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

May 14, 2026
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

CEAL@UNC Guest Columns: McKnight’s Senior Living

May 4, 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

Personal Care Aide Staffing in U.S. Residential Care Communities: The Role of Aide Training Hours, Training Reimbursement, and Organizational Structures

Dec 1, 2025
Residential care communities (RCCs) employ nearly 660,000 personal care aides but few studies have examined personal care aide staffing nationwide. This study examines RCC characteristics associated with aide hours per resident day. We used the 2022 National Post-acute and Long-term Care Study to analyze variables of interest without missing data (n = 518) and produced […]

Personal Care Aide Staffing in U.S. Residential Care Communities: The Role of Aide Training Hours, Training Reimbursement, and Organizational Structures

by Lea Efird-Green

Residential care communities (RCCs) employ nearly 660,000 personal care aides but few studies have examined personal care aide staffing nationwide. This study examines RCC characteristics associated with aide hours per resident day. We used the 2022 National Post-acute and Long-term Care Study to analyze variables of interest without missing data (n = 518) and produced […]

End-of-Life Outcomes and Staff Visits for Hospice Recipients Residing in Assisted Living

Dec 1, 2025
Objectives: To examine (1) whether hospice staff visits are associated with end-of-life (EOL) transitions, place of death (POD), and live discharges among assisted living (AL) residents, and (2) whether state AL regulations on staffing and medication administration influence these outcomes. We hypothesized that more frequent staff visits and specific regulatory provisions would be associated with […]

End-of-Life Outcomes and Staff Visits for Hospice Recipients Residing in Assisted Living

by Lea Efird-Green

Objectives: To examine (1) whether hospice staff visits are associated with end-of-life (EOL) transitions, place of death (POD), and live discharges among assisted living (AL) residents, and (2) whether state AL regulations on staffing and medication administration influence these outcomes. We hypothesized that more frequent staff visits and specific regulatory provisions would be associated with […]

Trends in Assisted Living and Memory Care Supply from 2019 to 2023

Dec 1, 2025
Objectives: Describe geographic variation from 2019 to 2023 in assisted living (AL) and memory care supply, and its correlation with county-level characteristics. Design: Descriptive study of the supply of AL and memory care. Setting and participants: Licensed AL communities in the United States operating in 2019 and 2023. Methods: Data come from a national list […]

Trends in Assisted Living and Memory Care Supply from 2019 to 2023

by Lea Efird-Green

Objectives: Describe geographic variation from 2019 to 2023 in assisted living (AL) and memory care supply, and its correlation with county-level characteristics. Design: Descriptive study of the supply of AL and memory care. Setting and participants: Licensed AL communities in the United States operating in 2019 and 2023. Methods: Data come from a national list […]

Minnesota’s Assisted Living License: Engagement of Small Assisted Living Providers

Oct 1, 2025
When Minnesota passed State Statute 144 G in 2019, it fundamentally changed the licensure of assisted living facilities in the state. This new regulatory framework was developed by a group of stakeholders representing consumer advocates, provider advocates, and state government. However, assisted living providers who served culturally specific communities (Black, Indigenous, and other People of Color) […]

Minnesota’s Assisted Living License: Engagement of Small Assisted Living Providers

by Lea Efird-Green

When Minnesota passed State Statute 144 G in 2019, it fundamentally changed the licensure of assisted living facilities in the state. This new regulatory framework was developed by a group of stakeholders representing consumer advocates, provider advocates, and state government. However, assisted living providers who served culturally specific communities (Black, Indigenous, and other People of Color) […]

Review of State Regulations Related to Environmental Sanitation in Long-Term Care Facilities

Aug 1, 2025
Background: We examined how state regulations for long-term care facilities address environmental sanitation. Methods: State regulations for nursing homes and assisted living facilities across all 50 US states and the District of Columbia were sourced from government Web sites. We searched using key terms about environmental sanitation and then quantified our findings to answer 4 […]

Review of State Regulations Related to Environmental Sanitation in Long-Term Care Facilities

by Lea Efird-Green

Background: We examined how state regulations for long-term care facilities address environmental sanitation. Methods: State regulations for nursing homes and assisted living facilities across all 50 US states and the District of Columbia were sourced from government Web sites. We searched using key terms about environmental sanitation and then quantified our findings to answer 4 […]

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.

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.

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.

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.