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.

The Gerontologist

A Qualitative Analysis of Safety Culture in Minnesota’s Assisted Living Facilities

May 1, 2025
WHAT THIS MEANS FOR YOU: This qualitative analysis applied the Agency for Healthcare Research and Quality's safety domains to post-2019 health inspection reports from assisted living communities in Minnesota to better understand regulation and safety. Three themes emerged in survey violations that harmed patients: staffing, compliance, and communication. Improving policies and practices related to these domains could improve safety for residents in Minnesota AL communities.

A Qualitative Analysis of Safety Culture in Minnesota’s Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This qualitative analysis applied the Agency for Healthcare Research and Quality’s safety domains to post-2019 health inspection reports from assisted living communities in Minnesota to better understand regulation and safety. Three themes emerged in survey violations that harmed patients: staffing, compliance, and communication. Improving policies and practices related to these domains could improve safety for residents in Minnesota AL communities.

Differing Realities Among Assisted Living Residents With Dementia: Understanding Care Partner Responses

Apr 1, 2025
WHAT THIS MEANS FOR YOU: This analysis of 73 residents with dementia and 103 care partners from eight assisted living communities in the Atlanta area examined differing realities of residents with dementia and their care partners' responses. A qualitative analysis revealed most residents experienced confusion, which led to reality management strategies deployed by care partners. These strategies ranged from ignoring or dismissing to correcting, redirecting, or joining the resident in their reality. Factors such as type of confusion and resident/care partner characteristics influenced which strategy was deployed.

Differing Realities Among Assisted Living Residents With Dementia: Understanding Care Partner Responses

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This analysis of 73 residents with dementia and 103 care partners from eight assisted living communities in the Atlanta area examined differing realities of residents with dementia and their care partners’ responses. A qualitative analysis revealed most residents experienced confusion, which led to reality management strategies deployed by care partners. These strategies ranged from ignoring or dismissing to correcting, redirecting, or joining the resident in their reality. Factors such as type of confusion and resident/care partner characteristics influenced which strategy was deployed.

A Cluster Randomized Controlled Trial of Visual Cues, Signage, and Spaced Retrieval for Wayfinding Within Long-Term Care Communities

Feb 1, 2025
WHAT THIS MEANS FOR YOU: This randomized control trial of 172 residents in 15 long-term care communities in two midwestern states to examine the impact of cues and signage, with or without spaced retrieval (SR), a memory strategy to improve wayfinding within communities. For simple routes, cues improved wayfinding. SR with cues reduced the number of errors participants made the most, but cues alone also lowered errors in wayfinding, supporting the potential implementation of cues and signage to reduce wayfinding errors in communities.

A Cluster Randomized Controlled Trial of Visual Cues, Signage, and Spaced Retrieval for Wayfinding Within Long-Term Care Communities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This randomized control trial of 172 residents in 15 long-term care communities in two midwestern states to examine the impact of cues and signage, with or without spaced retrieval (SR), a memory strategy to improve wayfinding within communities. For simple routes, cues improved wayfinding. SR with cues reduced the number of errors participants made the most, but cues alone also lowered errors in wayfinding, supporting the potential implementation of cues and signage to reduce wayfinding errors in communities.

“What Does ‘Age-Friendly’ Mean to You?”: The Role of Microaggressions in a Retirement and Assisted Living Community

Dec 1, 2024
WHAT THIS MEANS FOR YOU: This case study compared four residents' perspectives on the age-friendliness of an AL in the Midwest using semi-structured interviews and observational data. Themes of built design vs. identity of age-friendliness, resident-resident microaggressions, and desired experiences of age-friendliness emerged. Visible diversity created experiences of ableism and racism, whereas invisible diversity did not have the same negative effects. Resident-resident microaggressions undermined the age-friendliness of the facility.

“What Does ‘Age-Friendly’ Mean to You?”: The Role of Microaggressions in a Retirement and Assisted Living Community

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This case study compared four residents’ perspectives on the age-friendliness of an AL in the Midwest using semi-structured interviews and observational data. Themes of built design vs. identity of age-friendliness, resident-resident microaggressions, and desired experiences of age-friendliness emerged. Visible diversity created experiences of ableism and racism, whereas invisible diversity did not have the same negative effects. Resident-resident microaggressions undermined the age-friendliness of the facility.

Admission and Discharge Practices Among Assisted Living Communities: The Role of State Regulations and Organizational Characteristics

Aug 1, 2024
WHAT THIS MEANS FOR YOU: This study examined state regulations and characteristics from 250 AL communities in 7 states related to admission and discharge practices and three activities of daily living (ADLs). State regulations were not associated with admission and discharge practices, but communities who were above the mean in staff-resident ratio were 17% more likely to admit residents with feeding difficulties and 25% less likely to discharge them. For-profit facilities were more likely to admit residents with bathing and feeding difficulties. These relationships mean that organizational characteristics may drive admission and discharge practices more than state regulations.

Admission and Discharge Practices Among Assisted Living Communities: The Role of State Regulations and Organizational Characteristics

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined state regulations and characteristics from 250 AL communities in 7 states related to admission and discharge practices and three activities of daily living (ADLs). State regulations were not associated with admission and discharge practices, but communities who were above the mean in staff-resident ratio were 17% more likely to admit residents with feeding difficulties and 25% less likely to discharge them. For-profit facilities were more likely to admit residents with bathing and feeding difficulties. These relationships mean that organizational characteristics may drive admission and discharge practices more than state regulations.

A National Typology of Health Service Regulation in Assisted Living

Aug 1, 2023
WHAT THIS MEANS FOR YOU: This study categorized 350 assisted living state licensure types into six different types that differed by regulations about health services: housing, holistic, hybrid, hospitality, healthcare, and health support. This categorization may support consumer decision-making and improve the specificity of assisted living research and policy.

A National Typology of Health Service Regulation in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study categorized 350 assisted living state licensure types into six different types that differed by regulations about health services: housing, holistic, hybrid, hospitality, healthcare, and health support. This categorization may support consumer decision-making and improve the specificity of assisted living research and policy.

Feasibility of the Palliative Care Education in Assisted Living Intervention for Dementia Care Providers: A Cluster Randomized Trial

Feb 1, 2023
WHAT THIS MEANS FOR YOU: A study in Florida assessed a staff education intervention in 10 different AL communities, in which 118 AL residents with dementia participated. The intervention focused on person-centered palliative care for residents with dementia. It showed initial positive results by increasing palliative care practices, specifically advance care planning discussions and hospice admissions.

Feasibility of the Palliative Care Education in Assisted Living Intervention for Dementia Care Providers: A Cluster Randomized Trial

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A study in Florida assessed a staff education intervention in 10 different AL communities, in which 118 AL residents with dementia participated. The intervention focused on person-centered palliative care for residents with dementia. It showed initial positive results by increasing palliative care practices, specifically advance care planning discussions and hospice admissions.

Survey Deficiencies as Quality Indicators in Oregon Assisted Living Communities

Oct 1, 2022
WHAT THIS MEANS FOR YOU: Almost 80% of inspections from 526 assisted living communities in Oregon revealed at least one deficiency; the most common deficiency types were medications and medical treatments, monitoring changes in residents' conditions, and health services. Characteristics associated with more deficiencies included larger size, memory care designation, shorter administrator tenure, and for-profit status. The number and likelihood of a given community receiving a deficiency decreased over the study period (2008-2016).

Survey Deficiencies as Quality Indicators in Oregon Assisted Living Communities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Almost 80% of inspections from 526 assisted living communities in Oregon revealed at least one deficiency; the most common deficiency types were medications and medical treatments, monitoring changes in residents’ conditions, and health services. Characteristics associated with more deficiencies included larger size, memory care designation, shorter administrator tenure, and for-profit status. The number and likelihood of a given community receiving a deficiency decreased over the study period (2008-2016).

“What Keeps Me Awake at Night”: Assisted Living Administrator Responses to COVID-19

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study assessed how the early COVID-19 pandemic (Feb-Aug 2020) affected 40 assisted living administrators in Oregon. Three resulting themes from the interviews were emotion and burnout management (e.g., monitoring staff reactions), information management (e.g., monitoring latest recommendations and safety protocols), and crisis management (e.g., decision-making, emergency planning).

“What Keeps Me Awake at Night”: Assisted Living Administrator Responses to COVID-19

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study assessed how the early COVID-19 pandemic (Feb-Aug 2020) affected 40 assisted living administrators in Oregon. Three resulting themes from the interviews were emotion and burnout management (e.g., monitoring staff reactions), information management (e.g., monitoring latest recommendations and safety protocols), and crisis management (e.g., decision-making, emergency planning).

Factors Associated With Assisted Living Facility Closure

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study analyzed almost 2,000 Florida assisted living communities to understand factors related to assisted living closure between 2013-2015. During this time, 7.3% of communities closed; those with increased odds of closing had fewer beds, did not accept Medicaid, and had more regulatory deficiencies.

Factors Associated With Assisted Living Facility Closure

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study analyzed almost 2,000 Florida assisted living communities to understand factors related to assisted living closure between 2013-2015. During this time, 7.3% of communities closed; those with increased odds of closing had fewer beds, did not accept Medicaid, and had more regulatory deficiencies.

Staff Reports of Behavioral Expressions of Persons with Dementia in 250 Assisted Living Communities 

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study included health care supervisors from 250 assisted living communities in 7 states to understand how staff respond to behavioral expressions of residents with dementia. The most commonly reported expressions were combativeness and anxiety. A thematic analysis found that in about 25% of cases, staff recognized the events preceding behavioral expressions (antecedents). Staff in smaller and memory-care only communities were more adept at identifying antecedents; additional training to anticipate expressions may help prevent them.

Staff Reports of Behavioral Expressions of Persons with Dementia in 250 Assisted Living Communities 

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study included health care supervisors from 250 assisted living communities in 7 states to understand how staff respond to behavioral expressions of residents with dementia. The most commonly reported expressions were combativeness and anxiety. A thematic analysis found that in about 25% of cases, staff recognized the events preceding behavioral expressions (antecedents). Staff in smaller and memory-care only communities were more adept at identifying antecedents; additional training to anticipate expressions may help prevent them.

Assisted Living Residents With Dementia: Being Out in the World and Negotiating Connections

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This year-long study observed 33 individuals and their caregivers in 4 assisted living communities, focusing on the significance of outdoor and offsite activities for persons living with dementia. Data included 1,560 observation hours, 114 interviews with residents, staff, family, and visitors, and resident record reviews. Qualitative findings suggested that engaging with others and with nature is important for better quality of life. Most residents were able to at least occasionally go out, and those who went outdoors generally had positive experiences, but not all experiences were positive.

Assisted Living Residents With Dementia: Being Out in the World and Negotiating Connections

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This year-long study observed 33 individuals and their caregivers in 4 assisted living communities, focusing on the significance of outdoor and offsite activities for persons living with dementia. Data included 1,560 observation hours, 114 interviews with residents, staff, family, and visitors, and resident record reviews. Qualitative findings suggested that engaging with others and with nature is important for better quality of life. Most residents were able to at least occasionally go out, and those who went outdoors generally had positive experiences, but not all experiences were positive.