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.

Academic Publication

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.

Survey Deficiencies as Quality Indicators in Oregon Assisted Living Communities

Oct 1, 2022
WHAT THIS MEANS FOR YOU: Almost 80% of inspections from 526 assisted living communities in Oregon revealed at least one deficiency; the most common deficiency types were medications and medical treatments, monitoring changes in residents' conditions, and health services. Characteristics associated with more deficiencies included larger size, memory care designation, shorter administrator tenure, and for-profit status. The number and likelihood of a given community receiving a deficiency decreased over the study period (2008-2016).

Survey Deficiencies as Quality Indicators in Oregon Assisted Living Communities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Almost 80% of inspections from 526 assisted living communities in Oregon revealed at least one deficiency; the most common deficiency types were medications and medical treatments, monitoring changes in residents’ conditions, and health services. Characteristics associated with more deficiencies included larger size, memory care designation, shorter administrator tenure, and for-profit status. The number and likelihood of a given community receiving a deficiency decreased over the study period (2008-2016).

Recommendations for Medical and Mental Health Care in Assisted Living Based on an Expert Delphi Consensus Panel

Sep 1, 2022
Importance: Assisted living (AL) is the largest provider of residential long-term care in the US, and the morbidity of AL residents has been rising. However, AL is not a health care setting, and concern has been growing about residents’ medical and mental health needs. No guidance exists to inform this care. Objective: To identify consensus […]

Recommendations for Medical and Mental Health Care in Assisted Living Based on an Expert Delphi Consensus Panel

by Lea Efird-Green

Importance: Assisted living (AL) is the largest provider of residential long-term care in the US, and the morbidity of AL residents has been rising. However, AL is not a health care setting, and concern has been growing about residents’ medical and mental health needs. No guidance exists to inform this care. Objective: To identify consensus […]

Caregivers’ Concerns about Assisted Living Residents’ Mental Health during the COVID-19 Pandemic: A Cross-Sectional Survey Study

Sep 1, 2022
WHAT THIS MEANS FOR YOU: Surveys with 673 caregivers from Western Canada found that concerns about residents' depressed mood, loneliness, and anxiety doubled three months after the COVID-19 pandemic started, compared with three months before the pandemic. Factors that may alleviate concerns in the future include improving residents' access to counseling services and better informing caregivers about resident care.

Caregivers’ Concerns about Assisted Living Residents’ Mental Health during the COVID-19 Pandemic: A Cross-Sectional Survey Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Surveys with 673 caregivers from Western Canada found that concerns about residents’ depressed mood, loneliness, and anxiety doubled three months after the COVID-19 pandemic started, compared with three months before the pandemic. Factors that may alleviate concerns in the future include improving residents’ access to counseling services and better informing caregivers about resident care.

Successful Aging in Assisted Living: The Importance of Near Visual Acuity

Sep 1, 2022
Successful aging among independent community-dwelling older adults and those in residential settings is paramount to aging in place. The purpose of the current study was to explore how sensory, cognitive, and functional impairments affect successful aging in assisted living (AL) settings. Vision compromise was noted for near visual acuity (NVA) (14.3%) and distance visual acuity […]

Successful Aging in Assisted Living: The Importance of Near Visual Acuity

by Lea Efird-Green

Successful aging among independent community-dwelling older adults and those in residential settings is paramount to aging in place. The purpose of the current study was to explore how sensory, cognitive, and functional impairments affect successful aging in assisted living (AL) settings. Vision compromise was noted for near visual acuity (NVA) (14.3%) and distance visual acuity […]

Staff Attitudes Related to Antipsychotic Prescribing in Assisted Living

Sep 1, 2022
WHAT THIS MEANS FOR YOU: Data from over 13,500 residents from 247 assisted living communities indicated that healthcare supervisors who were more supportive of using medication to treat behaviors were more likely to have higher rates of antipsychotic prescribing in their communities. Health care supervisor attitudes may be leveraged to reduce antipsychotic prescribing.

Staff Attitudes Related to Antipsychotic Prescribing in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Data from over 13,500 residents from 247 assisted living communities indicated that healthcare supervisors who were more supportive of using medication to treat behaviors were more likely to have higher rates of antipsychotic prescribing in their communities. Health care supervisor attitudes may be leveraged to reduce antipsychotic prescribing.

Prevalence and Correlates of Anxiety and Depression in Caregivers to Assisted Living Residents during COVID-19: A Cross-Sectional Study

Aug 1, 2022
WHAT THIS MEANS FOR YOU: A study of 673 family and friend caregivers of residents in AL from two Canadian provinces from Oct 2020 – Mar 2021 found that 29% had clinically significant anxiety and 39% had clinically significant depression. Caregivers who faced personal stressors such as health issues, reduced income, and lack of social support, along with concerns about residents due to COVID-19, were more likely to experience anxiety and depression. Healthcare providers and assisted living staff should be aware of caregivers' mental health challenges during public health crises and provide appropriate screening and support.

Prevalence and Correlates of Anxiety and Depression in Caregivers to Assisted Living Residents during COVID-19: A Cross-Sectional Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A study of 673 family and friend caregivers of residents in AL from two Canadian provinces from Oct 2020 – Mar 2021 found that 29% had clinically significant anxiety and 39% had clinically significant depression. Caregivers who faced personal stressors such as health issues, reduced income, and lack of social support, along with concerns about residents due to COVID-19, were more likely to experience anxiety and depression. Healthcare providers and assisted living staff should be aware of caregivers’ mental health challenges during public health crises and provide appropriate screening and support.

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

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Using confirmed COVID-19 cases from 5 states, assisted living communities with a higher population of Medicare/Medicaid dual-eligible minority residents were more likely to have COVID-19 cases, as were those located in more socioeconomically deprived neighborhoods. Communities in states with stricter social distancing policies had significantly lower numbers of cases.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Using confirmed COVID-19 cases from 5 states, assisted living communities with a higher population of Medicare/Medicaid dual-eligible minority residents were more likely to have COVID-19 cases, as were those located in more socioeconomically deprived neighborhoods. Communities in states with stricter social distancing policies had significantly lower numbers of cases.

Beyond the Medication Pass: Attitudes, Ethics, Agency, and Antipsychotic Medications in Assisted Living/Residential Care

Aug 1, 2022
WHAT THIS MEANS FOR YOU: This qualitative study based on 11 interviews with various professionals in Oregon, including direct care staff, nurses, administrators, and consultant pharmacists, found factors influencing antipsychotic prescribing decision-making: the rationale behind prescribing, moral viewpoints on psychotropic medications, and the challenge of balancing community and individual resident needs with external regulations.

Beyond the Medication Pass: Attitudes, Ethics, Agency, and Antipsychotic Medications in Assisted Living/Residential Care

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This qualitative study based on 11 interviews with various professionals in Oregon, including direct care staff, nurses, administrators, and consultant pharmacists, found factors influencing antipsychotic prescribing decision-making: the rationale behind prescribing, moral viewpoints on psychotropic medications, and the challenge of balancing community and individual resident needs with external regulations.

A Home, an Institution and a Community – Frames of Social Relationships and Interaction in Assisted Living

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Through qualitative observations of an AL community and interviews with ten residents, those who perceived the assisted living community as a home reported more meaningful, informal relationships. When the community was perceived as an institution, residents reported impersonal, formal interactions.

A Home, an Institution and a Community – Frames of Social Relationships and Interaction in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Through qualitative observations of an AL community and interviews with ten residents, those who perceived the assisted living community as a home reported more meaningful, informal relationships. When the community was perceived as an institution, residents reported impersonal, formal interactions.

Depression within the First Year of Relocation to Residential Care/Assisted Living: Where You Come From Matters

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Data from a national survey of 2,651 assisted living residents found that approximately 35% moved to assisted living from an acute/post-acute facility; they were more likely to have depression compared to those moving from community-based residences.

Depression within the First Year of Relocation to Residential Care/Assisted Living: Where You Come From Matters

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Data from a national survey of 2,651 assisted living residents found that approximately 35% moved to assisted living from an acute/post-acute facility; they were more likely to have depression compared to those moving from community-based residences.

Pilot Testing of the Promoting Positive Care Interactions Intervention in Assisted Living

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Promoting Positive Care Interactions, a staff training program to establish positive care interactions with residents, was tested with 17 care staff in the memory care unit of one assisted living community. Although there were no significant changes in staff outcomes, participants’ perception of the community’s environment and policies improved, and staff showed good engagement throughout the study.

Pilot Testing of the Promoting Positive Care Interactions Intervention in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Promoting Positive Care Interactions, a staff training program to establish positive care interactions with residents, was tested with 17 care staff in the memory care unit of one assisted living community. Although there were no significant changes in staff outcomes, participants’ perception of the community’s environment and policies improved, and staff showed good engagement throughout the study.

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

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Medicare data from 23,000 residents in more than 6,000 assisted living communities found that 56% received hospice care during their last month of life. Communities in states with more supportive hospice regulations had significantly more hospice use, especially a more intense type called continuous home care (CHC). Modifications to state regulations to be more supportive of hospice care/CHC might increase the number of residents who use hospice, which might improve quality of life in the days immediately preceding death.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Medicare data from 23,000 residents in more than 6,000 assisted living communities found that 56% received hospice care during their last month of life. Communities in states with more supportive hospice regulations had significantly more hospice use, especially a more intense type called continuous home care (CHC). Modifications to state regulations to be more supportive of hospice care/CHC might increase the number of residents who use hospice, which might improve quality of life in the days immediately preceding death.

Health Care Use and Outcomes in Assisted Living Communities: Race, Ethnicity, and Dual Eligibility

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Using Medicare data from 2018, data from over 255,000 people across 24,000 assisted living communities found differences in health outcomes based on race/ethnicity and dual eligibility, including hospital admissions, emergency room (ER) visits, and nursing home placements. For instance, Black and Hispanic residents had lower proportions of ER visits than their white counterparts, but Hispanic residents had higher 30-day readmission rates. Dual eligibility negatively impacted these outcomes more than race/ethnicity alone.

Health Care Use and Outcomes in Assisted Living Communities: Race, Ethnicity, and Dual Eligibility

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Using Medicare data from 2018, data from over 255,000 people across 24,000 assisted living communities found differences in health outcomes based on race/ethnicity and dual eligibility, including hospital admissions, emergency room (ER) visits, and nursing home placements. For instance, Black and Hispanic residents had lower proportions of ER visits than their white counterparts, but Hispanic residents had higher 30-day readmission rates. Dual eligibility negatively impacted these outcomes more than race/ethnicity alone.

Interactions, Relationships and Belonging: Comparing Social Connectedness and Perceived Isolation among Older Women Living Alone in Private Homes and in Assisted Living

Jul 1, 2022
WHAT THIS MEANS FOR YOU: This qualitative study of social connections among 16 women aged 75 and older found that those living in the community focus on feeling connected to the world at large, while those in assisted living have more casual interactions and feel like they are a part of the community. Most women in both groups did not experience perceived isolation; they had adjusted their expectations about socializing to fit their living situation.

Interactions, Relationships and Belonging: Comparing Social Connectedness and Perceived Isolation among Older Women Living Alone in Private Homes and in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This qualitative study of social connections among 16 women aged 75 and older found that those living in the community focus on feeling connected to the world at large, while those in assisted living have more casual interactions and feel like they are a part of the community. Most women in both groups did not experience perceived isolation; they had adjusted their expectations about socializing to fit their living situation.

Class and Culture in the Making of an Assisted Living Market

Jul 1, 2022
WHAT THIS MEANS FOR YOU: A qualitative study of high-end assisted living communities in Chile based on 40 staff, resident, and family interviews found that managers explain these communities’ purpose as meeting the need for household help, making it a class privilege for wealthy residents. Residents view their communities as a luxury and emphasize their choice to live there, indicating control and independence. This research highlights how social class influences perceptions and acceptance of different forms of care.

Class and Culture in the Making of an Assisted Living Market

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A qualitative study of high-end assisted living communities in Chile based on 40 staff, resident, and family interviews found that managers explain these communities’ purpose as meeting the need for household help, making it a class privilege for wealthy residents. Residents view their communities as a luxury and emphasize their choice to live there, indicating control and independence. This research highlights how social class influences perceptions and acceptance of different forms of care.

The Impact of FFC-AL-EIT-D in Assisted Living during the COVID-19 Pandemic

Jun 1, 2022
WHAT THIS MEANS FOR YOU: Function Focused Care was tested in 51 assisted living communities in one state during the COVID-19 pandemic. Although there was no change in resident falls, emergency room visits, hospitalizations, or transfers to nursing homes, organizational policies and environments supporting physical activity for residents improved.

The Impact of FFC-AL-EIT-D in Assisted Living during the COVID-19 Pandemic

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Function Focused Care was tested in 51 assisted living communities in one state during the COVID-19 pandemic. Although there was no change in resident falls, emergency room visits, hospitalizations, or transfers to nursing homes, organizational policies and environments supporting physical activity for residents improved.

Governance of Assisted Living in Singapore: Lessons for Aging Countries

Jun 1, 2022
WHAT THIS MEANS FOR YOU: In Singapore, assisted living regulations relate to required physical infrastructure, admission assessments, and staffing requirements. They are primarily practice guidelines, with a plan to make them legislatively explicit and permanent by 2023. Other regulations remain missing, such as staff training requirements and a monitoring structure, and must be addressed if assisted living is to be a safe and viable option for quality care.

Governance of Assisted Living in Singapore: Lessons for Aging Countries

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: In Singapore, assisted living regulations relate to required physical infrastructure, admission assessments, and staffing requirements. They are primarily practice guidelines, with a plan to make them legislatively explicit and permanent by 2023. Other regulations remain missing, such as staff training requirements and a monitoring structure, and must be addressed if assisted living is to be a safe and viable option for quality care.

Yoga Practice as a Coping Strategy for Older Adults in Assisted Living Facilities: A Qualitative Content Analysis

Jun 1, 2022
WHAT THIS MEANS FOR YOU: This study explored how 15 residents of 4 assisted living communities used yoga as a coping strategy during and after an 8-week yoga intervention. Qualitative interviews indicated that residents found yoga helpful for relaxing, felt more energized, and that it helped connect them with others.

Yoga Practice as a Coping Strategy for Older Adults in Assisted Living Facilities: A Qualitative Content Analysis

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study explored how 15 residents of 4 assisted living communities used yoga as a coping strategy during and after an 8-week yoga intervention. Qualitative interviews indicated that residents found yoga helpful for relaxing, felt more energized, and that it helped connect them with others.

Impact of Dentures on Oral Health-Related Quality of Life in Assisted Living Facility Elders, Guntur District, Andhra Pradesh

Jun 1, 2022
WHAT THIS MEANS FOR YOU: This study investigated how wearing dentures affects the oral health-related quality of life and wellbeing of older adults residing in assisted living in India. Among 587 residents, those using removable partial dentures were more satisfied with their appearance and dental function than those with complete dentures. However, oral health impact (e.g., functional limitations, physical pain, social disability) was higher for complete denture users.

Impact of Dentures on Oral Health-Related Quality of Life in Assisted Living Facility Elders, Guntur District, Andhra Pradesh

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study investigated how wearing dentures affects the oral health-related quality of life and wellbeing of older adults residing in assisted living in India. Among 587 residents, those using removable partial dentures were more satisfied with their appearance and dental function than those with complete dentures. However, oral health impact (e.g., functional limitations, physical pain, social disability) was higher for complete denture users.

Factors Associated with the Quality of Staff-Resident Interactions in Assisted Living

Jun 1, 2022
WHAT THIS MEANS FOR YOU: Using data from 379 residents from 59 assisted living communities, residents who were more frequently agitated tended to have worse care interactions with staff, while being in a for-profit community was associated with more positive interactions. Staff training in how to minimize resident agitation may improve the positivity of care interactions.

Factors Associated with the Quality of Staff-Resident Interactions in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Using data from 379 residents from 59 assisted living communities, residents who were more frequently agitated tended to have worse care interactions with staff, while being in a for-profit community was associated with more positive interactions. Staff training in how to minimize resident agitation may improve the positivity of care interactions.

Dementia and COVID-19 Infection Control in Assisted Living in Seven States

Jun 1, 2022
WHAT THIS MEANS FOR YOU: The study examined how 119 assisted living administrators in 7 states implemented COVID-19 infection control practices from July 2020 to September 2021, including the feasibility of select infection control practices. Results indicated that although there were infection control challenges across all community types, dementia-specific communities faced the most difficulties. Less than half of administrators found it feasible to close indoor common areas, and residents, especially in dementia-specific communities, were less likely to wear masks and -wearing and physical distancing.

Dementia and COVID-19 Infection Control in Assisted Living in Seven States

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: The study examined how 119 assisted living administrators in 7 states implemented COVID-19 infection control practices from July 2020 to September 2021, including the feasibility of select infection control practices. Results indicated that although there were infection control challenges across all community types, dementia-specific communities faced the most difficulties. Less than half of administrators found it feasible to close indoor common areas, and residents, especially in dementia-specific communities, were less likely to wear masks and -wearing and physical distancing.

Administrator Turnover in Oregon Assisted Living and Residential Care Communities, March 2020–February 2021

Jun 1, 2022
WHAT THIS MEANS FOR YOU: This study analyzed staffing records from 549 assisted living communities in Oregon and found approximately one-third of administrators left their jobs between March 2020 and February 2021. Nonprofit communities and those with more beds had less administrator turnover; administrators who had been in their roles for a longer time before the pandemic were less likely to leave their jobs. Offering memory care services, accepting Medicaid, rurality, and number of assisted living communities in the county did not relate to administrator turnover.

Administrator Turnover in Oregon Assisted Living and Residential Care Communities, March 2020–February 2021

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study analyzed staffing records from 549 assisted living communities in Oregon and found approximately one-third of administrators left their jobs between March 2020 and February 2021. Nonprofit communities and those with more beds had less administrator turnover; administrators who had been in their roles for a longer time before the pandemic were less likely to leave their jobs. Offering memory care services, accepting Medicaid, rurality, and number of assisted living communities in the county did not relate to administrator turnover.

Melatonin Prescribing in Assisted Living

Jun 1, 2022
WHAT THIS MEANS FOR YOU: The study investigated the use of melatonin among more than 5,700 residents from 250 assisted living communities across 7 states. Overall, 82% of communities prescribed melatonin to at least one resident, and on average, 9% of residents in a community received melatonin. Melatonin usage varied depending on community characteristics and was more likely if there was an RN or LPN on site or if the health care supervisor was more favorable to nonpharmacological practices.

Melatonin Prescribing in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: The study investigated the use of melatonin among more than 5,700 residents from 250 assisted living communities across 7 states. Overall, 82% of communities prescribed melatonin to at least one resident, and on average, 9% of residents in a community received melatonin. Melatonin usage varied depending on community characteristics and was more likely if there was an RN or LPN on site or if the health care supervisor was more favorable to nonpharmacological practices.