Center for Excellence in Assisted Living CEAL@UNC

Advancing the well-being of the people who live and work in assisted living through research, practice, and policy.

Journal of Applied Gerontology

Personal Care Aide Staffing in U.S. Residential Care Communities: The Role of Aide Training Hours, Training Reimbursement, and Organizational Structures

Dec 1, 2025
This study investigated residential care communities (RCCs) characteristics associated with care aide hours per resident day using data from 518 RCCs in the 2022 National Post-acute and Long-term Care Study. Factors related to higher staffing hours included reimbursement for training and occupancy greater than 85%, whereas factors such as initial training of more than 60 hours, increased Medicaid involement, and being a larger community were associated with lower staffing hours.

Personal Care Aide Staffing in U.S. Residential Care Communities: The Role of Aide Training Hours, Training Reimbursement, and Organizational Structures

by Lea Efird-Green

This study investigated residential care communities (RCCs) characteristics associated with care aide hours per resident day using data from 518 RCCs in the 2022 National Post-acute and Long-term Care Study. Factors related to higher staffing hours included reimbursement for training and occupancy greater than 85%, whereas factors such as initial training of more than 60 hours, increased Medicaid involement, and being a larger community were associated with lower staffing hours.

Physical Activity and Sedentary Behavior in Assisted Living Residents: Feasibility and Acceptability of a Longitudinal Study

Dec 1, 2025
This study of 44 residents from 9 AL communities in Michigan examined the feasibility of a longitudinal study on physical activity and sedentary behavior. Over the six months, physical activity slightly decreased, which was more prominent in residents with cognitive change, and sedentary behaviors slightly increased. The study supported the feasibility of longitudinal testing to track these behavior changes.

Physical Activity and Sedentary Behavior in Assisted Living Residents: Feasibility and Acceptability of a Longitudinal Study

by Lea Efird-Green

This study of 44 residents from 9 AL communities in Michigan examined the feasibility of a longitudinal study on physical activity and sedentary behavior. Over the six months, physical activity slightly decreased, which was more prominent in residents with cognitive change, and sedentary behaviors slightly increased. The study supported the feasibility of longitudinal testing to track these behavior changes.

Recruiting Sexual and Gender Minority Older Adults With and Without Dementia in Long-Term Care: Overcoming Barriers and Lessons Learned

Sep 1, 2025
This qualitative study of 20 AL and nursing home administrators explored the barriers and facilitators of recruiting sexual and gender minority (SGM) residents for research projects. Three key themes emerged: challenges identifying SGM residents, a need to address discrimination, and special considerations for SGM residents who also have cognitive impairment. These findings can guide researchers trying to recruit SGM residents more ethically and effectively.

Recruiting Sexual and Gender Minority Older Adults With and Without Dementia in Long-Term Care: Overcoming Barriers and Lessons Learned

by Lea Efird-Green

This qualitative study of 20 AL and nursing home administrators explored the barriers and facilitators of recruiting sexual and gender minority (SGM) residents for research projects. Three key themes emerged: challenges identifying SGM residents, a need to address discrimination, and special considerations for SGM residents who also have cognitive impairment. These findings can guide researchers trying to recruit SGM residents more ethically and effectively.

Delivering Engaging and Meaningful Activities for Older Adults in Long-Term Care Using Principles of Interpretation

Sep 1, 2025
This article presented new guidelines to promote more meaningful activities for long-term care residents using principles of interpretation, originating in the environmental education field. Example guidelines include activities that are "personally relatable" and "facilitate meaning."

Delivering Engaging and Meaningful Activities for Older Adults in Long-Term Care Using Principles of Interpretation

by Lea Efird-Green

This article presented new guidelines to promote more meaningful activities for long-term care residents using principles of interpretation, originating in the environmental education field. Example guidelines include activities that are “personally relatable” and “facilitate meaning.”

Collecting, Sharing, and Using Information for Person-Centered Dementia Care: Perspectives of Residents, Care Partners, and Staff in Low-Resource Long-Term Care Settings

Aug 1, 2025
This qualitative study explored the perspectives of 59 administrative leaders, direct care staff, residents, and care partners in 4 long-term care communities in medically underserved areas about how collecting and sharing information can be used to support person-centered care. Effective communication strategies included communication logs, leaving notes, and verbal reports, and, to support person-centered care, interdisciplinary collaboration, engaging care partners, and peer mentorship. These strategies can improve information collection and sharing in long-term care.

Collecting, Sharing, and Using Information for Person-Centered Dementia Care: Perspectives of Residents, Care Partners, and Staff in Low-Resource Long-Term Care Settings

by Lea Efird-Green

This qualitative study explored the perspectives of 59 administrative leaders, direct care staff, residents, and care partners in 4 long-term care communities in medically underserved areas about how collecting and sharing information can be used to support person-centered care. Effective communication strategies included communication logs, leaving notes, and verbal reports, and, to support person-centered care, interdisciplinary collaboration, engaging care partners, and peer mentorship. These strategies can improve information collection and sharing in long-term care.

Care Refusal by Older Adults With Dementia Receiving Professional Care: A Scoping Review

Jul 1, 2025
This scoping review examined 19 studies to understand determinants and effects of care refusal by long-term care residents living with dementia. Factors such as cognitive impairment, communication challenges, elderspeak, unfamiliar environments, and task-oriented care were identified as determinants of care refusal, while megative effects included compromised health outcomes, disrupted provision of care, and increased neuropsychiatric symptoms, highlighting factors that could be addressed to reduce care refusal.

Care Refusal by Older Adults With Dementia Receiving Professional Care: A Scoping Review

by Lea Efird-Green

This scoping review examined 19 studies to understand determinants and effects of care refusal by long-term care residents living with dementia. Factors such as cognitive impairment, communication challenges, elderspeak, unfamiliar environments, and task-oriented care were identified as determinants of care refusal, while megative effects included compromised health outcomes, disrupted provision of care, and increased neuropsychiatric symptoms, highlighting factors that could be addressed to reduce care refusal.

The Influence of Physical, Social, and Organizational Environments on Recreational Activities in Long-Term Care for Residents With Dementia: A Scoping Review

Jul 1, 2025
This scoping review of 28 studies examined how physical, social, and organizational factors influence activity engagement for residents with dementia in long-term care (LTC) settings. Factors such as small house-like environments, familiar routines, and closer staff-resident relationships can increase participation, highlighting the importance of using inclusive and person-centered approaches to improve activity planning in LTC settings.

The Influence of Physical, Social, and Organizational Environments on Recreational Activities in Long-Term Care for Residents With Dementia: A Scoping Review

by Lea Efird-Green

This scoping review of 28 studies examined how physical, social, and organizational factors influence activity engagement for residents with dementia in long-term care (LTC) settings. Factors such as small house-like environments, familiar routines, and closer staff-resident relationships can increase participation, highlighting the importance of using inclusive and person-centered approaches to improve activity planning in LTC settings.

Understanding Digital Literacy of Persons With Dementia and Their Caregivers: A Scoping Review and an Evolutionary Concept Analysis of Empirical Studies

Jun 1, 2025
WHAT THIS MEANS FOR YOU: This scoping review of 22 studies examined digitial literacy for people with dementia and their caregivers across settings and aimed to understand antecedents, attributes, and consequences of digital literacy. Support systems, and individual and sociodemographic characteristics were identified as antecedents; technological and critical thinking skills are attributes; and technology acceptance, psychosocial impacts, and digital equity were consequences. These concepts could guide the development and implementation of digital interventions for people with dementia and their caregivers.

Understanding Digital Literacy of Persons With Dementia and Their Caregivers: A Scoping Review and an Evolutionary Concept Analysis of Empirical Studies

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This scoping review of 22 studies examined digitial literacy for people with dementia and their caregivers across settings and aimed to understand antecedents, attributes, and consequences of digital literacy. Support systems, and individual and sociodemographic characteristics were identified as antecedents; technological and critical thinking skills are attributes; and technology acceptance, psychosocial impacts, and digital equity were consequences. These concepts could guide the development and implementation of digital interventions for people with dementia and their caregivers.

Considerations for Use of the Cornell Scale for Depression in Dementia Among Assisted Living Residents: Factor Analysis Results

Feb 1, 2025
WHAT THIS MEANS FOR YOU: This study tested the Cornell Scale for Depression in Dementia (CSDD) with 511 residents from 85 assisted living (AL) communities in three states to understand if it is an appropriate scale for assessing depression in AL residents. Measure-related analysis led to three items being removed from the scale and a five-factor model showed a better fit than the four-factor model, although both showed poor fit. Although a modified CSDD is partially supported for use with this population, future research should explore more appropriate measures for measuring depression in AL residents.

Considerations for Use of the Cornell Scale for Depression in Dementia Among Assisted Living Residents: Factor Analysis Results

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study tested the Cornell Scale for Depression in Dementia (CSDD) with 511 residents from 85 assisted living (AL) communities in three states to understand if it is an appropriate scale for assessing depression in AL residents. Measure-related analysis led to three items being removed from the scale and a five-factor model showed a better fit than the four-factor model, although both showed poor fit. Although a modified CSDD is partially supported for use with this population, future research should explore more appropriate measures for measuring depression in AL residents.

Examining Engagement Calendar Deviations in Assisted Living: A Focus on Residents With Dementia

Dec 1, 2024
WHAT THIS MEANS FOR YOU: This study used data from 3 AL communities over one year to examine deviations from scheduled activity programming, identify influential factors, and understand the outcomes on residents. The analysis showed general adherence to calendars, but deviations did occur. Staffing, capacity, programming guidance and support, staff attitudes, and unforeseen circumstances all influenced these deviations. Cancellations of programming were more detrimental to resident well-being than substitutions.

Examining Engagement Calendar Deviations in Assisted Living: A Focus on Residents With Dementia

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study used data from 3 AL communities over one year to examine deviations from scheduled activity programming, identify influential factors, and understand the outcomes on residents. The analysis showed general adherence to calendars, but deviations did occur. Staffing, capacity, programming guidance and support, staff attitudes, and unforeseen circumstances all influenced these deviations. Cancellations of programming were more detrimental to resident well-being than substitutions.

Impact of Antecedent and Organizational Differences on Nurse-Social Worker Collaboration in a Retirement and Assisted Living Community with Skilled Nursing Care

Aug 1, 2024
WHAT THIS MEANS FOR YOU: This qualitative thematic study of 23 workers at a Midwestern AL community explored nurses' and social workers' collaborative experiences. Contrasts arose in responding to resident complexity and peer-to-peer work, with a main difference being social workers' focus on resident self-determination and nurses' focus on resident safety. Social workers showed greater openness to working with nurses while nurses showed greater separation, which has implications for teamwork in these settings.

Impact of Antecedent and Organizational Differences on Nurse-Social Worker Collaboration in a Retirement and Assisted Living Community with Skilled Nursing Care

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This qualitative thematic study of 23 workers at a Midwestern AL community explored nurses’ and social workers’ collaborative experiences. Contrasts arose in responding to resident complexity and peer-to-peer work, with a main difference being social workers’ focus on resident self-determination and nurses’ focus on resident safety. Social workers showed greater openness to working with nurses while nurses showed greater separation, which has implications for teamwork in these settings.

A Cross-Sectional Study of Nurse Turnover in Residential Care Communities

Aug 1, 2024
WHAT THIS MEANS FOR YOU: This cross-sectional study examined 2018 public data of RNs and aides in residential care communities (RCCs) to examine factors related to turnover. On average, RN turnover was 72% and aide turnover was 48%. Non-profit RCCs had lower turnover and chain facilities had higher turnover. Contrary to predictions, large RCCs had lower turnover rates.

A Cross-Sectional Study of Nurse Turnover in Residential Care Communities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This cross-sectional study examined 2018 public data of RNs and aides in residential care communities (RCCs) to examine factors related to turnover. On average, RN turnover was 72% and aide turnover was 48%. Non-profit RCCs had lower turnover and chain facilities had higher turnover. Contrary to predictions, large RCCs had lower turnover rates.

Bioethics in Gerontology: Developing a Typology of Ethical Issues in Assisted Living

May 1, 2024
WHAT THIS MEANS FOR YOU: A team of researchers developed a typology of the ethical conflicts that are likely to exist within AL communities. Drawing on data from a 5-year qualitative study in four ALs for validation, this typology aims to help families, staff, and residents identify and understand ethical best practices in AL communities.

Bioethics in Gerontology: Developing a Typology of Ethical Issues in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A team of researchers developed a typology of the ethical conflicts that are likely to exist within AL communities. Drawing on data from a 5-year qualitative study in four ALs for validation, this typology aims to help families, staff, and residents identify and understand ethical best practices in AL communities.

Objectively Measured Physical Activity and Sedentary Behaviors Among Older Adults in Assisted Living Facilities: A Scoping Review

Apr 1, 2024
WHAT THIS MEANS FOR YOU: This scoping review included 20 articles from 15 studies that used devices to track physical activity behavior in AL residents. On average, residents spent between 96 and 201 minutes each day doing light physical activity, but only 1 to 9.74 minutes on moderate to vigorous activity. In addition, residents were sedentary for 8.5 to 11 hours while awake. Personal, social, and environmental factors influenced completion of physical activity in the included studies; however, none of the included interventions successfully increased activity or reduced sedentary behavior.

Objectively Measured Physical Activity and Sedentary Behaviors Among Older Adults in Assisted Living Facilities: A Scoping Review

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This scoping review included 20 articles from 15 studies that used devices to track physical activity behavior in AL residents. On average, residents spent between 96 and 201 minutes each day doing light physical activity, but only 1 to 9.74 minutes on moderate to vigorous activity. In addition, residents were sedentary for 8.5 to 11 hours while awake. Personal, social, and environmental factors influenced completion of physical activity in the included studies; however, none of the included interventions successfully increased activity or reduced sedentary behavior.

Home Time and State Regulations Among Medicare Beneficiaries in Assisted Living Communities

Dec 1, 2023
WHAT THIS MEANS FOR YOU: A study of “home time" (days alive and not in healthcare institutions such as hospitals or skilled nursing facilities) of over 59,000 Medicare beneficiaries who transitioned into assisted living in 2018 found that residents spent 94% of their first year at home in the community. Characteristics associated with lower home time included dual Medicare-Medicaid eligibility, having more chronic conditions, and specific conditions (e.g., dementia). Additionally, in states with more specific regulations for direct care worker staffing and training, and lower specificity for staff licensing requirements, residents tended to spend more time at home. Thus, both individual characteristics and state regulations may impact home time for new assisted living residents.

Home Time and State Regulations Among Medicare Beneficiaries in Assisted Living Communities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A study of “home time” (days alive and not in healthcare institutions such as hospitals or skilled nursing facilities) of over 59,000 Medicare beneficiaries who transitioned into assisted living in 2018 found that residents spent 94% of their first year at home in the community. Characteristics associated with lower home time included dual Medicare-Medicaid eligibility, having more chronic conditions, and specific conditions (e.g., dementia). Additionally, in states with more specific regulations for direct care worker staffing and training, and lower specificity for staff licensing requirements, residents tended to spend more time at home. Thus, both individual characteristics and state regulations may impact home time for new assisted living residents.

Paperwork, Paradox, and PRN: Psychotropic Medication Deficiencies in Assisted Living

Jun 1, 2023
WHAT THIS MEANS FOR YOU: This study analyzed 170 psychotropic medication deficiency citations from 152 Oregon assisted living communities to determine discrepancies in state licensing and oversight of psychotropic medication use. It found most deficiencies involved documentation errors; there were unclear regulations for direct care workers who distribute medications; and there was a persistent disconnect about when to seek expertise before requesting psychotropic use.

Paperwork, Paradox, and PRN: Psychotropic Medication Deficiencies in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study analyzed 170 psychotropic medication deficiency citations from 152 Oregon assisted living communities to determine discrepancies in state licensing and oversight of psychotropic medication use. It found most deficiencies involved documentation errors; there were unclear regulations for direct care workers who distribute medications; and there was a persistent disconnect about when to seek expertise before requesting psychotropic use.

Depression within the First Year of Relocation to Residential Care/Assisted Living: Where You Come From Matters

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Data from a national survey of 2,651 assisted living residents found that approximately 35% moved to assisted living from an acute/post-acute facility; they were more likely to have depression compared to those moving from community-based residences.

Depression within the First Year of Relocation to Residential Care/Assisted Living: Where You Come From Matters

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Data from a national survey of 2,651 assisted living residents found that approximately 35% moved to assisted living from an acute/post-acute facility; they were more likely to have depression compared to those moving from community-based residences.

Ethics of Health Information Sharing and Social Relationships at End of Life in Assisted Living

Apr 1, 2022
WHAT THIS MEANS FOR YOU: This qualitative study of observation and 61 interviews with assisted living residents, family members, staff, and external care workers in one large community in Atlanta, found that while sharing health information could strengthen social bonds among residents, there were concerns about privacy; for example, when inappropriate public exchanges occurred, they hindered social relationship building. Barriers to communicating health information contributed to resident isolation, but negotiating privacy boundaries to share such information may promote resident wellbeing.

Ethics of Health Information Sharing and Social Relationships at End of Life in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This qualitative study of observation and 61 interviews with assisted living residents, family members, staff, and external care workers in one large community in Atlanta, found that while sharing health information could strengthen social bonds among residents, there were concerns about privacy; for example, when inappropriate public exchanges occurred, they hindered social relationship building. Barriers to communicating health information contributed to resident isolation, but negotiating privacy boundaries to share such information may promote resident wellbeing.

The Ethics in Long-Term Care Model: Everyday Ethics and the Unseen Moral Landscape of Assisted Living

Apr 1, 2022
WHAT THIS MEANS FOR YOU: Drawing from existing research, theories, and case examples, this article highlighted moral complexities experienced in assisted living (e.g., privacy, sexual intimacy, safety and risk) and proposed a framework to identify and address these issues and promote more ethically sound practices. The proposed model centers on moral decision-making and interpersonal encounters and is intended to guide future research, policy, and practice.

The Ethics in Long-Term Care Model: Everyday Ethics and the Unseen Moral Landscape of Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Drawing from existing research, theories, and case examples, this article highlighted moral complexities experienced in assisted living (e.g., privacy, sexual intimacy, safety and risk) and proposed a framework to identify and address these issues and promote more ethically sound practices. The proposed model centers on moral decision-making and interpersonal encounters and is intended to guide future research, policy, and practice.

Potential Side Effects and Adverse Events of Antipsychotic Use for Residents With Dementia in Assisted Living: Implications for Prescribers, Staff, and Families

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study examined the use of antipsychotic medications among residents with dementia in 91 AL communities across seven states. The prevalence of potential side effects was high (93%) and of possible adverse events low, (6%), potentially associated with medication side effects. Quetiapine (Seroquel) and risperidone (Risperdal) were the most frequently prescribed antipsychotics. Most, but not all, residents’ family members were aware of their relative’s antipsychotic use.

Potential Side Effects and Adverse Events of Antipsychotic Use for Residents With Dementia in Assisted Living: Implications for Prescribers, Staff, and Families

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined the use of antipsychotic medications among residents with dementia in 91 AL communities across seven states. The prevalence of potential side effects was high (93%) and of possible adverse events low, (6%), potentially associated with medication side effects. Quetiapine (Seroquel) and risperidone (Risperdal) were the most frequently prescribed antipsychotics. Most, but not all, residents’ family members were aware of their relative’s antipsychotic use.

Model Testing of the Factors that Influence Performance of Function Focused Care and Function among Assisted Living Residents

Feb 1, 2022
WHAT THIS MEANS FOR YOU: A study of 550 AL residents from 59 communities found that factors such as better physical and cognitive health, positive care interactions, and supportive environments were associated with increased participation in function-focused care. Additionally, for-profit communities had higher levels of function-focused care despite having residents with lower functioning.

Model Testing of the Factors that Influence Performance of Function Focused Care and Function among Assisted Living Residents

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A study of 550 AL residents from 59 communities found that factors such as better physical and cognitive health, positive care interactions, and supportive environments were associated with increased participation in function-focused care. Additionally, for-profit communities had higher levels of function-focused care despite having residents with lower functioning.

Assisted Living Administrators’ Approaches to Advance Care Planning

Feb 1, 2022
WHAT THIS MEANS FOR YOU: Interviews with 27 AL administrators revealed different approaches to advanced care planning (ACP). They all acknowledged the importance of ACP and often discussed topics like “do-not-resuscitate” orders when new residents arrived. Challenges included insufficient ACP training for staff and administrators and some reluctance from residents and families to discuss ACP. Most communities lacked a systematic, structured ACP approach.

Assisted Living Administrators’ Approaches to Advance Care Planning

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Interviews with 27 AL administrators revealed different approaches to advanced care planning (ACP). They all acknowledged the importance of ACP and often discussed topics like “do-not-resuscitate” orders when new residents arrived. Challenges included insufficient ACP training for staff and administrators and some reluctance from residents and families to discuss ACP. Most communities lacked a systematic, structured ACP approach.