There are many options for someone with dementia moving into assisted living. At least 30,000 assisted living homes are open in the U.S., many with memory care whose staff is specially trained to communicate with and help people with Alzheimer’s disease or a related dementia. The best way to find the right home is, of course, to do some research, visit options in your community, and choose the home that will best manage your loved one’s symptoms.
But a more general question is worth exploring: Is it better to live in a large assisted living home, with dozens or even more than 100 beds, or a small community that has something like 10 to 20 residents? On this page we’ll explore the pros and cons of large and small assisted living homes for loved ones with dementia.
What do we mean by “large” and “small”? When the Center For Disease Control studied quality of care based on a community’s size (study available here), they classified “small” to mean an assisted living home with between four and 25 beds, and “large” to mean more than 25 beds. Large, however, can mean 200 or more beds. The average number of beds in an assisted living community is about 33. Interestingly, there are more small assisted living homes in America than large homes, but more residents (about 70 percent of all residents) live in a larger community.
General differences include:
– Small communities are normally independently owned while larger homes are often part of a corporation (also called a “chain” or “big box” company).
– Larger residences are usually older, while more than half of smaller homes have been open less than 10 years.
– Residents in larger communities are, on average, older.
– Residents in smaller communities are more likely to be enrolled in Medicaid.
Quality of care should be the most important consideration when finding a home for your loved one with dementia. You need to fully assess what level of care is required – know your loved one’s specific type of dementia, and what stage – and investigate communities to find the best match.
That said, personal preference also plays a role, because comfort is essential. The fit can’t just be about health and personal care. Is your loved one an introvert? Is exercise or entertainment a big part of their life? When you start visiting assisted living options, you are likely to find that size does matter.
Let’s say your loved one likes to get up especially early and have breakfast while most people are still asleep. A smaller residence is more likely to allow for quirks of personality like this, whereas a larger home is usually more structured, with meals and activities taking place at specific times, following specific rules. If your loved one would prefer the walls in her room painted green, this is also more likely to be allowed in a smaller community.
The math is pretty simple: If there are fewer residents, then each person can receive more attention. While larger assisted living homes will of course try to accommodate personal preferences, someone who’s picky about their diet, room, or the structure of the day might be better served in a smaller community.
Bigger communities are more likely to have multiple levels of care. People with dementia deteriorate until they eventually require memory care, where staff is specially trained to assist and communicate with people who have dementia. Often in larger communities, however, there is a memory-care wing separate from the bigger facility. Multiple levels of care mean that as dementia progresses, your loved one has a place to advance within the residence that is fully prepared to deal with these issues.
Smaller assisted living residences, including those with memory care or Alzheimer’s care units, offer a more intimate living environment partly because of more consistency with staff. Smaller homes will employ the same handful of healthcare professionals for about five days per week, meaning there is a smaller circle of people working with your loved one.
Staff-to-patient ratio is a big deal in healthcare, including in assisted living, and in smaller assisted living communities there is bound to be a better staff-to-patient ratio. Most states don’t require specific ratios; regulations usually say there must be adequate staff on-hand to fulfill every resident’s needs. It is undeniable, however, that a higher number of staff for every resident leads to more personalized care. This may be another reason there are more falls in homes with more residents (shown in the study cited above).
Larger residences have more complex staffing and management issues. The administration can feel more corporate, less friendly or personalized, in a larger community. Administrators are less likely to get to know residents and their families in larger communities.
That said, corporations that run larger assisted living homes are likely to pay higher salaries than smaller homes, so the best-qualified administrators (based on education and experience) are likely to work in larger residences. Management-wise, large versus small assisted living may be a choice between better communication or better qualifications, so it’s a good idea to speak with management at any home you’re considering and decide for yourself what’s most important.
Smaller residences may not be as financially secure, and are more likely to go out of business within 10 years. Larger residences, typically backed by a corporation, are more secure. If you want stability, therefore, larger is probably better. That said, given that the average length of stay in an assisted living community is only 22 months, this might not be an important factor.
The feeling of large and small assisted living can be completely different. Larger residences are typically multiple stories, and often look more like hospitals or hotels. Smaller residences look and feel more homely, as they’re usually made up of one or more houses within a complex. Smaller may seem more appealing, but there are tradeoffs. Bigger residences are more likely to have options like a gym, pool, spa, hairdresser or even a movie theater.
You want to pick a home that matches your loved one’s personality. Someone who is more social might like a larger residence where there are more residents, like roommates or neighbors, to interact with. Someone who was always more of an introvert would probably prefer a small home, where solitude and calm are easier to come by.
Any assisted living home, large or small, should be safe for all residents. State regulators inspect and supervise these homes, and there are numerous rules concerning supervision and security that must be followed to ensure everyone there is safe at all times. That said, there is a difference when it comes to infectious diseases like the flu or COVID. In smaller residences, fewer residents and staff means it’s much less likely the disease will come to the home. A person who is sick with a contagious illness is more quickly identified, and can be treated away from the others, so illnesses like COVID are less likely to spread.
On the flip side, larger residences, as evidenced with the Coronavirus pandemic, may be able to dedicate an entire wing to only treating those with a disease. Smaller residences simply may not have the physical space to separate.
|Pros & Cons of Large Assisted Living / Memory Care Residences
|Availability: Easier to find a room in a larger residence than smaller
|Levels of care: Larger homes likely to have regular assisted living and memory care both, also more likely to have nurses on-staff
|Amenities: Swimming pool, hairdresser, entertainment centers with TV or games are more likely in larger residences
|More friends and neighbors for sociable residents to interact with
|Less expensive (on average)
|Less homely: More like a hospital or hotel
|Larger staff is more routine-oriented than patient-oriented
|More residents means less personalized care
|Management is less accessible, especially if residence is owned by a corporation
|Easier for infectious illnesses like flu or COVID to spread
|Statistics show more falls, on average, than in smaller homes
|Pros & Cons of Small Assisted Living / Memory Care Residences
|Better staff-to-patient ratio means more personalized care
|Smaller, more homely environment
|More accessible / flexible management
|Better able to accommodate personal tastes (diet, decorations, etc.)
|Fewer staff and residents helps prevent spread of infectious illnesses like flu and COVID
|Statistically safer (fewer falls, bed sores, etc.)
|Less availability, more wait lists
|Fewer amenities like gym and pool
|More expensive, on average
|Fewer levels of care, less likely to change care as dementia progresses
|Less financially stable (about half of small homes close within 10 years)
|Extrovert residents have fewer neighbors/friends to spend time with