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When Is Assisted Living Not An Option?

Updated: Dec 3, 2023

When is Assisted Living not an option?

To a novice with no experience in Assisted Living, the amount of information discovered during the research can beoverwhelming. You will be offered a plethora of information on the community amenities, apartment options, square footage, pricing structures, level of care fees, and the list goes on. While these variables are important checklists to discerning clients, one question that is often neglected is “How much care can the community provide?”. After all, care, not amenities, is paramount. Does the community have the resources to meet the current identified needs, and under what conditions would the community require a discharge?

Although there are guidelines imposed by regulation, the fine print may differ from one community to the other. It is important to review the residency agreement and ask these important questions before signing a lease.

We have narrowed situations that can result in a mandatory discharge down to three basic categories: regulations, resources,and resident behaviors.


Assisted Living Communities in the Commonwealth of Virginia are regulated by the Department of Social Services (DSS), which sets guidelines approved by the legislature. These regulations outline what can be admitted and retained in Assisted Living and Memory Care communities. The law specifies that the following could NOT be admitted or retained:

• Individuals on ventilators

• Individuals with dermal ulcers (pressure wounds) of stage III or IV unless they are healing

• Individuals who have continuous IV therapy or injections directly into the vein (In this case, intermittent could be allowed if the community has or can secure the health care professional licensed or permitted to offer this treatment.)

• Individuals with airborne infectious diseases (Talk about challenging during a global airborne pandemic!)

• Individuals who take psychotropic medications without a diagnosis or treatment plan

• Individuals who have Nasogastric Tubes (commonly referred to as NG tubes - a special tube that carries food and medicine to the stomach through the nose). However, gastric tubes (when the tube is inserted through the belly) are permitted as long as a resident is capable of independently self-feeding with the written approval of a physician.

• Individuals who are an imminent threat to self or others

• Individuals who require continuous nursing care

• Individuals whose physician documents that residency is no longer appropriate

The community has a regulatory responsibility to deny admission to a potential resident and to initiate discharge plans for any resident that fits into any of the above-referenced categories.

The challenge for many residents and family members is the perception of surprise. The dialogue during the research phase often includes reassurance that care could be provided through the end of life. The restrictive conditions outlined above,however, are not an area over which the community has control. Families and future residents should be aware and ask questions on how the community handles discharges for residents.

The resources:

A more vague, and perhaps subjective, regulation is that a community should not admit or retain a resident for whom they cannot provide or secure appropriate care.In essence, this means that a community could simply state that they don’t have the resources and deny care or initiate a discharge.

To be clear, the community wants to admit and retain residents. Occupancy is the driving force of the business model. However, there are situations that require transparency and tough business choices. Recent staffing challenges are a real concern on whether a community can continue to meet residents’ needs. For example, if a resident requires two-person assistance with transfers, but there is only one staff member available, this could hinder their abilities to meet that need.

The resident behaviors:

It is a common-sense implication that assisted living residents are socially appropriate for communal living. They must be appropriately dressed to attend the dining room, properly groomed and not self-neglecting, must not violate other residents’ or staff members’ rights, and more.

It is a resident’s right to refuse care, but it is not uncommon for residents to be combative with staff, even for alert and oriented residents. If there is inappropriate language, harassment, or physical assault, the community may be out of options and obligated to issue a discharge notice, as they must ensure the safety of other residents and staff.

If the community decides to issue a discharge notice, they must provide reasoning in writing and assist with discharge plans. Most reputable communities will contact additional resources,such as the local Ombudsman, to offer additional guidance to families and residents.

Of course, a resident that has been issued a discharge notice raises red flags for other communities. Our experts and resources can help during these challenging scenarios and guide a successful transition to a different community.

What to do if care needs increase?

If a current resident’s care needs increase, and the community has the resources to continue to meet those needs, expect an adjustment in the level of care. If the increase in care needs is temporarily (i.e., following a recent fall or a return from a hospitalization), the community may adjust the level of care and offer additional “outsourced” resources including home health agencies and staffing companies to mitigate short term concerns. However, if the identified care needs are permanent or care needs will continue to increase, residents and family members should have a candid discussion with the community’s clinical leadership team.

It is imperative that residents and family members participate in care plan meetings in order to stay informed on whether the community can continue to meet the identified needs. Residents and families should never be surprised by a community’s decision to initiate a move-out.

The decision and the resulting dialogues of the community having to deny a move-in or having to issue a discharge notice are difficult. The experienced resources of Encore Senior Advisors can serve as a liaison to ensure a more transparent discussion, successful move-out coordination, and guidance in identifying different care options that can meet with theresident’s evolving needs.


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