Promoting and Highlighting Research in Assisted Living to Inform Practice and Policy
Regulation/Monitoring
CEAL@UNC Strategic Advisor Presentations
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
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
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
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
ADvancing States 2026 Aging Summit Report
2025 CEAL@UNC Research Award Summary
2025 NCAL Assisted Living Regulatory Review
Personal Care Aide Staffing in U.S. Residential Care Communities: The Role of Aide Training Hours, Training Reimbursement, and Organizational Structures
This study investigated residential care communities (RCCs) characteristics associated with care aide hours per resident day using data from 518 RCCs in the 2022 National Post-acute and Long-term Care Study. Factors related to higher staffing hours included reimbursement for training and occupancy greater than 85%, whereas factors such as initial training of more than 60 hours, increased Medicaid involement, and being a larger community were associated with lower staffing hours.
Personal Care Aide Staffing in U.S. Residential Care Communities: The Role of Aide Training Hours, Training Reimbursement, and Organizational Structures
This study investigated residential care communities (RCCs) characteristics associated with care aide hours per resident day using data from 518 RCCs in the 2022 National Post-acute and Long-term Care Study. Factors related to higher staffing hours included reimbursement for training and occupancy greater than 85%, whereas factors such as initial training of more than 60 hours, increased Medicaid involement, and being a larger community were associated with lower staffing hours.
End-of-Life Outcomes and Staff Visits for Hospice Recipients Residing in Assisted Living
This study used 2018 to 2019 Medicare claims data from over 42,000 AL residents to examine whether hospice staff visits were associated with end-of-life transitions, place of death, and discharges, and whether state AL regulations influence these outcomes. More frequent visits were associated with less end-of-life transitions, discharges, and increased likelihood of dying in place. Regulations requiring on-site staffing and medication delegation were also associated with fewer transitions and increased dying in place, highlighting the role that both organizational and regulatory policies in shaping end-of-life outcomes.
End-of-Life Outcomes and Staff Visits for Hospice Recipients Residing in Assisted Living
This study used 2018 to 2019 Medicare claims data from over 42,000 AL residents to examine whether hospice staff visits were associated with end-of-life transitions, place of death, and discharges, and whether state AL regulations influence these outcomes. More frequent visits were associated with less end-of-life transitions, discharges, and increased likelihood of dying in place. Regulations requiring on-site staffing and medication delegation were also associated with fewer transitions and increased dying in place, highlighting the role that both organizational and regulatory policies in shaping end-of-life outcomes.
Trends in Assisted Living and Memory Care Supply from 2019 to 2023
This study examined geographic variation in AL and memory care, and their correlation with county-level characteristics from 2019-2023. In 2023, counties with more AL and memory care were generally wealthier, higher in educational attainment, and urban. During the study period, 43% of counties had a decrease of AL supply ae, which was associated with a higher proportion of older adults in the population, lower income, and increased rurality as compared to those with an increase in supply. In the same period, 29% of counties had a decrease in memory care supply, which was associated with lower educational attainment, more poverty, and increased rurality than the 34% that had an increase in memory care supply. Overall, rural and poorer counties had less access to AL and memory care, showing the importance of increasing access to services in these counties.
Trends in Assisted Living and Memory Care Supply from 2019 to 2023
This study examined geographic variation in AL and memory care, and their correlation with county-level characteristics from 2019-2023. In 2023, counties with more AL and memory care were generally wealthier, higher in educational attainment, and urban. During the study period, 43% of counties had a decrease of AL supply ae, which was associated with a higher proportion of older adults in the population, lower income, and increased rurality as compared to those with an increase in supply. In the same period, 29% of counties had a decrease in memory care supply, which was associated with lower educational attainment, more poverty, and increased rurality than the 34% that had an increase in memory care supply. Overall, rural and poorer counties had less access to AL and memory care, showing the importance of increasing access to services in these counties.
Trends in Private Equity Acquisitions of Assisted Living Facilities
This study examined trends in private equity (PE) acquisitions of AL communities (ALCs) from 2006-2023. They found a total of 252 PE acquisitions of 912 ALCs. Although acquisitions occurred in 47 states, more than one third of them were in Florida. Rates of acquisition increased after 2013, with the highest adjusted value occurring in 2019. Since PE acquisitions are likely to continue, future research should examine PE-involved ALCs' impacts on residents and their access to AL.
Trends in Private Equity Acquisitions of Assisted Living Facilities
This study examined trends in private equity (PE) acquisitions of AL communities (ALCs) from 2006-2023. They found a total of 252 PE acquisitions of 912 ALCs. Although acquisitions occurred in 47 states, more than one third of them were in Florida. Rates of acquisition increased after 2013, with the highest adjusted value occurring in 2019. Since PE acquisitions are likely to continue, future research should examine PE-involved ALCs’ impacts on residents and their access to AL.
Minnesota’s Assisted Living License: Engagement of Small Assisted Living Providers
This qualitative study included interviews with 14 licensed AL directors of small, culturally specific communities in Minnesota to discuss the impacts of a new state regulatory framework. Four main themes emerged: lack of participation in the initial development, challenges to implementation of requirements, inconsistency in inspections, and inadequate funds. Recommendations were identified, including ensuring all stakeholders participate in future policy development and developing a new methodology for Medicaid waivers.
Minnesota’s Assisted Living License: Engagement of Small Assisted Living Providers
This qualitative study included interviews with 14 licensed AL directors of small, culturally specific communities in Minnesota to discuss the impacts of a new state regulatory framework. Four main themes emerged: lack of participation in the initial development, challenges to implementation of requirements, inconsistency in inspections, and inadequate funds. Recommendations were identified, including ensuring all stakeholders participate in future policy development and developing a new methodology for Medicaid waivers.
Improving Fire Safety In Assisted Living
Oregon Adult Foster/Care Home Technical Assistance Webinars
Review of State Regulations Related to Environmental Sanitation in Long-Term Care Facilities
This review examined environmental sanitation regulations in nursing homes (NHs) and AL communities (ALCs) in all 50 states and the District of Columbia. Infection preventionists and infection control training were more commonly required in NHs than ALCs, but still required in only about 30 states. Findings also show that regulations inadequately address environmental service workers, training, personal protective equipment, and the cleaning of carpets and high-touch items, which could pose significant health risks to residents and staff if regulatory gaps are not addressed.
Review of State Regulations Related to Environmental Sanitation in Long-Term Care Facilities
This review examined environmental sanitation regulations in nursing homes (NHs) and AL communities (ALCs) in all 50 states and the District of Columbia. Infection preventionists and infection control training were more commonly required in NHs than ALCs, but still required in only about 30 states. Findings also show that regulations inadequately address environmental service workers, training, personal protective equipment, and the cleaning of carpets and high-touch items, which could pose significant health risks to residents and staff if regulatory gaps are not addressed.
A Qualitative Analysis of Safety Culture in Minnesota’s Assisted Living Facilities
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
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
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
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.
Public Health Response to SARS-CoV-2 in Assisted Living Facilities in New York State: March 2020-December 2022
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
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.
Does Assisted Living Provide Assistance And Promote Living?
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?
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.
Potential Actions to Advance Well-being in Assisted Living
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
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
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
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
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
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
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
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
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
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.
Paperwork, Paradox, and PRN: Psychotropic Medication Deficiencies in Assisted Living
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
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.
