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 the American Medical Directors Association

Prevalence and Correlates of Antipsychotic Medication Use in Oregon Assisted Living

Jun 1, 2024
WHAT THIS MEANS FOR YOU: An analysis of data from 463 AL communities in Oregon from 2017-2019 revealed that on average, 30.7% of residents had received antipsychotics in the past 90 days. Nonprofit settings had lower usage compared to for-profit settings, while communities with more residents using Medicaid had higher rates of antipsychotic usage. Residents in memory care were more likely to receive these medications than residents in general AL settings.

Prevalence and Correlates of Antipsychotic Medication Use in Oregon Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: An analysis of data from 463 AL communities in Oregon from 2017-2019 revealed that on average, 30.7% of residents had received antipsychotics in the past 90 days. Nonprofit settings had lower usage compared to for-profit settings, while communities with more residents using Medicaid had higher rates of antipsychotic usage. Residents in memory care were more likely to receive these medications than residents in general AL settings.

Changes in Nursing Staff Levels and Injury-Related Emergency Department Visits among Assisted Living Residents with Alzheimers Disease and Related Dementias

Jun 1, 2024
WHAT THIS MEANS FOR YOU: An analysis of 2007-2015 Medicare data for over 12,000 AL residents with ADRD in 455 Ohio AL communities showed that higher levels of RN staffing hours per resident per day led to a 53% decrease in injury-related emergency department visits.

Changes in Nursing Staff Levels and Injury-Related Emergency Department Visits among Assisted Living Residents with Alzheimers Disease and Related Dementias

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: An analysis of 2007-2015 Medicare data for over 12,000 AL residents with ADRD in 455 Ohio AL communities showed that higher levels of RN staffing hours per resident per day led to a 53% decrease in injury-related emergency department visits.

Excess Deaths in Assisted Living and Nursing Homes during the COVID-19 Pandemic in Alberta, Canada

May 1, 2024
WHAT THIS MEANS FOR YOU: This retrospective cohort study used health records from residents in publicly funded AL communities and nursing homes (NHs) in Alberta, Canada from 2017 to 2021 to examine excess deaths during the first two years of the pandemic. Excess deaths were higher in AL communities compared to NHs, especially during weeks identified as pandemic waves (i.e., a surge in COVID-19 infections). The risk of excess death was also greater among residents with dementia or significant cognitive impairment in both AL communities and NHs.

Excess Deaths in Assisted Living and Nursing Homes during the COVID-19 Pandemic in Alberta, Canada

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This retrospective cohort study used health records from residents in publicly funded AL communities and nursing homes (NHs) in Alberta, Canada from 2017 to 2021 to examine excess deaths during the first two years of the pandemic. Excess deaths were higher in AL communities compared to NHs, especially during weeks identified as pandemic waves (i.e., a surge in COVID-19 infections). The risk of excess death was also greater among residents with dementia or significant cognitive impairment in both AL communities and NHs.

Serious Mental Illness in Assisted Living Communities: Association with Nursing Home Placement

May 1, 2024
WHAT THIS MEANS FOR YOU: An analysis of data from over 289,000 Medicare beneficiaries in 17,265 ALs from 2018 to 2019 revealed that over half of AL residents had at least one serious mental illness diagnosis, with major depression being the most common (93%). Residents with schizophrenia or bipolar disorder were statistically significantly less likely to be permanently placed in NHs (as opposed to continued AL residency) respective to the average rate of placement for all residents in the analysis. However, the risk of permanent NH placement was higher for residents with ADRD, including residents with a schizophrenia or bipolar disorder diagnosis.

Serious Mental Illness in Assisted Living Communities: Association with Nursing Home Placement

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: An analysis of data from over 289,000 Medicare beneficiaries in 17,265 ALs from 2018 to 2019 revealed that over half of AL residents had at least one serious mental illness diagnosis, with major depression being the most common (93%). Residents with schizophrenia or bipolar disorder were statistically significantly less likely to be permanently placed in NHs (as opposed to continued AL residency) respective to the average rate of placement for all residents in the analysis. However, the risk of permanent NH placement was higher for residents with ADRD, including residents with a schizophrenia or bipolar disorder diagnosis.

Psychotropic, Anticonvulsant, and Opioid Use in Assisted Living Residents Before and During the COVID-19 Pandemic

Oct 1, 2023
WHAT THIS MEANS FOR YOU: Administrative data from 256 assisted living communities in Alberta during the COVID-19 pandemic found that during waves 2 to 4, antipsychotic use increased, (significantly more for dementia care residents), and that anticonvulsant use increased for assisted living (but not dementia care) residents. Additionally, there was an increase in antidepressant use and a decrease in benzodiazepine use for both assisted living and dementia care residents. The persistence of a pandemic-associated increase in these medications raises concerns about well-established health and wellbeing impacts for residents.

Psychotropic, Anticonvulsant, and Opioid Use in Assisted Living Residents Before and During the COVID-19 Pandemic

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Administrative data from 256 assisted living communities in Alberta during the COVID-19 pandemic found that during waves 2 to 4, antipsychotic use increased, (significantly more for dementia care residents), and that anticonvulsant use increased for assisted living (but not dementia care) residents. Additionally, there was an increase in antidepressant use and a decrease in benzodiazepine use for both assisted living and dementia care residents. The persistence of a pandemic-associated increase in these medications raises concerns about well-established health and wellbeing impacts for residents.

Clinical Comorbidities and Transitions Between Care Settings Among Residents of Assisted Living Facilities: A Repeated Cross-Sectional Study

Jul 1, 2023
WHAT THIS MEANS FOR YOU: Administrative data from 2013-2019 in Ontario, Canada found a 34% increase in the resident population, and residents experienced increased instances of health conditions including renal disease, mental health issues, cardiac arrhythmias, diabetes, and cancer. Approximately 20% of residents still lived in an assisted living community at the end of the 6-year period, while 10% transitioned to nursing homes. In less than a decade, data revealed increasing medical complexity of assisted living residents, which must be considered for improved policy and practice.

Clinical Comorbidities and Transitions Between Care Settings Among Residents of Assisted Living Facilities: A Repeated Cross-Sectional Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Administrative data from 2013-2019 in Ontario, Canada found a 34% increase in the resident population, and residents experienced increased instances of health conditions including renal disease, mental health issues, cardiac arrhythmias, diabetes, and cancer. Approximately 20% of residents still lived in an assisted living community at the end of the 6-year period, while 10% transitioned to nursing homes. In less than a decade, data revealed increasing medical complexity of assisted living residents, which must be considered for improved policy and practice.

End-of-Life Care Transitions in Assisted Living: Associations With State Staffing and Training Regulations

Jun 1, 2023
WHAT THIS MEANS FOR YOU: This study examined associations between end-of-life care transitions (meaning stays in hospitals and nursing homes in either the 7 or 30 days before death in this study) and state staffing and training requirements for nearly 114,000 Medicare beneficiaries who died in an assisted living community in 2018-2019. A higher proportion of transitions was associated with stricter regulations about licensed and direct care worker staffing, whereas a lower proportion was associated with more specific regulations about direct care worker training. Therefore, policymakers and practitioners may want to implement regulations that make staff training requirements more specific to better address end-of-life care.

End-of-Life Care Transitions in Assisted Living: Associations With State Staffing and Training Regulations

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined associations between end-of-life care transitions (meaning stays in hospitals and nursing homes in either the 7 or 30 days before death in this study) and state staffing and training requirements for nearly 114,000 Medicare beneficiaries who died in an assisted living community in 2018-2019. A higher proportion of transitions was associated with stricter regulations about licensed and direct care worker staffing, whereas a lower proportion was associated with more specific regulations about direct care worker training. Therefore, policymakers and practitioners may want to implement regulations that make staff training requirements more specific to better address end-of-life care.

Online Customer Reviews of Assisted Living Communities: Association with Community, County, and State Factors

Jun 1, 2023
WHAT THIS MEANS FOR YOU: In this study, almost 150,000 on-line consumer reviews from nearly 9,000 assisted living communities were analyzed in the context of community, county, and state variables (e.g., regulatory specificity, rurality). Communities with greater proportions of Medicare/Medicaid residents had lower odds of positive reviews, but communities in states with more direct care worker hours per week per bed had higher odds of positive reviews. Higher staffing may advantage positive consumer perceptions.

Online Customer Reviews of Assisted Living Communities: Association with Community, County, and State Factors

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: In this study, almost 150,000 on-line consumer reviews from nearly 9,000 assisted living communities were analyzed in the context of community, county, and state variables (e.g., regulatory specificity, rurality). Communities with greater proportions of Medicare/Medicaid residents had lower odds of positive reviews, but communities in states with more direct care worker hours per week per bed had higher odds of positive reviews. Higher staffing may advantage positive consumer perceptions.

Pathways into Assisted Living Communities: Admission Limitations and Assessment Requirements Across the United States

Jun 1, 2023
WHAT THIS MEANS FOR YOU: This study examined differences in who may be admitted to an assisted living community using regulatory data from 2018. Admission restrictions were categorized into 1) health-related conditions, 2) specified behavior, 3) mental health condition, and 4) cognitive impairment. Almost one-third (29%) of communities are governed by regulations limiting admission of individuals with only a health condition, and slightly fewer (24%) of communities have limitations based on all four categories. Just over 11% of AL communities have no restrictions on who may be admitted.

Pathways into Assisted Living Communities: Admission Limitations and Assessment Requirements Across the United States

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined differences in who may be admitted to an assisted living community using regulatory data from 2018. Admission restrictions were categorized into 1) health-related conditions, 2) specified behavior, 3) mental health condition, and 4) cognitive impairment. Almost one-third (29%) of communities are governed by regulations limiting admission of individuals with only a health condition, and slightly fewer (24%) of communities have limitations based on all four categories. Just over 11% of AL communities have no restrictions on who may be admitted.

Hospital Proximity and Emergency Department Use among Assisted Living Residents

Jun 1, 2023
WHAT THIS MEANS FOR YOU: This study assessed if the distance between AL communities and the nearest hospital was associated with the frequency of emergency department (ED) visits. Almost 541,000 Medicare beneficiaries aged 55 or older residing in over 16,500 AL communities in 2018-2019 were included. The median distance to the nearest hospital was 2.5 miles. Distance was related to ED use, especially for non-critical, visits, such that communities 5 or more miles from a hospital had fewer ED visits than those that were closer to a hospital.

Hospital Proximity and Emergency Department Use among Assisted Living Residents

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study assessed if the distance between AL communities and the nearest hospital was associated with the frequency of emergency department (ED) visits. Almost 541,000 Medicare beneficiaries aged 55 or older residing in over 16,500 AL communities in 2018-2019 were included. The median distance to the nearest hospital was 2.5 miles. Distance was related to ED use, especially for non-critical, visits, such that communities 5 or more miles from a hospital had fewer ED visits than those that were closer to a hospital.

“I Have a Lotta Sad Feelin'” – Unaddressed Mental Health Needs and Self-Support Strategies in Medicaid-Funded Assisted Living

Jun 1, 2023
WHAT THIS MEANS FOR YOU: This study investigated mental health needs and barriers among residents at Medicaid-funded AL communities. At one AL community in the Bronx, 13 residents completed questionnaires and interviews; analysis revealed patterns of mental health needs, feelings of losing control, mistrust of organizational staff, and lack of resources and support.

“I Have a Lotta Sad Feelin'” – Unaddressed Mental Health Needs and Self-Support Strategies in Medicaid-Funded Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study investigated mental health needs and barriers among residents at Medicaid-funded AL communities. At one AL community in the Bronx, 13 residents completed questionnaires and interviews; analysis revealed patterns of mental health needs, feelings of losing control, mistrust of organizational staff, and lack of resources and support.

Primary Care Telemedicine Use among Assisted Living Residents with Dementia during COVID-19: Race and Dual Enrollment Status

May 1, 2023
WHAT THIS MEANS FOR YOU: This study used Medicare and CDC datasets to examine telemedicine primary care among 62,000 AL residents with dementia during the first year of the COVID-19 pandemic (2020). During the first three quarters of the pandemic, racially minoritized groups (Black, Hispanic) and Medicare-Medicaid dual eligibles were able to successfully use telemedicine at high rates. Gaps in primary care access between these groups and others (white, non-Medicaid eligible) were reduced due to telemedicine. This could inform CMS decisions about Medicare coverage for telemedicine primary care.

Primary Care Telemedicine Use among Assisted Living Residents with Dementia during COVID-19: Race and Dual Enrollment Status

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study used Medicare and CDC datasets to examine telemedicine primary care among 62,000 AL residents with dementia during the first year of the COVID-19 pandemic (2020). During the first three quarters of the pandemic, racially minoritized groups (Black, Hispanic) and Medicare-Medicaid dual eligibles were able to successfully use telemedicine at high rates. Gaps in primary care access between these groups and others (white, non-Medicaid eligible) were reduced due to telemedicine. This could inform CMS decisions about Medicare coverage for telemedicine primary care.

Identifying a National Cohort of Medicare Beneficiaries Residing in Assisted Living Settings: An Updated Method

May 1, 2023
WHAT THIS MEANS FOR YOU: A new methodology was developed for identifying Medicare beneficiaries residing in licensed AL communities in the US using zip code data, Medicare enrollment data, and claims data, and exclusion based on AL capacity (licensing information). Results suggested that using licensing information makes identifying AL residents receiving Medicare more accurate, which could inform research and policy by providing new insights into the health of AL residents.

Identifying a National Cohort of Medicare Beneficiaries Residing in Assisted Living Settings: An Updated Method

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A new methodology was developed for identifying Medicare beneficiaries residing in licensed AL communities in the US using zip code data, Medicare enrollment data, and claims data, and exclusion based on AL capacity (licensing information). Results suggested that using licensing information makes identifying AL residents receiving Medicare more accurate, which could inform research and policy by providing new insights into the health of AL residents.

State Variation in Antipsychotic Use Among Assisted Living Residents With Dementia

Apr 1, 2023
WHAT THIS MEANS FOR YOU: This study of almost 21,000 AL residents in 2017 revealed that those with dementia were prescribed antipsychotics during about 13% of their time residing in AL. This proportion varied by state, with Hawaii having the lowest prescription rate (8%), and Wyoming having the highest (21%). Variations may be due to state regulation of AL communities, but the study was not able to determine if prescription practices were appropriate and tied to health outcomes.

State Variation in Antipsychotic Use Among Assisted Living Residents With Dementia

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study of almost 21,000 AL residents in 2017 revealed that those with dementia were prescribed antipsychotics during about 13% of their time residing in AL. This proportion varied by state, with Hawaii having the lowest prescription rate (8%), and Wyoming having the highest (21%). Variations may be due to state regulation of AL communities, but the study was not able to determine if prescription practices were appropriate and tied to health outcomes.

Using Medicare Enrollment Data to Identify Beneficiaries in Assisted Living

Mar 1, 2023
WHAT THIS MEANS FOR YOU: Because AL is state-regulated, obtaining information about Medicare beneficiaries in AL can be difficult. This study identified AL Medicare beneficiaries using zip code files, Medicare databases, and other data sets, which can aid researchers and policymakers.

Using Medicare Enrollment Data to Identify Beneficiaries in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Because AL is state-regulated, obtaining information about Medicare beneficiaries in AL can be difficult. This study identified AL Medicare beneficiaries using zip code files, Medicare databases, and other data sets, which can aid researchers and policymakers.

Coping Behaviors and Health Status during the COVID-19 Pandemic among Caregivers of Assisted Living Residents in Western Canada

Dec 1, 2022
WHAT THIS MEANS FOR YOU: Surveys from 673 assisted living direct caregivers revealed that coping behaviors such as alcohol and smoking/cannabis use, and psychotropic drug use increased during the first two waves of the COVID-19 pandemic and were more common among caregivers who had anxiety or depression symptoms before the pandemic. These caregivers are thus particularly vulnerable to negative coping behaviors during stressful events and may require additional support.

Coping Behaviors and Health Status during the COVID-19 Pandemic among Caregivers of Assisted Living Residents in Western Canada

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Surveys from 673 assisted living direct caregivers revealed that coping behaviors such as alcohol and smoking/cannabis use, and psychotropic drug use increased during the first two waves of the COVID-19 pandemic and were more common among caregivers who had anxiety or depression symptoms before the pandemic. These caregivers are thus particularly vulnerable to negative coping behaviors during stressful events and may require additional support.

Patient Safety Culture in Assisted Living: Staff Perceptions and Association with State Regulations

Dec 1, 2022
WHAT THIS MEANS FOR YOU: A total of 714 administrators and direct care workers in 257 assisted living communities reported that direct care workers had a more negative perception of patient safety culture (PSC) than administrators. Stricter state regulations, particularly regarding staffing, were associated with better perceptions of PSC among direct care workers.

Patient Safety Culture in Assisted Living: Staff Perceptions and Association with State Regulations

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A total of 714 administrators and direct care workers in 257 assisted living communities reported that direct care workers had a more negative perception of patient safety culture (PSC) than administrators. Stricter state regulations, particularly regarding staffing, were associated with better perceptions of PSC among direct care workers.

Excess Mortality Among Assisted Living Residents with Dementia during the COVID-19 Pandemic

Oct 1, 2022
WHAT THIS MEANS FOR YOU: Data from over 560,000 Medicare recipients revealed that residents with dementia experienced 33.4 more excess deaths per 100,000 compared to those without dementia during the COVID-19 pandemic. Residents in memory care communities did not have significantly different mortality rates compared to those in general assisted living settings.

Excess Mortality Among Assisted Living Residents with Dementia during the COVID-19 Pandemic

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Data from over 560,000 Medicare recipients revealed that residents with dementia experienced 33.4 more excess deaths per 100,000 compared to those without dementia during the COVID-19 pandemic. Residents in memory care communities did not have significantly different mortality rates compared to those in general assisted living settings.

Staff Attitudes Related to Antipsychotic Prescribing in Assisted Living

Sep 1, 2022
WHAT THIS MEANS FOR YOU: Data from over 13,500 residents from 247 assisted living communities indicated that healthcare supervisors who were more supportive of using medication to treat behaviors were more likely to have higher rates of antipsychotic prescribing in their communities. Health care supervisor attitudes may be leveraged to reduce antipsychotic prescribing.

Staff Attitudes Related to Antipsychotic Prescribing in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Data from over 13,500 residents from 247 assisted living communities indicated that healthcare supervisors who were more supportive of using medication to treat behaviors were more likely to have higher rates of antipsychotic prescribing in their communities. Health care supervisor attitudes may be leveraged to reduce antipsychotic prescribing.

State Regulations and Hospice Utilization in Assisted Living during the Last Month of Life

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Medicare data from 23,000 residents in more than 6,000 assisted living communities found that 56% received hospice care during their last month of life. Communities in states with more supportive hospice regulations had significantly more hospice use, especially a more intense type called continuous home care (CHC). Modifications to state regulations to be more supportive of hospice care/CHC might increase the number of residents who use hospice, which might improve quality of life in the days immediately preceding death.

State Regulations and Hospice Utilization in Assisted Living during the Last Month of Life

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Medicare data from 23,000 residents in more than 6,000 assisted living communities found that 56% received hospice care during their last month of life. Communities in states with more supportive hospice regulations had significantly more hospice use, especially a more intense type called continuous home care (CHC). Modifications to state regulations to be more supportive of hospice care/CHC might increase the number of residents who use hospice, which might improve quality of life in the days immediately preceding death.

Administrator Turnover in Oregon Assisted Living and Residential Care Communities, March 2020–February 2021

Jun 1, 2022
WHAT THIS MEANS FOR YOU: This study analyzed staffing records from 549 assisted living communities in Oregon and found approximately one-third of administrators left their jobs between March 2020 and February 2021. Nonprofit communities and those with more beds had less administrator turnover; administrators who had been in their roles for a longer time before the pandemic were less likely to leave their jobs. Offering memory care services, accepting Medicaid, rurality, and number of assisted living communities in the county did not relate to administrator turnover.

Administrator Turnover in Oregon Assisted Living and Residential Care Communities, March 2020–February 2021

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study analyzed staffing records from 549 assisted living communities in Oregon and found approximately one-third of administrators left their jobs between March 2020 and February 2021. Nonprofit communities and those with more beds had less administrator turnover; administrators who had been in their roles for a longer time before the pandemic were less likely to leave their jobs. Offering memory care services, accepting Medicaid, rurality, and number of assisted living communities in the county did not relate to administrator turnover.

Melatonin Prescribing in Assisted Living

Jun 1, 2022
WHAT THIS MEANS FOR YOU: The study investigated the use of melatonin among more than 5,700 residents from 250 assisted living communities across 7 states. Overall, 82% of communities prescribed melatonin to at least one resident, and on average, 9% of residents in a community received melatonin. Melatonin usage varied depending on community characteristics and was more likely if there was an RN or LPN on site or if the health care supervisor was more favorable to nonpharmacological practices.

Melatonin Prescribing in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: The study investigated the use of melatonin among more than 5,700 residents from 250 assisted living communities across 7 states. Overall, 82% of communities prescribed melatonin to at least one resident, and on average, 9% of residents in a community received melatonin. Melatonin usage varied depending on community characteristics and was more likely if there was an RN or LPN on site or if the health care supervisor was more favorable to nonpharmacological practices.

As-Needed Prescribing and Administration of Psychotropic Medications in Assisted Living: A 7-State Study

Jun 1, 2022
WHAT THIS MEANS FOR YOU: In 250 assisted living communities in 7 states, 10% of residents were prescribed psychotropic medications; less than 3% were administered a psychotropic medication in the previous week. Most (70%) prescriptions had a written reason for administration. Residents with both dementia and a psychiatric diagnosis were more likely to have a prescription, and communities that were larger or had a higher proportion of dementia care beds had a higher prescription rate.

As-Needed Prescribing and Administration of Psychotropic Medications in Assisted Living: A 7-State Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: In 250 assisted living communities in 7 states, 10% of residents were prescribed psychotropic medications; less than 3% were administered a psychotropic medication in the previous week. Most (70%) prescriptions had a written reason for administration. Residents with both dementia and a psychiatric diagnosis were more likely to have a prescription, and communities that were larger or had a higher proportion of dementia care beds had a higher prescription rate.

Antibiotic Deescalation Opportunities for Residents in Assisted Living Facilities

Jun 1, 2022
WHAT THIS MEANS FOR YOU: During one-year in three assisted living communities, over 52% of the 106 residents were prescribed an antibiotic medication, similar to the rate of prescribing in nursing homes. Different from nursing homes, assisted living prescribers appeared less likely to reduce antibiotic use, and more likely to switch from narrow- to broad-spectrum antibiotics. Differences may be due to less frequent on-site visits of prescribing physicians in assisted living, which could lead to less familiarity with residents.

Antibiotic Deescalation Opportunities for Residents in Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: During one-year in three assisted living communities, over 52% of the 106 residents were prescribed an antibiotic medication, similar to the rate of prescribing in nursing homes. Different from nursing homes, assisted living prescribers appeared less likely to reduce antibiotic use, and more likely to switch from narrow- to broad-spectrum antibiotics. Differences may be due to less frequent on-site visits of prescribing physicians in assisted living, which could lead to less familiarity with residents.