Here's a perspective of ALFs from a nurse who's been there several times:
As the only licensed nurse in a building of 80+ residents, I held a position of great responsibility but very little authority, even though I was the DON and staff trainer. I had no say-so in the discharge of residents who were no longer appropriate for ALF due to cognitive deficits, falls, exit-seeking behaviors etc. because "the family is paying $4,000 bucks a month and doesn't want their Mom in memory care" or "he could fall just as easily in a nursing home as here".
People with psychiatric issues were mixed in with residents with dementia, and then the powers that be had the nerve to be surprised when fights broke out. There were only four resident assistants and two med aides for the entire facility---on day AND evening shifts, and only two at night. On any given day, about 85% of our population needed medication, toileting, and other ADL assistance, 50% needed escorting to meals or meal reminders, and about 25% needed a higher level of care due to falls, need for 2-3 person transfers, or behaviors associated with dementia. One particularly memorable resident had a history of Alzheimer's, bipolar 1 disorder with psychotic features, adjustment disorder, and ADD; she was finally moved out only after she'd beaten the hell out of several staff members, destroyed the carpet in her room with daily incontinence episodes, and tried to get herself run over in the street.
And I, as the Registered Nurse, had the privilege of co-signing Corporate's B.S. in keeping my mouth shut about the need to move residents at risk for wandering or those with severe memory loss to a higher level of care. Well, I didn't stay quiet, but nobody listened to me when I did
advocate for move-out, and in the meantime I had a minimum of 15 incident reports to comb through every week, staff who didn't know how to manage behaviors, and NO other nurse to consult with when I ran into a wall trying to figure out what might be going on with one resident, while still dealing with four score others.
Looking back, it's a wonder that I didn't have my nervous breakdown a year or more before I did. I felt 100% responsible for these souls entrusted to my care, but the little I could do to improve their situation was a spit in the ocean.
What's sad is, this was actually a GOOD facility. I've seen a couple of bad ones, and I wouldn't put my worst enemy's dog
in there, let alone anyone I care about. The purpose of assisted living is SUPPOSED to be as a sort of halfway house for elders who are no longer safe to live at home, but who don't need 24/7 nursing care and can perform most of their own ADLs. Fifteen years ago, ALFs didn't even consider
sliding-scale diabetics, two-person transfers, assisted feeders or anyone with a catheter; now they take all that and much more. Yet the staffing hasn't increased, and often, one nurse must oversee several
of the company's buildings and delegate most nursing care to unlicensed assistants who haven't even taken CNA courses.