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.

Regulation/Monitoring

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

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.

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.

Does Assisted Living Provide Assistance And Promote Living?

May 1, 2024
WHAT THIS MEANS FOR YOU: AL communities in the United States serve more than 918,000 older adults as of 2018. In this commentary, the authors examined how workforce limitations, the complexity of regulations, consumer needs, and lack of financing contribute to negative consequences for aging in place and well-being. They suggest policy changes in those four areas, such as increased staffing, boosting wages and training, encouraging uniform data reporting, and making community disclosure statements more accessible.

Does Assisted Living Provide Assistance And Promote Living?

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: AL communities in the United States serve more than 918,000 older adults as of 2018. In this commentary, the authors examined how workforce limitations, the complexity of regulations, consumer needs, and lack of financing contribute to negative consequences for aging in place and well-being. They suggest policy changes in those four areas, such as increased staffing, boosting wages and training, encouraging uniform data reporting, and making community disclosure statements more accessible.

Public Health Response to SARS-CoV-2 in Assisted Living Facilities in New York State: March 2020-December 2022

May 1, 2024
WHAT THIS MEANS FOR YOU: This narrative review examined New York state regulation and guidance related to COVID-19 in AL communities from March 2020 to December 2022. Early in the pandemic, strict lockdowns were put in place; then, the vaccine was authorized and implemented during phased reopening of communities. About 90% of New York AL residents were vaccinated by early 2021. As communities reopened, booster shots were required to keep residents protected, especially with new COVID-19 variants. These regulatory efforts were crucial in keeping vulnerable AL residents safe, but they led to social isolation and other psychological impacts; this highlights the complexity of AL regulatory responses in emergency situations.

Public Health Response to SARS-CoV-2 in Assisted Living Facilities in New York State: March 2020-December 2022

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This narrative review examined New York state regulation and guidance related to COVID-19 in AL communities from March 2020 to December 2022. Early in the pandemic, strict lockdowns were put in place; then, the vaccine was authorized and implemented during phased reopening of communities. About 90% of New York AL residents were vaccinated by early 2021. As communities reopened, booster shots were required to keep residents protected, especially with new COVID-19 variants. These regulatory efforts were crucial in keeping vulnerable AL residents safe, but they led to social isolation and other psychological impacts; this highlights the complexity of AL regulatory responses in emergency situations.

Potential Actions to Advance Well-being in Assisted Living

Apr 23, 2024
CEAL@UNC recognizes the benefit of ongoing quality improvement in assisted living. Numerous feasible solutions have been suggested that may improve care and outcomes in assisted living, including those in this information sheet. Feel free to utilize and distribute this information sheet among your networks to advance the well-being of the people who live and work […]

Potential Actions to Advance Well-being in Assisted Living

by Lea Efird-Green

CEAL@UNC recognizes the benefit of ongoing quality improvement in assisted living. Numerous feasible solutions have been suggested that may improve care and outcomes in assisted living, including those in this information sheet. Feel free to utilize and distribute this information sheet among your networks to advance the well-being of the people who live and work […]

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.

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.

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.

State Regulations and Assisted Living Residents’ Potentially Burdensome Transitions at the End of Life

Jun 1, 2023
WHAT THIS MEANS FOR YOU: The study examined potentially burdensome end-of-life transitions (e.g., repeated hospitalizations) in relation to state regulations, using Medicare claims data for over 129,000 assisted living residents in communities with 25 or more beds between 2017-2019. There were no associations between transitions and regulations about third-party services or staffing, and small associations between transitions and medication management regulations. These inconclusive results indicate that more research is needed to understand the wide variety of end-of-life outcomes experienced by assisted living residents.

State Regulations and Assisted Living Residents’ Potentially Burdensome Transitions at the End of Life

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: The study examined potentially burdensome end-of-life transitions (e.g., repeated hospitalizations) in relation to state regulations, using Medicare claims data for over 129,000 assisted living residents in communities with 25 or more beds between 2017-2019. There were no associations between transitions and regulations about third-party services or staffing, and small associations between transitions and medication management regulations. These inconclusive results indicate that more research is needed to understand the wide variety of end-of-life outcomes experienced by 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.

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.

Preparedness and Response of Assisted Living Facilities Toward COVID-19 Infection Control in Houston, Texas, USA

Feb 1, 2023
WHAT THIS MEANS FOR YOU: The Houston Health Department conducted onsite assessments at AL communities to assess infection prevention and control practices. Larger AL communities better implemented CDC guidelines and were more proactive in their COVID-19 response activities. For example, many medium and small communities lacked access to COVID-19 PCR testing and had lower resident vaccination rates.

Preparedness and Response of Assisted Living Facilities Toward COVID-19 Infection Control in Houston, Texas, USA

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: The Houston Health Department conducted onsite assessments at AL communities to assess infection prevention and control practices. Larger AL communities better implemented CDC guidelines and were more proactive in their COVID-19 response activities. For example, many medium and small communities lacked access to COVID-19 PCR testing and had lower resident vaccination rates.

Implementation of an Emergency Power Rule: Compliance of Florida Nursing Homes and Assisted Living Facilities

Jan 1, 2023
WHAT THIS MEANS FOR YOU: Data from 680 nursing homes (NHs) and 2940 AL communities in Florida examined compliance with an emergency power rule to have a secondary power source. The rule had higher implementation rates in AL than NH. AL communities were more likely to implement the new policy if they were smaller, did not offer memory care, accepted Medicaid, and had a mental health specialty license. Therefore, organizational characteristics and policies may help or hinder implementing new regulations.

Implementation of an Emergency Power Rule: Compliance of Florida Nursing Homes and Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Data from 680 nursing homes (NHs) and 2940 AL communities in Florida examined compliance with an emergency power rule to have a secondary power source. The rule had higher implementation rates in AL than NH. AL communities were more likely to implement the new policy if they were smaller, did not offer memory care, accepted Medicaid, and had a mental health specialty license. Therefore, organizational characteristics and policies may help or hinder implementing new regulations.

Now You’re Tax‐Exempt, Now You’re Not: Property Taxation of Assisted Living Facilities

Jan 1, 2023
WHAT THIS MEANS FOR YOU: Nonprofit AL communities in Florida lost their tax-exempt status in 2006 and regained it in 2017. Even when nonprofit AL communities had to pay property taxes, they provided higher-quality services than for-profit communities: more nursing staff, residents, and variety in care. In contrast, for-profit AL communities had more substantiated complaints and deficiencies, faced more sanctions after inspections, and incurred higher fines on average.

Now You’re Tax‐Exempt, Now You’re Not: Property Taxation of Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Nonprofit AL communities in Florida lost their tax-exempt status in 2006 and regained it in 2017. Even when nonprofit AL communities had to pay property taxes, they provided higher-quality services than for-profit communities: more nursing staff, residents, and variety in care. In contrast, for-profit AL communities had more substantiated complaints and deficiencies, faced more sanctions after inspections, and incurred higher fines on average.

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.

Promoting Quality of Life and Safety in Assisted Living: A Survey of State Monitoring and Enforcement Agents

Oct 1, 2022
WHAT THIS MEANS FOR YOU: Surveys from regulatory administrators in 48 states indicated that in more than half of states, regulatory monitoring was handled by at least three agencies with differing resources (e.g., budget, staffing) and methods (e.g., inspections). Less than half of the states compiled data from inspections, violations, and penalties, and fewer than 10 made this information easily available to the public.

Promoting Quality of Life and Safety in Assisted Living: A Survey of State Monitoring and Enforcement Agents

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Surveys from regulatory administrators in 48 states indicated that in more than half of states, regulatory monitoring was handled by at least three agencies with differing resources (e.g., budget, staffing) and methods (e.g., inspections). Less than half of the states compiled data from inspections, violations, and penalties, and fewer than 10 made this information easily available to the public.

Association between State Regulations Supportive of Third-Party Services and Likelihood of Assisted Living Residents in the US Dying in Place

Oct 1, 2022
WHAT THIS MEANS FOR YOU: Medicare data from nearly 170,000 residents from over 8,000 assisted communities with more than 25 beds who died between 2017 and 2019 indicated that in states with regulations supportive of third-party hospice services, residents were significantly more likely to die in assisted living than in a hospital or nursing home.

Association between State Regulations Supportive of Third-Party Services and Likelihood of Assisted Living Residents in the US Dying in Place

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Medicare data from nearly 170,000 residents from over 8,000 assisted communities with more than 25 beds who died between 2017 and 2019 indicated that in states with regulations supportive of third-party hospice services, residents were significantly more likely to die in assisted living than in a hospital or nursing home.