% Male)
  • Member of professional society
  • For-profit
  • Non-profit
  • Chain
  • Occupancy
  • Bed size (number of beds)
  • RN hours/patient-day
  • LPN hours/patient-day
  • Nurse aide hours/patient-day

Assessing assisted living facilities helps you identify areas of safety and the weak links that lead to resident health risks. Clearly, assessing a facility is your first step toward peace of mind and deciding where to live; a place that keeps you safe and healthy.

This is a tool to help you figure out if the facility supports a safety culture. In other words, if the culture supports safety and takes action(s) that enhance a facility's safety--they are safer. But it starts with a culture of commitment around the issues and evidently accreditation, especially one by the Joint Commission--they help facilitate that.

Does Your Assisted Living Community Have a Disaster Plan?

By law, assisted living facilities (ALFs) need to have a disaster or emergency plan prepared in writing. Then the state or local licensing agency approves the plan. The safety of all residents is a top priority for the assisted living. As we discussed in our Dealing with Emergencies and Natural Disasters post, the proper plans and precautions be placed.

Make Sure of Disaster Plans
Make Sure of Disaster Plans

Depending on the natural surroundings of the facility, a disaster plan may include procedures for any of the following emergencies:

  • Tornadoes
  • Earthquakes
  • Flooding
  • Food/Water contamination
  • Volcano
  • Landslide
  • Fire
  • Power failure
  • Communications failure
  • Wildfires

An assisted living facility should also have disaster supply kits stocked with necessary items, usually on the ground floor of the building. The following items be in the kit: enough canned food to last about a week, enough water for each person to use a gallon every day for about a week, battery-powered radio, flashlights, matches, candles, a first aid kit, trash bags, a copy of the disaster plan and sanitation items.

Keeping Residents Safe

In addition to the standard items in the disaster preparedness kit, an assisted living facility also needs to make sure that a resident's care plan can continue with little or no interruption. Facilities should have a backup plan for administrating important medications to seniors, and a copy of each resident's care plan be easily accessible.

In addition to staff, each assisted living facility resident and their families should have a copy of the emergency plan to go over.

Questions to Ask

If you are searching for an assisted living home, here are some questions to ask employees about the building's disaster planning:

  • Does the facility go over plans with residents? Are drills conducted, and how often?
  • If a disaster strikes, will family members be notified? Is there a number that family can call to check on the safety of a loved one?
  • What kinds of supplies are kept on hand? Can residents keep their own supplies?
  • How are staff members trained to deal with emergencies?
  • If the facility must be evacuated, where will residents be taken?
  • How will the facility keep track medicines and individual care plans in the event of an emergency or natural disaster?
  • What number should I call in an emergency to check on my loved one?
  • What emergency supplies are kept at the facility? Can the residents keep their own emergency supplies in their room or another safe place?
  • What kind of emergency training to the staff members receive?
  • Do new residents receive training and instruction for disaster plans?
  • Are routine drills conducted for staff and residents? How often?
  • Does the facility notify family members when a natural disaster or other emergency strikes?
  • If the facility's residents evacuate for some reason, where will they be taken?
  • How will the staff keep track of residents' medicines and their individual care plans?

Family Should Be Prepared Too

As the loved one of an elderly resident, you should be familiar with the safety procedures too. You never know when fires, dangerous weather, or other natural emergencies will happen. If you are visiting the facility at the time of an emergency, your own safety will be an issue.

Personal Safety in Assisted Living

Assisted living facilities should strive to make sure their residents' personal safety is protected. In addition to emergency plans, fire evacuation procedures, and grounds security, safety must be assured at the individual level.

Resident Admission Standards

Safety begins with the admission process. If assisted living facilities accept residents with needs that exceed their staff's expertise, the safety of elders can be compromised. Some states have established standards for admission that would exclude seniors with extensive needs from being admitted. Be aware that regulations are different in every state, but the following list gives you examples of conditions that might prevent a person's admission:

  • The person could harm herself or others.
  • The person has a contagious disease.
  • The person requires restraint physically or chemically.
  • The person requires specialized long-term care.
  • The person requires meals by feeding tube.

In cases like these, it is often in the patient's best interest to be attended by licensed nurses around the clock, and those needs may be more adequately met by a nursing home. Not all assisted living facilities have 24-hour licensed care available.

Preventing Falls

Falls are quite common among the elderly, and they can result in broken bones and other complications. When selecting assisted care, check for facilities that have good lighting, handrails in halls and common areas, carpeting and flooring that will not hinder mobility, and bathrooms with non-slip surfaces, call assistance devices, and support rails. Scheduled activities that include exercises to improve balance and coordination - games, dancing, and walking - are an added bonus.

Preventing falls is not as challenging as one might think. Sometimes what prevents the falls are things that are overlooked, or unnoticed by those who tend not to trip easily. The following checklist will help prevent falls:

  • Keep all pathways in the home between furnishings clear.
  • Avoid using rugs and, if they are still necessary, secure then to the floor.
  • Keep the floor tidy of all loose paper, magazines, mail, books and bags.
  • Do not trail extension cords or other long cords (phone cords, for example) across walkways, or hallways.
  • Cords placed next to tables and stands should be coiled up and held together with wire ties or tape.
  • Keep step stools with handles in each room where items are placed beyond reach. If at all possible, keep all items at waist height so the need for step stools is eliminated.
  • Create a handicapped accessible bathroom to include grab bars next to the toilet and in the shower.
  • Use a rubber mat in the bottom of the bathtub or a shower chair.
  • Keep night-lights on in hallways and in the bathrooms.
  • Clear all clutter up off of staircases, as well as stairways leading to porches.
  • Repair all loose wood, brick, concrete or other building materials used to construct porches and stairs outdoors, as well as flooring and staircases indoors.
  • Avoid loose-fitting shoes, or slippers, as well as shoes without socks.
  • Adjust the height of the bed (i.e. use a hospital bed or, if it is a wooden bed frame, as a family member to cut it down) to ensure it is easy to get in and out of without falling.
  • Avoid using shiny tiles on floor - slipping is less likely to happen on carpeting or flooring with an unglazed finish.
  • Keep rooms well-lit at night and even during the day.
  • Keep a flashlight on bedside tables for at night, and on end tables in the living room in case of power outages.

As you can see, there are a lot of things to consider when creating a fall-proof home. It is not impossible, though. With some effort, your loved one can be safe in their home. Visit regularly if they do not have live in care or assisted living services in their home to ensure this check list is being followed consistently.


Protect against wandering
Protect against wandering

Assisted living providers must also protect the safety of elderly residents who wander, become disoriented and confused, and put themselves at risk. Employees need to be aware of residents who wander, and wanderers should be monitored at all times. Security measures should be in place to prevent wanderers from leaving the facility or suffering injuries from falls.

It's a sad fact that because assisted living facilities are designed for transition periods, it's possible for residents with deteriorating mental faculties to find their way away from their new home.

Helpful suggestions to consider for dealing with wandering

It's a story that reflects the worst case scenario for many adult children of parents who may suffer from early onset Alzheimer's disease or even just deteriorating mental faculties. But there are steps that can be taken to minimize the risk, although the facility where the Boulder man had left was filled with skilled nurses.

First, if you're still considering a facility but have noted a parent who likes to wander, take notes and try to re-trace any potential triggers. Even if you eventually help a loved one move to an assisted living residence or other place for care, knowing that both you and the staff have a list of symptoms can limit the chance of flight.

Especially in the early stages, the desire to wander may be semi-conscious to the point where an elderly person recognizes that they want to go out and about. Scheduling walks and other activities, or being willing to offer them at home is a start. Choosing activities at an assisted living residence that can be done on a daily or thrice weekly basis can also help.

If things have progressed somewhat, then preventive and responsive measures may be needed. The easiest is a bracelet with your relative's information and a number to call. Those with a bit more time can call the local police department and let them know that there's the possibility. Leave a photo, too.

It can seem scary at first because the person who helped raise you or played an important part of your life is losing some of the ability to think that once made them vibrant. By taking the steps to limit the problems at early stages, however, you may be able to keep it from growing worse as time passes.

Security in Assisted Living

These days any nursing home that receives federal funds must meet certain standards, thanks to legislation passed in 1987. The Nursing Home Reform Act stipulates that assisted living facilities must provide or maintain the highest feasible level of care in regards to a patient's physical, mental, and social well-being, and a written plan must be put into action. In addition, some states have passed even tougher laws. These minimum standards should bring you some comfort in your decision to move a loved one to assisted care.

Don't be afraid to ask the facility director if you can have copies of their guidelines, procedures and emergency plans. Use the following questions to help you assess the level of security in an assisted living facility:

Common Security Procedures

  • Are visitors required to check-in before seeing residents?
  • Does the facility have security guards on staff?
  • Are video-cameras used to monitor the premises?
  • Does the assisted living facility keep auxiliary entrances locked or require a card key or numeric code to gain access?
  • How does the facility ensure the safety of patients with Alzheimer's or dementia who may wander or become confused and disoriented?

Are Proper Emergency Plans in Place?

Emergency Plans

  • What are the procedures for emergency evacuation in the case of bad weather, fire or other emergency?
  • How is staff trained for dealing with emergencies?
  • Are routine drills conducted?

Building Design and Security

  • Is the building up to code? When was the last inspection and were there any building code violations?
  • Are beds, furniture, and equipment in good repair?
  • Do resident doors have peepholes and locks that are easy to operate, even for patients who are weak or who may have arthritis?

All assisted living residents should have a sense of safety and security. Taking the time to assess the level of security offered should bring you peace of mind.

Carol Marak
Carol Marak

After seven years of helping her aging parents, Carol Marak has become a dedicated senior care writer. Since 2007, she has been doing the research to find answers to common concerns: housing, aging and health, staying safe and independent, and planning long-term.