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

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

Jun 1, 2023
Objectives We examined the frequency and categories of end-of-life care transitions among assisted living community decedents and their associations with state staffing and training regulations. Design Cohort study. Setting and Participants Medicare beneficiaries who resided in assisted living facilities and had validated death dates in 2018-2019 (N = 113,662). Methods We used Medicare claims and assessment […]

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

by Lea Efird-Green

Objectives We examined the frequency and categories of end-of-life care transitions among assisted living community decedents and their associations with state staffing and training regulations. Design Cohort study. Setting and Participants Medicare beneficiaries who resided in assisted living facilities and had validated death dates in 2018-2019 (N = 113,662). Methods We used Medicare claims and assessment […]

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

Jun 1, 2023
Objectives Online reviews provided by users of assisted living communities may offer a unique source of heretofore unexamined data. We explored online reviews as a possible source of information about these communities and examined the association between the reviews and aspects of state regulations, while controlling for assisted living, county, and state market-level factors. Design […]

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

by Lea Efird-Green

Objectives Online reviews provided by users of assisted living communities may offer a unique source of heretofore unexamined data. We explored online reviews as a possible source of information about these communities and examined the association between the reviews and aspects of state regulations, while controlling for assisted living, county, and state market-level factors. Design […]

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

Jun 1, 2023
Objectives Limitations to admission play a critical role in shaping the composition of residents residing within licensed assisted living (AL) communities. Design We document variation across 165 licensure classifications in how state agencies limit who AL communities may admit and what assessments are required to make those determinations. Setting and Participants AL regulations and licensed […]

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

by Lea Efird-Green

Objectives Limitations to admission play a critical role in shaping the composition of residents residing within licensed assisted living (AL) communities. Design We document variation across 165 licensure classifications in how state agencies limit who AL communities may admit and what assessments are required to make those determinations. Setting and Participants AL regulations and licensed […]

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

Jun 1, 2023
Background Potentially burdensome transitions at the end of life (e.g., repeated hospitalizations toward the end of life and/or health care transitions in the last three days of life) are common among residential care/assisted living (RC/AL) residents, and are associated with lower quality of end of-life care reported by bereaved family members. We examined the association […]

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

by Lea Efird-Green

Background Potentially burdensome transitions at the end of life (e.g., repeated hospitalizations toward the end of life and/or health care transitions in the last three days of life) are common among residential care/assisted living (RC/AL) residents, and are associated with lower quality of end of-life care reported by bereaved family members. We examined the association […]

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

Jun 1, 2023
Individual state approaches to assisted living/residential care (AL/RC) licensing and oversight in the United States result in different practice standards and requirements, including psychotropic medication use. We examined 170 psychotropic medication deficiency citations issued to 152 Oregon AL/RC settings from 2015 to 2019. Applied thematic analysis resulted in the following themes: (1) documentation issues are […]

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

by Lea Efird-Green

Individual state approaches to assisted living/residential care (AL/RC) licensing and oversight in the United States result in different practice standards and requirements, including psychotropic medication use. We examined 170 psychotropic medication deficiency citations issued to 152 Oregon AL/RC settings from 2015 to 2019. Applied thematic analysis resulted in the following themes: (1) documentation issues are […]

State Variation in Antipsychotic Use Among Assisted Living Residents With Dementia

Apr 1, 2023
Objectives More than two-thirds of assisted living (AL) residents have dementia or cognitive impairment and antipsychotics are commonly prescribed for behavioral disturbances. As AL communities are regulated by state-level policies, which vary significantly regarding the care for people with dementia, we examined how antipsychotic prescribing varied across states among AL residents with dementia. Design This […]

State Variation in Antipsychotic Use Among Assisted Living Residents With Dementia

by Lea Efird-Green

Objectives More than two-thirds of assisted living (AL) residents have dementia or cognitive impairment and antipsychotics are commonly prescribed for behavioral disturbances. As AL communities are regulated by state-level policies, which vary significantly regarding the care for people with dementia, we examined how antipsychotic prescribing varied across states among AL residents with dementia. Design This […]

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

Feb 1, 2023
Background Long-term care facilities (LTCFs) including assisted living facilities (ALFs) are hubs for high transmission and poor prognosis of COVID-19 among the residents who are more susceptible due to old age and comorbidities. Aim Houston Health Department conducted assessments of ALFs within the City of Houston to determine preparedness and existing preventive measures at the […]

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

by Lea Efird-Green

Background Long-term care facilities (LTCFs) including assisted living facilities (ALFs) are hubs for high transmission and poor prognosis of COVID-19 among the residents who are more susceptible due to old age and comorbidities. Aim Houston Health Department conducted assessments of ALFs within the City of Houston to determine preparedness and existing preventive measures at the […]

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

Jan 1, 2023
Objective The aim of this study was to explore the relationship between Florida nursing home and assisted living facility characteristics and their ability to comply with a new emergency power rule in the aftermath of Hurricane Irma. Methods This study used characteristics data on Florida nursing homes (NHs) (N = 680) and assisted living facilities […]

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

by Lea Efird-Green

Objective The aim of this study was to explore the relationship between Florida nursing home and assisted living facility characteristics and their ability to comply with a new emergency power rule in the aftermath of Hurricane Irma. Methods This study used characteristics data on Florida nursing homes (NHs) (N = 680) and assisted living facilities […]

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

Jan 1, 2023
This research is motivated by a change in Florida that affected assisted living facilities (ALFs) by removing the property tax exemptions for those operated by nonprofit organizations. As such, this paper addresses two research questions: (1) Are there systematic differences between Florida’s for‐profit and nonprofit‐designated ALFs in terms of operations and service provision? (2) What […]

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

by Lea Efird-Green

This research is motivated by a change in Florida that affected assisted living facilities (ALFs) by removing the property tax exemptions for those operated by nonprofit organizations. As such, this paper addresses two research questions: (1) Are there systematic differences between Florida’s for‐profit and nonprofit‐designated ALFs in terms of operations and service provision? (2) What […]

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

Dec 1, 2022
ObjectivesTo examine perceptions of patient safety culture (PSC) among assisted living (AL) administrators and direct care workers (DCWs), and their associations with state regulations. DesignWe conducted a survey using the PSC instrument developed by the Agency for Healthcare Research & Quality. Secondary data on ALs and residents were derived from the Medicare Master Beneficiary Summary […]

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

by Lea Efird-Green

ObjectivesTo examine perceptions of patient safety culture (PSC) among assisted living (AL) administrators and direct care workers (DCWs), and their associations with state regulations. DesignWe conducted a survey using the PSC instrument developed by the Agency for Healthcare Research & Quality. Secondary data on ALs and residents were derived from the Medicare Master Beneficiary Summary […]

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

Oct 1, 2022
Importance: Older adults are increasingly residing in assisted living residences during their last year of life. The regulations guiding these residential care settings differ between and within the states in the US, resulting in diverse policies that may support residents who wish to die in place. Objective: To examine the association between state regulations and […]

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

Importance: Older adults are increasingly residing in assisted living residences during their last year of life. The regulations guiding these residential care settings differ between and within the states in the US, resulting in diverse policies that may support residents who wish to die in place. Objective: To examine the association between state regulations and […]

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

Oct 1, 2022
Our goal was to learn about monitoring and enforcement of state assisted living (AL) regulations. Using survey responses provided in 2019 from administrative agents across 48 states, we described state agency structures, accounted for operational processes concerning monitoring and enforcement, and documented data collecting and public reporting efforts. In half of the states, oversight of […]

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

by Lea Efird-Green

Our goal was to learn about monitoring and enforcement of state assisted living (AL) regulations. Using survey responses provided in 2019 from administrative agents across 48 states, we described state agency structures, accounted for operational processes concerning monitoring and enforcement, and documented data collecting and public reporting efforts. In half of the states, oversight of […]

Coronavirus Disease 2019 (COVID-19) in Assisted Living Communities: Neighborhood Deprivation and State Social Distancing Policies Matter

Aug 1, 2022
Background: Residents of long-term care facilities face significantly greater risk of contracting or dying from coronavirus disease 2019 (COVID-19). However, little is known about COVID-19 in assisted living communities (ALCs) and the potential determinants of its spread. We examined the association between COVID-19 cases in ALCs and the proportion of Medicare-Medicaid (dual) eligible minority residents, […]

Coronavirus Disease 2019 (COVID-19) in Assisted Living Communities: Neighborhood Deprivation and State Social Distancing Policies Matter

by Lea Efird-Green

Background: Residents of long-term care facilities face significantly greater risk of contracting or dying from coronavirus disease 2019 (COVID-19). However, little is known about COVID-19 in assisted living communities (ALCs) and the potential determinants of its spread. We examined the association between COVID-19 cases in ALCs and the proportion of Medicare-Medicaid (dual) eligible minority residents, […]

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

Aug 1, 2022
Objectives: To examine the association between hospice/staffing regulations in residential care or assisted living (RC/AL) and hospice utilization among a national cohort of Medicare decedents residing in RC/AL at least 1 day during the last month of life, and to describe patterns of hospice utilization. Design: Retrospective cohort study of fee-for-service Medicare beneficiaries who died […]

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

by Lea Efird-Green

Objectives: To examine the association between hospice/staffing regulations in residential care or assisted living (RC/AL) and hospice utilization among a national cohort of Medicare decedents residing in RC/AL at least 1 day during the last month of life, and to describe patterns of hospice utilization. Design: Retrospective cohort study of fee-for-service Medicare beneficiaries who died […]

Class and Culture in the Making of an Assisted Living Market

Jul 1, 2022
This article examines the growing industry of elite assisted living in Chile, which represents a break with a longstanding culture of care provided at home by family members and domestic workers. How does this market, locally associated with deprivation, abandonment and standardization, become a legitimate option for the rich clientele it caters to? Drawing on […]

Class and Culture in the Making of an Assisted Living Market

by Lea Efird-Green

This article examines the growing industry of elite assisted living in Chile, which represents a break with a longstanding culture of care provided at home by family members and domestic workers. How does this market, locally associated with deprivation, abandonment and standardization, become a legitimate option for the rich clientele it caters to? Drawing on […]

Governance of Assisted Living in Singapore: Lessons for Aging Countries

Jun 1, 2022
A global trend toward aging populations means that the challenge of providing adequate long-term care to older people looms large in many countries. In Singapore, a public discourse revolving around the expansion of assisted living to create age-friendly environments in long-term care has emerged. This study examines Singapore’s experience in developing regulations for assisted living […]

Governance of Assisted Living in Singapore: Lessons for Aging Countries

by Lea Efird-Green

A global trend toward aging populations means that the challenge of providing adequate long-term care to older people looms large in many countries. In Singapore, a public discourse revolving around the expansion of assisted living to create age-friendly environments in long-term care has emerged. This study examines Singapore’s experience in developing regulations for assisted living […]

End-Of-Life Care In Assisted Living Communities: Race And Ethnicity, Dual Enrollment Status, And State Regulations

May 1, 2022
Assisted living communities are the final home for many of their residents, most of whom are older, frail, and cognitively or functionally impaired. Yet little is known about end-of-life care in this setting. We examined associations of both death at home and home hospice care with individual characteristics, such as race or ethnicity and dual […]

End-Of-Life Care In Assisted Living Communities: Race And Ethnicity, Dual Enrollment Status, And State Regulations

by Lea Efird-Green

Assisted living communities are the final home for many of their residents, most of whom are older, frail, and cognitively or functionally impaired. Yet little is known about end-of-life care in this setting. We examined associations of both death at home and home hospice care with individual characteristics, such as race or ethnicity and dual […]

Factors Associated With Assisted Living Facility Closure

Mar 1, 2022
Background and Objectives Assisted living facilities (ALFs) have experienced rapid growth in the past few decades. The expansion in the number of ALFs may cause markets to become oversaturated, and a greater risk of unprofitable ALFs to close. However, no studies have investigated ALF closure. This study adapted a model developed for the nursing home […]

Factors Associated With Assisted Living Facility Closure

by Lea Efird-Green

Background and Objectives Assisted living facilities (ALFs) have experienced rapid growth in the past few decades. The expansion in the number of ALFs may cause markets to become oversaturated, and a greater risk of unprofitable ALFs to close. However, no studies have investigated ALF closure. This study adapted a model developed for the nursing home […]

State Variation in Potentially Burdensome Transitions among Assisted Living Residents at the End of Life

Feb 1, 2022
This cohort study uses Medicare administrative claims data to describe potentially burdensome transitions among assisted living residents at the end of life and assesses variations by US state.

State Variation in Potentially Burdensome Transitions among Assisted Living Residents at the End of Life

by Lea Efird-Green

This cohort study uses Medicare administrative claims data to describe potentially burdensome transitions among assisted living residents at the end of life and assesses variations by US state.

Prevalence and Persistency of Deficiency Citations in Florida Assisted Living Facilities

Jan 1, 2022
Background Assisted living facilities (ALFs) are plagued with quality issues but there are limited studies on the quality of ALFs. In Florida, state surveyors conduct inspections of ALFs and cite and/or fine facilities that are in violation of regulations. Yet, we do not know the types of quality problems identified and the extent to which […]

Prevalence and Persistency of Deficiency Citations in Florida Assisted Living Facilities

by Lea Efird-Green

Background Assisted living facilities (ALFs) are plagued with quality issues but there are limited studies on the quality of ALFs. In Florida, state surveyors conduct inspections of ALFs and cite and/or fine facilities that are in violation of regulations. Yet, we do not know the types of quality problems identified and the extent to which […]