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

Challenges and Possibilities in Preventing Emerging Infectious Diseases in Long-Term Care: A Qualitative Descriptive Study

Oct 1, 2025
This qualitative study examined the experiences of 12 staff in Taiwanese long-term care communities related to preventing infectious disease during the COVID-19 pandemic. Two challenges emerged: inadequate preparation, and physical/emotional strain; and two areas for improvement emerged: ongoing education and the need for adaptive surveillance and tailored crisis response plans.

Challenges and Possibilities in Preventing Emerging Infectious Diseases in Long-Term Care: A Qualitative Descriptive Study

by Lea Efird-Green

This qualitative study examined the experiences of 12 staff in Taiwanese long-term care communities related to preventing infectious disease during the COVID-19 pandemic. Two challenges emerged: inadequate preparation, and physical/emotional strain; and two areas for improvement emerged: ongoing education and the need for adaptive surveillance and tailored crisis response plans.

Resonances of Feeling Alone: A Systematic Review Unveiling Older Persons’ Loneliness and Its Mechanisms in Residential Care Facilities

Oct 1, 2025
This systematic review of 16 articles assessed long-term care (LTC) community residents' experiences of loneliness and the mechanisms underlying those experiences. Three themes emerged, leading to the development of a conceptual model of loneliness: relational and individual loneliness, perception and emotional distress, and the impact of context and cognitive processes. Perceptions of reduced social control and connections exacerbate loneliness. Developing supportive social environments within LTC communities was identified as a key factor in addressing resident loneliness general quality of life.

Resonances of Feeling Alone: A Systematic Review Unveiling Older Persons’ Loneliness and Its Mechanisms in Residential Care Facilities

by Lea Efird-Green

This systematic review of 16 articles assessed long-term care (LTC) community residents’ experiences of loneliness and the mechanisms underlying those experiences. Three themes emerged, leading to the development of a conceptual model of loneliness: relational and individual loneliness, perception and emotional distress, and the impact of context and cognitive processes. Perceptions of reduced social control and connections exacerbate loneliness. Developing supportive social environments within LTC communities was identified as a key factor in addressing resident loneliness general quality of life.

Denture Care in Assisted Living: Best Practices and Clinical Importance for Resident Health

Sep 1, 2025
This editorial discusses the implications of denture management in long-term care settings, focusing on barriers to consistent removal, the risks of continuous wear, and the nutritional consequences of poor denture fit. Strategies focusing on infection prevention, adequate nutrition, integrating tasks into routine workflows, and engaging both staff and families are presented to improve denture care.

Denture Care in Assisted Living: Best Practices and Clinical Importance for Resident Health

by Lea Efird-Green

This editorial discusses the implications of denture management in long-term care settings, focusing on barriers to consistent removal, the risks of continuous wear, and the nutritional consequences of poor denture fit. Strategies focusing on infection prevention, adequate nutrition, integrating tasks into routine workflows, and engaging both staff and families are presented to improve denture care.

Person-Focused Interventions for Fall Risk Assessment, Fall Prevention and Fall Injury Prevention in Long-Term Care Facilities: A Scoping Review

Sep 1, 2025
This scoping review included 20 articles regarding the effects of person-focused interventions for risk assessment and prevention of falls in long-term care settings. The authors identified three types of person-focused interventions: exercise programs, multifactorial programs, and other interventions (including sensory interventions. Evidence suggests that well-designed person-focused interventions can reduce both falls and fear of falls for long-term care residents.

Person-Focused Interventions for Fall Risk Assessment, Fall Prevention and Fall Injury Prevention in Long-Term Care Facilities: A Scoping Review

by Lea Efird-Green

This scoping review included 20 articles regarding the effects of person-focused interventions for risk assessment and prevention of falls in long-term care settings. The authors identified three types of person-focused interventions: exercise programs, multifactorial programs, and other interventions (including sensory interventions. Evidence suggests that well-designed person-focused interventions can reduce both falls and fear of falls for long-term care residents.

Perception of Therapeutic Music in Community Settings

Sep 1, 2025
This study focused on the experiences of 42 older adults relating to a live therapeutic music performance conducted in 1 Veterans Affairs Medical Center and 2 AL communities. Generally, participants enjoyed the performance and felt music was important in their lives; results indicate that customized therapeutic music could be supportive of a relaxed atmosphere.

Perception of Therapeutic Music in Community Settings

by Lea Efird-Green

This study focused on the experiences of 42 older adults relating to a live therapeutic music performance conducted in 1 Veterans Affairs Medical Center and 2 AL communities. Generally, participants enjoyed the performance and felt music was important in their lives; results indicate that customized therapeutic music could be supportive of a relaxed atmosphere.

Long Fever as a Long-Term Risk Factor for Mortality in Persons in Assisted Living Facilities

Sep 1, 2025
This study examined long-term impacts of fever as a risk factor for mortality up to two years post-fever using data from over 16,000 AL residents between 2012 and 2022. Compared with not having a fever, fever was significantly associated with increased mortality, as were higher temperature fevers and more days with fever. The findings showed that fever increased mortality risk, suggesting that "long-fever" may play a role and that fever should be incorporated into risk management strategies to enhance monitoring and care.

Long Fever as a Long-Term Risk Factor for Mortality in Persons in Assisted Living Facilities

by Lea Efird-Green

This study examined long-term impacts of fever as a risk factor for mortality up to two years post-fever using data from over 16,000 AL residents between 2012 and 2022. Compared with not having a fever, fever was significantly associated with increased mortality, as were higher temperature fevers and more days with fever. The findings showed that fever increased mortality risk, suggesting that “long-fever” may play a role and that fever should be incorporated into risk management strategies to enhance monitoring and care.

Staff Satisfaction and Burnout in Assisted Living and Validity of the DCW Job Satisfaction Scale

Sep 1, 2025
This study examined the relationships between AL community and staff characteristics and staff satisfaction/burnout, as well as psychometrically assessing the Direct Care Worker Staff Satisfaction Scale. Satisfaction was. On average, staff were "satisfied" (a three on a scale of four) and 18.5% of staff were experiencing symptoms of burnout. When satisfaction was higher, burnout was lower (negatively correlated), and there were significant associations between satisfaction and organizational characteristics, such as staff to resident ratios.

Staff Satisfaction and Burnout in Assisted Living and Validity of the DCW Job Satisfaction Scale

by Lea Efird-Green

This study examined the relationships between AL community and staff characteristics and staff satisfaction/burnout, as well as psychometrically assessing the Direct Care Worker Staff Satisfaction Scale. Satisfaction was. On average, staff were “satisfied” (a three on a scale of four) and 18.5% of staff were experiencing symptoms of burnout. When satisfaction was higher, burnout was lower (negatively correlated), and there were significant associations between satisfaction and organizational characteristics, such as staff to resident ratios.

Mouth Care Without a Battle: Change in Assisted Living Staff Self-Efficacy and Attitudes

Sep 1, 2025
This study evaluated 24 AL communities to see if the modified Mouth Care Without a Battle (MCWB) for AL improved efficacy and attitudes of staff providing mouth care. AL staff's ratings of self-efficacy and attitudes did not significantly change after MCWB training, which differs from nursing home staff in another study. This may indicate AL staff do not view mouth care as high-priority, highlighting the need to emphasize it in training and supervision.

Mouth Care Without a Battle: Change in Assisted Living Staff Self-Efficacy and Attitudes

by Lea Efird-Green

This study evaluated 24 AL communities to see if the modified Mouth Care Without a Battle (MCWB) for AL improved efficacy and attitudes of staff providing mouth care. AL staff’s ratings of self-efficacy and attitudes did not significantly change after MCWB training, which differs from nursing home staff in another study. This may indicate AL staff do not view mouth care as high-priority, highlighting the need to emphasize it in training and supervision.

Happy by Nature: Nature Connection as a Source of Psychological Well-Being in Assisted Living Facilities

Sep 1, 2025
This study of over 850 residents in 25 Finnish AL communities examined whether connection with nature is associated with psychological well-being and mobility. A higher nature connection score was associated with higher psychological well-being, especially for residents with poor mobility. Other findings revealed residents experience nature in different ways, and that customized access to the outdoors is a framework for the development of nature-based interventions.

Happy by Nature: Nature Connection as a Source of Psychological Well-Being in Assisted Living Facilities

by Lea Efird-Green

This study of over 850 residents in 25 Finnish AL communities examined whether connection with nature is associated with psychological well-being and mobility. A higher nature connection score was associated with higher psychological well-being, especially for residents with poor mobility. Other findings revealed residents experience nature in different ways, and that customized access to the outdoors is a framework for the development of nature-based interventions.

Obesity and Transition to Assisted Living Services in Older Adults: An Analysis from the National Health and Aging Trends Study

Sep 1, 2025
This analysis of data from the National Health and Aging Trends Study examined the relationship between 2 measures of obesity - body mass index (BMI) and waist circumference - and transitioning from community settings to AL services (TALS). Overall, rates of TALS were 26%, but with increasing BMI, risk of TALS decreased suggesting increased BMI may be a protective factor. However, further study is suggested to understand why this relationship may be occuring.

Obesity and Transition to Assisted Living Services in Older Adults: An Analysis from the National Health and Aging Trends Study

by Lea Efird-Green

This analysis of data from the National Health and Aging Trends Study examined the relationship between 2 measures of obesity – body mass index (BMI) and waist circumference – and transitioning from community settings to AL services (TALS). Overall, rates of TALS were 26%, but with increasing BMI, risk of TALS decreased suggesting increased BMI may be a protective factor. However, further study is suggested to understand why this relationship may be occuring.

Stand When You Can: Feasibility of a Multilevel, Multisite Sedentary Behavior Intervention in Assisted-Living Residences

Sep 1, 2025
This study assessed the feasibility of Stand When You Can, an intervention designed to increase standing and movement in AL residents, with 68 residents in 5 Canadian AL communities. It was found that only one site showed good intervention fidelity and there was high attrition of participants due to limited capacity for staff to manage the program, meaning that additional staff support may be required for the best outcomes.

Stand When You Can: Feasibility of a Multilevel, Multisite Sedentary Behavior Intervention in Assisted-Living Residences

by Lea Efird-Green

This study assessed the feasibility of Stand When You Can, an intervention designed to increase standing and movement in AL residents, with 68 residents in 5 Canadian AL communities. It was found that only one site showed good intervention fidelity and there was high attrition of participants due to limited capacity for staff to manage the program, meaning that additional staff support may be required for the best outcomes.

Delivering Engaging and Meaningful Activities for Older Adults in Long-Term Care Using Principles of Interpretation

Sep 1, 2025
This article presented new guidelines to promote more meaningful activities for long-term care residents using principles of interpretation, originating in the environmental education field. Example guidelines include activities that are "personally relatable" and "facilitate meaning."

Delivering Engaging and Meaningful Activities for Older Adults in Long-Term Care Using Principles of Interpretation

by Lea Efird-Green

This article presented new guidelines to promote more meaningful activities for long-term care residents using principles of interpretation, originating in the environmental education field. Example guidelines include activities that are “personally relatable” and “facilitate meaning.”

Analgesic and Adjuvant Co-Prescribing in Australian and Finnish Residential Care Homes

Sep 1, 2025
This secondary analysis explored the co-prescribing of analgesic and/or adjuvant medications with data from 550 residents in 12 Australian long-term care (LTC) homes and over 2400 residents in 53 Finnish LTC homes. A total of 44% of Australian and 33% of Finnish residents were prescribed two or more analgesics and adjuvants. Acetaminophen was most commonly co-prescibed, but gabapentinoids and opioids were also co-prescribed. The frequency of co-prescribing these medications highlights a need for change in the field, given the risk of negative central nervous system outcomes.

Analgesic and Adjuvant Co-Prescribing in Australian and Finnish Residential Care Homes

by Lea Efird-Green

This secondary analysis explored the co-prescribing of analgesic and/or adjuvant medications with data from 550 residents in 12 Australian long-term care (LTC) homes and over 2400 residents in 53 Finnish LTC homes. A total of 44% of Australian and 33% of Finnish residents were prescribed two or more analgesics and adjuvants. Acetaminophen was most commonly co-prescibed, but gabapentinoids and opioids were also co-prescribed. The frequency of co-prescribing these medications highlights a need for change in the field, given the risk of negative central nervous system outcomes.

Developing and Implementing an Intervention to Increase Immunization Coverage Among Frontline Long-Term Care Staff

Sep 1, 2025
This study examined the attitudes of 200 post-acute and long-term care (PALTC) staff towards immunization, job-related education, and training. This feedback led to the development of a 45-minute training related to vaccines, which included information on the benefits and risks of immunizations for both residents and staff with a focus on objective, reliable information and staff autonomy.

Developing and Implementing an Intervention to Increase Immunization Coverage Among Frontline Long-Term Care Staff

by Lea Efird-Green

This study examined the attitudes of 200 post-acute and long-term care (PALTC) staff towards immunization, job-related education, and training. This feedback led to the development of a 45-minute training related to vaccines, which included information on the benefits and risks of immunizations for both residents and staff with a focus on objective, reliable information and staff autonomy.

Recruiting Sexual and Gender Minority Older Adults With and Without Dementia in Long-Term Care: Overcoming Barriers and Lessons Learned

Sep 1, 2025
This qualitative study of 20 AL and nursing home administrators explored the barriers and facilitators of recruiting sexual and gender minority (SGM) residents for research projects. Three key themes emerged: challenges identifying SGM residents, a need to address discrimination, and special considerations for SGM residents who also have cognitive impairment. These findings can guide researchers trying to recruit SGM residents more ethically and effectively.

Recruiting Sexual and Gender Minority Older Adults With and Without Dementia in Long-Term Care: Overcoming Barriers and Lessons Learned

by Lea Efird-Green

This qualitative study of 20 AL and nursing home administrators explored the barriers and facilitators of recruiting sexual and gender minority (SGM) residents for research projects. Three key themes emerged: challenges identifying SGM residents, a need to address discrimination, and special considerations for SGM residents who also have cognitive impairment. These findings can guide researchers trying to recruit SGM residents more ethically and effectively.

The Role of Aesthetics in Promoting Health-Related Quality of Life for Older Adults Transitioning to Long-Term Services and Support

Sep 1, 2025
This study investigated the relationship between the sense of aesthetics in the physical structure of a long-term care community and quality of life for 376 older adults recently enrolled in long-term services and supports. Increased social interaction and religious participation were positively associated with a sense of aesthetics, as was being in AL rather than nursing homes.

The Role of Aesthetics in Promoting Health-Related Quality of Life for Older Adults Transitioning to Long-Term Services and Support

by Lea Efird-Green

This study investigated the relationship between the sense of aesthetics in the physical structure of a long-term care community and quality of life for 376 older adults recently enrolled in long-term services and supports. Increased social interaction and religious participation were positively associated with a sense of aesthetics, as was being in AL rather than nursing homes.

Disproportionate Impact of Respiratory Syncytial Virus (RSV) Among Older Adults in Long-Term Care Settings

Sep 1, 2025
This examined data from the the 2022 to 2024 respiratory syncytial virus (RSV) seasons in one county in New York to compare disease burden, hospitalization, and in-hospital deaths between older adults living in community and long-term care (LTC) settings. Overall, infection rates were highest in nursing homes; hospitalization rates were highest in AL communities; and in-hospital death rates were significantly higher in LTC settings than in community-dwelling older adults. Findings highlight older adults in LTC settings are disproportionately affected by RSV, showing the need for targeted RSV prevention strategies which could include vaccinations and improved detection.

Disproportionate Impact of Respiratory Syncytial Virus (RSV) Among Older Adults in Long-Term Care Settings

by Lea Efird-Green

This examined data from the the 2022 to 2024 respiratory syncytial virus (RSV) seasons in one county in New York to compare disease burden, hospitalization, and in-hospital deaths between older adults living in community and long-term care (LTC) settings. Overall, infection rates were highest in nursing homes; hospitalization rates were highest in AL communities; and in-hospital death rates were significantly higher in LTC settings than in community-dwelling older adults. Findings highlight older adults in LTC settings are disproportionately affected by RSV, showing the need for targeted RSV prevention strategies which could include vaccinations and improved detection.

Primary Palliative Care in Assisted Living and Residential Care: A Metasynthesis

Aug 1, 2025
This metasynthesis of 88 qualitative studies examined the provision of palliative care in residential care settings, including challenges and opportunities of providing care in these settings. Resulting themes included addressing physical symptoms, psychological distress, social isolation, and spiritual needs among residents with serious illness and highlight the important role of palliative care in improving quality of life care continuity of residents.

Primary Palliative Care in Assisted Living and Residential Care: A Metasynthesis

by Lea Efird-Green

This metasynthesis of 88 qualitative studies examined the provision of palliative care in residential care settings, including challenges and opportunities of providing care in these settings. Resulting themes included addressing physical symptoms, psychological distress, social isolation, and spiritual needs among residents with serious illness and highlight the important role of palliative care in improving quality of life care continuity of residents.

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

Aug 1, 2025
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

by Lea Efird-Green

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.

Emergency Department Care Coordination Program for Assisted Living Residents with Dementia: A Qualitative Study

Aug 1, 2025
This qualitative study used data from 12 complex care managers (CCMs) in Florida and Minnesota to assess their perceptions of a care coordination program designed to improve communication related to transfers from AL communities to the emergency department (ED). Generally, the CCMs perceived the program as positively affecting both the ED experience for residents and goal-concordant care. Strengths of the program included CCM advocacy for patients and program adaptability, while a lack of knowledge about the program among ED staff and a lack of 24-hour coverage for CCMs were identified as areas for improvement.

Emergency Department Care Coordination Program for Assisted Living Residents with Dementia: A Qualitative Study

by Lea Efird-Green

This qualitative study used data from 12 complex care managers (CCMs) in Florida and Minnesota to assess their perceptions of a care coordination program designed to improve communication related to transfers from AL communities to the emergency department (ED). Generally, the CCMs perceived the program as positively affecting both the ED experience for residents and goal-concordant care. Strengths of the program included CCM advocacy for patients and program adaptability, while a lack of knowledge about the program among ED staff and a lack of 24-hour coverage for CCMs were identified as areas for improvement.

Real-Time Fatigue and Physical Activity of Older Adults in Assisted Living: Feasibility of Ecological Momentary Assessment

Aug 1, 2025
This study examined real-time measurements of fatigue and physical activity via monitoring devices, a type of ecological momentary assessment (EMA), in 34 residents in AL communities to assess the feasibility and acceptability of this data collection method. Participants rated the monitoring device as comfortable, had no trouble inputing fatigue scores (completing 76% on average). This study supports EMA as a feasible data collection method for establishing a temporal order of events in real time.

Real-Time Fatigue and Physical Activity of Older Adults in Assisted Living: Feasibility of Ecological Momentary Assessment

by Lea Efird-Green

This study examined real-time measurements of fatigue and physical activity via monitoring devices, a type of ecological momentary assessment (EMA), in 34 residents in AL communities to assess the feasibility and acceptability of this data collection method. Participants rated the monitoring device as comfortable, had no trouble inputing fatigue scores (completing 76% on average). This study supports EMA as a feasible data collection method for establishing a temporal order of events in real time.

“There Should Be a Nurse on Call”: Complex Care Needs of Low-Income Older Adults in Medicaid-Supported Assisted Living

Aug 1, 2025
This qualitative study explored the care needs and serious illness communication challenges of 17 residents of a Medicaid-supported AL community in New York. Four themes emerged: decreased quality of life, high burden from symptoms and low access to care, feeling unheard due to healthcare communication gaps, and uncoordinated care adding to feelings of distrust in the health system, indicating a need for policy changes related to care access and communication.

“There Should Be a Nurse on Call”: Complex Care Needs of Low-Income Older Adults in Medicaid-Supported Assisted Living

by Lea Efird-Green

This qualitative study explored the care needs and serious illness communication challenges of 17 residents of a Medicaid-supported AL community in New York. Four themes emerged: decreased quality of life, high burden from symptoms and low access to care, feeling unheard due to healthcare communication gaps, and uncoordinated care adding to feelings of distrust in the health system, indicating a need for policy changes related to care access and communication.

Anxiety Among Workers in Institutions for Older Adults During the COVID-19 Pandemic

Aug 1, 2025
This study examined questionnaires from 900 nursing home and AL workers in Puerto Rico to understand the factors that contributed to anxiety during the COVID-19 pandemic. Factors such as avoidance, emotional exhaustion, stress, and negative mood were major contributors to feelings of anxiety. The findings highlight the need for mental health support and interventions for long-term care workers both during and after crises to lessen feelings of anxiety and to prevent long-term impacts on well-being.

Anxiety Among Workers in Institutions for Older Adults During the COVID-19 Pandemic

by Lea Efird-Green

This study examined questionnaires from 900 nursing home and AL workers in Puerto Rico to understand the factors that contributed to anxiety during the COVID-19 pandemic. Factors such as avoidance, emotional exhaustion, stress, and negative mood were major contributors to feelings of anxiety. The findings highlight the need for mental health support and interventions for long-term care workers both during and after crises to lessen feelings of anxiety and to prevent long-term impacts on well-being.

Yearlong Evaluation of Fall Risk Determinants Among 40 Older Adults in Two Residential Assisted Living Facilities

Aug 1, 2025
This study examined the relationships among the physical activity, physical performance, falls, and cognitive functioning of 40 residents of 2 AL communities in Wisconsin. Up to 40% of participants had at least 1 fall in 6 months, and a significant association was found between number of falls, fear of falling, and a number of physical and cognitive measurements, offering new potential intervention points to reduce falls.

Yearlong Evaluation of Fall Risk Determinants Among 40 Older Adults in Two Residential Assisted Living Facilities

by Lea Efird-Green

This study examined the relationships among the physical activity, physical performance, falls, and cognitive functioning of 40 residents of 2 AL communities in Wisconsin. Up to 40% of participants had at least 1 fall in 6 months, and a significant association was found between number of falls, fear of falling, and a number of physical and cognitive measurements, offering new potential intervention points to reduce falls.