People are not always able to age in place and be cared for in their own homes. Sometimes they need round-the-clock nursing care that is too expensive for their family or not available in a rural location. Sometimes their long-term care insurance policy, or the state’s Medicaid system, will not cover the cost of overnight care unless the recipient is in a care facility. Other times seniors or their families believe they will receive better care and be safer inside an assisted living facility.

In any case, when you are selecting a care facility for yourself or for a loved one, there is one initial and critical factor to consider when making your selection—one that I haven’t seen identified by other geriatric care advisors. Yes, it is wise to consider census (good facilities are more in demand), and ratio (the number of caregivers on duty per shift), as well as staff turnover (unhappy staff means poor service).  And yes, the government rating system of care facilities at is helpful.

However, your primary consideration should be the management philosophy of the director of the facility. How the director views his or her position and authority will trickle down through every level of management to even the part-time caregivers working occasional weekend shifts. The management style of the facility—whether you are in an assisted living apartment, skilled nursing bed, or room in a memory care unit—will determine your quality of life and your ability to select and direct the services you want.

Facility management falls within one of two styles.

Many facility directors see themselves as the proprietors of a residential building, no different from a hotel manager who oversees guests in temporary housing and manages a diverse staff of housekeepers, kitchen helpers, janitors, and valets. What logically follows with that management style is the treatment of those who choose to live there as guests: people with no authority over the day-to-day functioning of the premises, able only to choose from a menu of services or go without. When the families and friends of these guests come to visit, they are considered guests of guests, with less standing yet. If families wish to make changes or bring in additional services, these facility directors tend to believe they have the authority to grant or deny permission, even determine suitability.

This isn’t the way all care facilities are run, however. You could select a facility where the director sees him or herself as the most senior executive charged with management of your home, someone in a role akin to that of Mrs. Hughes or Mr. Carson, the head housekeeper and chief butler at Downtown Abbey. These facility directors certainly run the place, but they see you as the proprietor, not themselves. They know that their role is to help you access the services you need while maximizing your enjoyment of your new home. They see it as your room, your apartment, your home. They see you as the homeowner or leaseholder that you are.

The significance of the management style of the facility is readily apparent when you consider the contrast between your ability to shape your care as a guest in a hotel versus as the owner of your own home. Only when management views the building as your home is it possible to enjoy person-centered care and a degree of autonomy.


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