States differ in what services they require to be licensed. Beyond those minimum requirements, facilities vary in what services they provide and in what services residents actually receive. Hawes and colleagues (2000) defined a set of "basic" services that RCFs offer that included two meals a day, housekeeping, 24-hour staff oversight, and assistance with either medications and at least one ADL or assistance with two or more ADLs. The study classified all RCFs as high, low, or minimal-service facilities. The minimal-service facilities, which did not provide any basic services, composed 5 percent of all facilities nationally; low-service facilities, which provided some but not all basic services, composed 65 percent of all facilities; and high-service facilities, which provided all basic services, composed 31 percent of all facilities. The survey data at the time showed that 99 percent of all facilities offered housekeeping services and at least two meals a day; 92 percent provided medication reminders; 97 percent provided assistance with bathing; 94 percent provided assistance with dressing; and 71 percent of all facilities had any full or part-time licensed nurse on staff (registered nurse [RN] or licensed practical nurse [LPN]), with 79.5 percent of facilities providing any care or monitoring by RNs or LPNs (Hawes et al., 2003).
Analyses of the 2010 NSRCF found that--although nearly all facilities provide personal care, basic health monitoring, incontinence care, social and recreational activities within the facility, special diets, and personal laundry services--provision of skilled nursing care, occupational and physical therapy, and social service counseling is less common (Park-Lee et al., 2011). It is important to note that offering ADL assistance or health-related services like medication management was one of the criteria for inclusion in the survey.
In the late 1990s, the National Survey of Assisted Living found that 75 percent of individuals leaving RCFs over a 7-month period did so because they needed more care (Phillips et al., 2003), indicating that the level of care provided was not sufficient to meet their needs. Some of this finding could be explained by state licensing rules that prohibit the provision of nursing care in RCFs. Although this study reported many positive aspects about RCFs, it also found that needs for assistance were unmet by 26 percent of residents for using the toilet, 12 percent for locomotion, and 12 percent for dressing.