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.

Quality Improvement

CEAL@UNC Guest Columns: McKnight’s Senior Living

Jan 16, 2026
Dr. Sheryl Zimmerman, Executive Director of CEAL@UNC, is a guest columnist for McKnight’s Senior Living. These regularly published articles reflect the perspectives of CEAL@UNC advisors, and address timely topics relevant to the well-being of the people who live and work in assisted living. View Articles

CEAL@UNC Guest Columns: McKnight’s Senior Living

by Lea Efird-Green

Dr. Sheryl Zimmerman, Executive Director of CEAL@UNC, is a guest columnist for McKnight’s Senior Living. These regularly published articles reflect the perspectives of CEAL@UNC advisors, and address timely topics relevant to the well-being of the people who live and work in assisted living. View Articles

CEAL@UNC Strategic Advisor Presentations

Nov 24, 2025
CEAL@UNC regularly invites organizations and individuals committed to advancing well-being in assisted living through practice, research, and policy to present emerging and relevant topics to its Strategic Advisors. View Presentations

CEAL@UNC Strategic Advisor Presentations

by Lea Efird-Green

CEAL@UNC regularly invites organizations and individuals committed to advancing well-being in assisted living through practice, research, and policy to present emerging and relevant topics to its Strategic Advisors. View Presentations

Optimizing Ethical Care, Quality, and Safety in Long-Term Services and Supports: A Position Paper from the American College of Physicians

Jun 1, 2025
WHAT THIS MEANS FOR YOU: This position paper examines the ethical implications of current business models and practices of long-term services and supports (LTSS) in the United States, and their effects on vulnerable populations. The paper reports four positions that would improve outcomes for vulnerable populations: optimizing care quality and incentivizing patient preferences, respecting individuals, prioritizing improvements in LTSS, and increased transparency and accountability, all of which support person-centered care.

Optimizing Ethical Care, Quality, and Safety in Long-Term Services and Supports: A Position Paper from the American College of Physicians

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This position paper examines the ethical implications of current business models and practices of long-term services and supports (LTSS) in the United States, and their effects on vulnerable populations. The paper reports four positions that would improve outcomes for vulnerable populations: optimizing care quality and incentivizing patient preferences, respecting individuals, prioritizing improvements in LTSS, and increased transparency and accountability, all of which support person-centered care.

Differences in Quality of Care Interactions Across Care Tasks in Assisted Living

May 1, 2025
WHAT THIS MEANS FOR YOU: This descriptive study of four assisted living communities in Maryland examined 152 staff-resident interactions to understand if quality of care interactions differs by care task type. Different categories of care interactions were identified with positive care interactions being the most common (36%), and supportive care being the most common type of task (34%). Supportive/ambulatory care (i.e., distracting, transferring, and walking) interactions were more negative than intimate personal care (i.e., bathing, dressing, and toileting) interactions, suggesting improvements in care interaction quality may be needed for supportive care.

Differences in Quality of Care Interactions Across Care Tasks in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This descriptive study of four assisted living communities in Maryland examined 152 staff-resident interactions to understand if quality of care interactions differs by care task type. Different categories of care interactions were identified with positive care interactions being the most common (36%), and supportive care being the most common type of task (34%). Supportive/ambulatory care (i.e., distracting, transferring, and walking) interactions were more negative than intimate personal care (i.e., bathing, dressing, and toileting) interactions, suggesting improvements in care interaction quality may be needed for supportive care.

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.

The Importance of Nature and Wishes for Nature-Based Experiences Among Older Adults in Assisted Living Facilities

May 1, 2025
WHAT THIS MEANS FOR YOU: This cross-sectional study of 25 assisted living communities in Finland examined 854 residents' views of nature-based interventions. Only 24% of residents could move outdoors independently, and only 51% had the amount of nature exposure they wanted, although 96% consider nature important and 83% stated interest in nature-based interventions. Results indicate developing nature-based interventions could be appealing for older adults.

The Importance of Nature and Wishes for Nature-Based Experiences Among Older Adults in Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This cross-sectional study of 25 assisted living communities in Finland examined 854 residents’ views of nature-based interventions. Only 24% of residents could move outdoors independently, and only 51% had the amount of nature exposure they wanted, although 96% consider nature important and 83% stated interest in nature-based interventions. Results indicate developing nature-based interventions could be appealing for older adults.

Salutogenic Architecture, Non-Therapeutic Environments and the Health of the Elderly: A Systematic Review

Apr 1, 2025
WHAT THIS MEANS FOR YOU: This systematic review of 26 articles aimed to identify architectural elements that can achieve salutogenic (positive wellbeing) goals for older adults, and how architectural design can bring salutogenic theory to life. Physical elements such as porches, balconies, and above-grade entrances are key elements in individuals' homes, while walls were identified as key elements in assisted living communities for supporting coherence due to their role in creating a personal, distinct space for residents.

Salutogenic Architecture, Non-Therapeutic Environments and the Health of the Elderly: A Systematic Review

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This systematic review of 26 articles aimed to identify architectural elements that can achieve salutogenic (positive wellbeing) goals for older adults, and how architectural design can bring salutogenic theory to life. Physical elements such as porches, balconies, and above-grade entrances are key elements in individuals’ homes, while walls were identified as key elements in assisted living communities for supporting coherence due to their role in creating a personal, distinct space for residents.

Keeping Assisted Living Communities Secure: A Comprehensive Approach from the Perimeter to the Interior

Mar 1, 2025
WHAT THIS MEANS FOR YOU: This article highlights the importance of physical and cybersecurity in assisted living using the People, Programs, Training, and Technology (P2T2) system. For the system to be effective, staff training, resident education, and collaboration with law enforcement are integral. Best practices like checklists can be implemented so that physical security, technological solutions, and emergency preparedness can be addressed for quality assurance.

Keeping Assisted Living Communities Secure: A Comprehensive Approach from the Perimeter to the Interior

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This article highlights the importance of physical and cybersecurity in assisted living using the People, Programs, Training, and Technology (P2T2) system. For the system to be effective, staff training, resident education, and collaboration with law enforcement are integral. Best practices like checklists can be implemented so that physical security, technological solutions, and emergency preparedness can be addressed for quality assurance.

“Nobody Can Be Equipped for This”: Advice from New Residents of Long-Term Care Facilities

Mar 1, 2025
WHAT THIS MEANS FOR YOU: This study involved interviews with 14 residents from a community offering assisted living (AL) and nursing home (NH) levels of care in California to understand residents' perspectives on moving into a long-term care community. Moving due to unexpected health crises was common. Advice for future residents included preparing for moving, avoiding moving, and acceptance of moving. Staff should be prepared to care for residents who often move due to unforseen/unwanted circumstances.

“Nobody Can Be Equipped for This”: Advice from New Residents of Long-Term Care Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study involved interviews with 14 residents from a community offering assisted living (AL) and nursing home (NH) levels of care in California to understand residents’ perspectives on moving into a long-term care community. Moving due to unexpected health crises was common. Advice for future residents included preparing for moving, avoiding moving, and acceptance of moving. Staff should be prepared to care for residents who often move due to unforseen/unwanted circumstances.

What Happens Behind Closed Doors? Investigating Care Practices in Nursing Home and Assisted Living Memory Care Units

Feb 1, 2025
WHAT THIS MEANS FOR YOU: This study investigated care practices in memory care units using data from the 2021 Biennial Survey of Ohio Long-Term Care Facilities. Analysis revealed that about 20% of nursing homes and AL communities had memory care units, and that physician monitoring, staffing, and adoption of practices and policies were similar in both settings, but that psychotropic medications were used more frequently in NH memory care units. This analysis indicates that improving memory care may require different interventions in NH vs. AL settings.

What Happens Behind Closed Doors? Investigating Care Practices in Nursing Home and Assisted Living Memory Care Units

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study investigated care practices in memory care units using data from the 2021 Biennial Survey of Ohio Long-Term Care Facilities. Analysis revealed that about 20% of nursing homes and AL communities had memory care units, and that physician monitoring, staffing, and adoption of practices and policies were similar in both settings, but that psychotropic medications were used more frequently in NH memory care units. This analysis indicates that improving memory care may require different interventions in NH vs. AL settings.

Two New Positive Psychosocial Measures for Persons Living with Dementia

Feb 1, 2025
WHAT THIS MEANS FOR YOU: Two pilot studies created and tested two new instruments for evaluating wellbeing for people living with dementia, the Living Well Inventory for Dementia (LWI-D) and the Quality of Day Scale (QODS). Seventeen individuals with early-stage dementia tested the LWI-D, and 30 care dyads tested the QODS. Both measures were supported for acceptability and feasibility, with initial support for reliability and validity; further testing of the instruments is recommended.

Two New Positive Psychosocial Measures for Persons Living with Dementia

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Two pilot studies created and tested two new instruments for evaluating wellbeing for people living with dementia, the Living Well Inventory for Dementia (LWI-D) and the Quality of Day Scale (QODS). Seventeen individuals with early-stage dementia tested the LWI-D, and 30 care dyads tested the QODS. Both measures were supported for acceptability and feasibility, with initial support for reliability and validity; further testing of the instruments is recommended.

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.

Measurement of Quality in Assisted Living in the United States of America: A Scoping Review

Jan 1, 2025
WHAT THIS MEANS FOR YOU: This scoping review examined 49 peer-reviewed and 45 gray literature articles from 2009-2019 to assess approaches to, and indicators of, quality in assisted living. After thematic analysis, nine domains emerged, with resident qualiy of life and satisfaction being the most prioritized. These nine domains may help inform future standardized quality measurement for AL settings.

Measurement of Quality in Assisted Living in the United States of America: A Scoping Review

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This scoping review examined 49 peer-reviewed and 45 gray literature articles from 2009-2019 to assess approaches to, and indicators of, quality in assisted living. After thematic analysis, nine domains emerged, with resident qualiy of life and satisfaction being the most prioritized. These nine domains may help inform future standardized quality measurement for AL settings.

Risk of Hospitalization Among Assisted Living Residents Dually Enrolled in Medicare and Medicaid

Dec 1, 2024
WHAT THIS MEANS FOR YOU: This retrospective cohort study used Medicare data from 2008-2018 from 12,451 AL communities to examine the risk of hospitalization for Medicare-Medicaid dual eligibles. Out of 620,542 Medicare beneficiaries, the 1-year risk of hospitalization was higher for dually enrolled individuals. The risk was higher in high-dual AL communities than in low-dual AL communities for both dually enrolled (7.4%) and Medicare only (9.4%) individuals.

Risk of Hospitalization Among Assisted Living Residents Dually Enrolled in Medicare and Medicaid

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This retrospective cohort study used Medicare data from 2008-2018 from 12,451 AL communities to examine the risk of hospitalization for Medicare-Medicaid dual eligibles. Out of 620,542 Medicare beneficiaries, the 1-year risk of hospitalization was higher for dually enrolled individuals. The risk was higher in high-dual AL communities than in low-dual AL communities for both dually enrolled (7.4%) and Medicare only (9.4%) individuals.

Transitions to Nursing Homes Among Residents of Assisted Living and Community-Dwelling Home Care Recipients

Dec 1, 2024
This Canadian cohort study included 10,012 AL residents and 131,679 home care recipients who applied for beds in nursing homes to examine the transition differences between the 2 groups. There were 6,049 transitions from AL residents and 85,190 from home care to nursing homes. Living in an AL, rather than in the community, led to a roughly 13% decrease in the 5-year risk of transition to nursing homes despite similar relative clinical complexity and healthcare needs, meaning that assisted living is an important part of the long-term care continuum.

Transitions to Nursing Homes Among Residents of Assisted Living and Community-Dwelling Home Care Recipients

by Lea Efird-Green

This Canadian cohort study included 10,012 AL residents and 131,679 home care recipients who applied for beds in nursing homes to examine the transition differences between the 2 groups. There were 6,049 transitions from AL residents and 85,190 from home care to nursing homes. Living in an AL, rather than in the community, led to a roughly 13% decrease in the 5-year risk of transition to nursing homes despite similar relative clinical complexity and healthcare needs, meaning that assisted living is an important part of the long-term care continuum.

Association Between Organizational Context and Resident Pain in Assisted Living: A Repeated Cross-Sectional Study

Nov 1, 2024
WHAT THIS MEANS FOR YOU: This repeated cross-sectional study linked survey data from COVID-19 waves 1 and 2 from 985 residents in 41 AL communities (wave 1) and 1134 residents in 42 AL communities (wave 2) to examine if organizational context was associated with resident pain. Overall pain prevalence decreased from 20.6% in wave 1 to 19.1% in wave 2, but it was non-significant.There were mixed results: better preparedness, room confinement, availability of a nurse practitioner, and staff shortages were associated with resident pain. Organizational context does therefore have an effect on resident pain, and future policy and management interventions should address these factors.

Association Between Organizational Context and Resident Pain in Assisted Living: A Repeated Cross-Sectional Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This repeated cross-sectional study linked survey data from COVID-19 waves 1 and 2 from 985 residents in 41 AL communities (wave 1) and 1134 residents in 42 AL communities (wave 2) to examine if organizational context was associated with resident pain. Overall pain prevalence decreased from 20.6% in wave 1 to 19.1% in wave 2, but it was non-significant.There were mixed results: better preparedness, room confinement, availability of a nurse practitioner, and staff shortages were associated with resident pain. Organizational context does therefore have an effect on resident pain, and future policy and management interventions should address these factors.

Factors Associated with Transfer from Assisted Living Facilities to a Nursing Home: National Health Aging Trends Study 2011-2019

Nov 1, 2024
WHAT THIS MEANS FOR YOU: This analysis used the National Health Aging Trends Study to identify factors associated with transfer from an AL community to a nursing home. Data from 970 AL residents over seven years showed that those with better baseline physical performance and college education were at lower risk of transfer. Residents who maintained physical less and had less difficulty with basic activities of daily living (ADLs) were also at lower risk of transfer.

Factors Associated with Transfer from Assisted Living Facilities to a Nursing Home: National Health Aging Trends Study 2011-2019

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This analysis used the National Health Aging Trends Study to identify factors associated with transfer from an AL community to a nursing home. Data from 970 AL residents over seven years showed that those with better baseline physical performance and college education were at lower risk of transfer. Residents who maintained physical less and had less difficulty with basic activities of daily living (ADLs) were also at lower risk of transfer.

Clinical and Sociodemographic Characteristics of New Residents of Assisted Living: A Nested Case-Control Study

Nov 1, 2024
WHAT THIS MEANS FOR YOU: This nested case-control study in Ontario examined differences between community-dwelling and new AL residents to understand transitions to AL communitiess. New residents had higher rates of diagnosed dementia, mood disorders, cardiac arrhythmias, mild cognitive impairment, and falls than community-dwelling peers. New AL residents also had lower odds of having a spousal caregiver than a child caregiver. However, these residents also had higher rates of participation in activities of interest in the last seven days.

Clinical and Sociodemographic Characteristics of New Residents of Assisted Living: A Nested Case-Control Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This nested case-control study in Ontario examined differences between community-dwelling and new AL residents to understand transitions to AL communitiess. New residents had higher rates of diagnosed dementia, mood disorders, cardiac arrhythmias, mild cognitive impairment, and falls than community-dwelling peers. New AL residents also had lower odds of having a spousal caregiver than a child caregiver. However, these residents also had higher rates of participation in activities of interest in the last seven days.

Effect of a Digital Two-Dimensional Animation Program on Attitude Toward Walking Aids, Performance, and Fall Avoidance Behaviors among Older Adults in Assisted Living Facilities

Nov 1, 2024
WHAT THIS MEANS FOR YOU: This quasi-experimental study of 128 AL residents investigated the impact of a two-dimensional animation program on attitudes towards walking aids, performance and fall avoidance behaviors. The intervention group had more positive attitudes towards walking aids, improved walking aid use, and reduced fall concerns than the control group, meaning this teaching strategy could be effective to enhance mobility and reduce falls in this setting.

Effect of a Digital Two-Dimensional Animation Program on Attitude Toward Walking Aids, Performance, and Fall Avoidance Behaviors among Older Adults in Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This quasi-experimental study of 128 AL residents investigated the impact of a two-dimensional animation program on attitudes towards walking aids, performance and fall avoidance behaviors. The intervention group had more positive attitudes towards walking aids, improved walking aid use, and reduced fall concerns than the control group, meaning this teaching strategy could be effective to enhance mobility and reduce falls in this setting.

Feasibility of a Novel Lighting System to Reduce Nighttime Falls in Assisted Living Residents With Dementia

Oct 1, 2024
WHAT THIS MEANS FOR YOU: This crossover trial examined 38 residents in 5 AL communities to test a new lighting system to reduce nighttime falls. Using cameras to capture falls, falls density was found to be 34% lower in the intervention condition than the control condition, although this reduction was not statistically significant. The results were promising enough to continue testing in a larger trial, which is ongoing.

Feasibility of a Novel Lighting System to Reduce Nighttime Falls in Assisted Living Residents With Dementia

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This crossover trial examined 38 residents in 5 AL communities to test a new lighting system to reduce nighttime falls. Using cameras to capture falls, falls density was found to be 34% lower in the intervention condition than the control condition, although this reduction was not statistically significant. The results were promising enough to continue testing in a larger trial, which is ongoing.