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

Bridging the Transition to Assisted Living: A Framework for Faith Community Nursing

Apr 1, 2022
WHAT THIS MEANS FOR YOU: Using an example of an 85-year-old resident, the article proposes a framework for faith community nursing, emphasizing observation, meaningful conversations, advocacy, and assertive communication to ease the move from independent to assisted living.

Bridging the Transition to Assisted Living: A Framework for Faith Community Nursing

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Using an example of an 85-year-old resident, the article proposes a framework for faith community nursing, emphasizing observation, meaningful conversations, advocacy, and assertive communication to ease the move from independent to assisted living.

Does Service Provider Matter during a Pandemic? COVID-19 Cases and Deaths among Nonprofit vs. For-Profit Assisted Living Facilities in Florida

Apr 1, 2022
WHAT THIS MEANS FOR YOU: This study investigated the relationship of ownership (nonprofit vs. for-profit) to Florida assisted living communities’ responses to COVID-19. In total, 672 of 3,019 communities reported at least one positive case by June 2020. Nonprofit communities had fewer cases, although there was no significant difference in resident deaths. Additionally, whether nursing services were provided in the community mattered in protecting residents from COVID-19 infections (i.e., not providing any nursing services was associated with more infections).

Does Service Provider Matter during a Pandemic? COVID-19 Cases and Deaths among Nonprofit vs. For-Profit Assisted Living Facilities in Florida

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study investigated the relationship of ownership (nonprofit vs. for-profit) to Florida assisted living communities’ responses to COVID-19. In total, 672 of 3,019 communities reported at least one positive case by June 2020. Nonprofit communities had fewer cases, although there was no significant difference in resident deaths. Additionally, whether nursing services were provided in the community mattered in protecting residents from COVID-19 infections (i.e., not providing any nursing services was associated with more infections).

SARS-CoV-2 in Assisted Living: Mortality and Asymptomatic Infection

Apr 1, 2022
WHAT THIS MEANS FOR YOU: Two assisted living communities in New York had 42% of residents test positive for COVID-19 in April 2020; 68% of infected residents were asymptomatic. The frequency of asymptomatic cases may have contributed to a more widespread infection and mortality; 25% of resident deaths in these communities in April 2020 were due to COVID-19.

SARS-CoV-2 in Assisted Living: Mortality and Asymptomatic Infection

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Two assisted living communities in New York had 42% of residents test positive for COVID-19 in April 2020; 68% of infected residents were asymptomatic. The frequency of asymptomatic cases may have contributed to a more widespread infection and mortality; 25% of resident deaths in these communities in April 2020 were due to COVID-19.

Physical Activity and Sedentary Behavior of Residents in Assisted Living: A Preliminary Study

Apr 1, 2022
WHAT THIS MEANS FOR YOU: This study examined physical activity and sedentary behavior in assisted living residents and their relationship with a variety of outcomes. Participants included 54 residents from 8 communities, who had an average of 253 minutes of physical activity per day and 661 minutes of sedentary behavior per day. Depression related to lower activity, while use of assistive devices and fatigue related to higher sedentary behavior.

Physical Activity and Sedentary Behavior of Residents in Assisted Living: A Preliminary Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined physical activity and sedentary behavior in assisted living residents and their relationship with a variety of outcomes. Participants included 54 residents from 8 communities, who had an average of 253 minutes of physical activity per day and 661 minutes of sedentary behavior per day. Depression related to lower activity, while use of assistive devices and fatigue related to higher sedentary behavior.

Potential Side Effects and Adverse Events of Antipsychotic Use for Residents With Dementia in Assisted Living: Implications for Prescribers, Staff, and Families

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study examined the use of antipsychotic medications among residents with dementia in 91 AL communities across seven states. The prevalence of potential side effects was high (93%) and of possible adverse events low, (6%), potentially associated with medication side effects. Quetiapine (Seroquel) and risperidone (Risperdal) were the most frequently prescribed antipsychotics. Most, but not all, residents’ family members were aware of their relative’s antipsychotic use.

Potential Side Effects and Adverse Events of Antipsychotic Use for Residents With Dementia in Assisted Living: Implications for Prescribers, Staff, and Families

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined the use of antipsychotic medications among residents with dementia in 91 AL communities across seven states. The prevalence of potential side effects was high (93%) and of possible adverse events low, (6%), potentially associated with medication side effects. Quetiapine (Seroquel) and risperidone (Risperdal) were the most frequently prescribed antipsychotics. Most, but not all, residents’ family members were aware of their relative’s antipsychotic use.

Replication of Implementing a Sit-to-Stand Exercise Program in an Assisted Living Facility

Mar 1, 2022
WHAT THIS MEANS FOR YOU: A 20-bed AL community in rural North Carolina implemented a sit-to-stand exercise program (i.e., having residents rise from a sitting position and then sit back down). A total of 13 residents participated in the program which was offered twice daily over 82 days. The average attendance rate for participants for all sessions was over 90%, and each participant was able to complete all 5 exercises during each session. Over the course of the program participants saw modest increases in average activities of daily living independence scores; however, these changes were not statistically significant. Activities that were measured included toileting, bathing, dressing, transferring, and continence.

Replication of Implementing a Sit-to-Stand Exercise Program in an Assisted Living Facility

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A 20-bed AL community in rural North Carolina implemented a sit-to-stand exercise program (i.e., having residents rise from a sitting position and then sit back down). A total of 13 residents participated in the program which was offered twice daily over 82 days. The average attendance rate for participants for all sessions was over 90%, and each participant was able to complete all 5 exercises during each session. Over the course of the program participants saw modest increases in average activities of daily living independence scores; however, these changes were not statistically significant. Activities that were measured included toileting, bathing, dressing, transferring, and continence.

Exploring the Effectiveness of Virtual Compassionate Presence Sessions in Reducing Loneliness and Isolation among Assisted-Living Older Adults: A Pilot Study

Mar 1, 2022
WHAT THIS MEANS FOR YOU: A pilot study investigated the effectiveness of virtual compassionate presence (CP) sessions in reducing loneliness and isolation among older adults in AL when facilitated by college students trained in CP. CP involves deep, attentive, and nonjudgmental listening while being fully present. Eighteen older adults participated in CP sessions over 10 weeks and were interviewed 2 months after the last session. Semi-structured interview results revealed a self-reported decrease in participants’ feelings of isolation and loneliness and an increase in overall mood.

Exploring the Effectiveness of Virtual Compassionate Presence Sessions in Reducing Loneliness and Isolation among Assisted-Living Older Adults: A Pilot Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A pilot study investigated the effectiveness of virtual compassionate presence (CP) sessions in reducing loneliness and isolation among older adults in AL when facilitated by college students trained in CP. CP involves deep, attentive, and nonjudgmental listening while being fully present. Eighteen older adults participated in CP sessions over 10 weeks and were interviewed 2 months after the last session. Semi-structured interview results revealed a self-reported decrease in participants’ feelings of isolation and loneliness and an increase in overall mood.

“You Lose Some Good Friends”: Death and Grief in Assisted Living

Mar 1, 2022
WHAT THIS MEANS FOR YOU: In a qualitative study including interviews with 18 residents in 21 assisted living communities, as well as reviews of community documents and observational field notes, residents reported that staff communication and community-level memorials following residents’ death were not consistent with a “family-like” atmosphere, and residents’ grief took many forms.

“You Lose Some Good Friends”: Death and Grief in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: In a qualitative study including interviews with 18 residents in 21 assisted living communities, as well as reviews of community documents and observational field notes, residents reported that staff communication and community-level memorials following residents’ death were not consistent with a “family-like” atmosphere, and residents’ grief took many forms.

Psychotropic and Pain Medication Use in Nursing Homes and Assisted Living Facilities during COVID-19

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study focused on the potential impact of COVID-19 on the prescription of psychotropic and pain medication in nursing homes and assisted living. Nationally, there was relatively no change in the use of psychotropic and pain medications between pre- and post-COVID periods. However, there was increased use among individuals newly admitted during the pandemic, the cause of which was uncertain.

Psychotropic and Pain Medication Use in Nursing Homes and Assisted Living Facilities during COVID-19

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study focused on the potential impact of COVID-19 on the prescription of psychotropic and pain medication in nursing homes and assisted living. Nationally, there was relatively no change in the use of psychotropic and pain medications between pre- and post-COVID periods. However, there was increased use among individuals newly admitted during the pandemic, the cause of which was uncertain.

Monitoring Laboratory Parameters for Drug Toxicity in Assisted Living Facilities

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This quality improvement project focused on performing recommended laboratory tests per FDA medication labeling in a 58-bed assisted living community. Before the project, almost 60% of resident records had gaps in lab monitoring of medications, which was worsened because of COVID-19 restrictions. The project focused on close provider collaboration to ensure labs were conducted; after the project, almost 90% of residents received necessary lab tests for their medications.

Monitoring Laboratory Parameters for Drug Toxicity in Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This quality improvement project focused on performing recommended laboratory tests per FDA medication labeling in a 58-bed assisted living community. Before the project, almost 60% of resident records had gaps in lab monitoring of medications, which was worsened because of COVID-19 restrictions. The project focused on close provider collaboration to ensure labs were conducted; after the project, almost 90% of residents received necessary lab tests for their medications.

“What Keeps Me Awake at Night”: Assisted Living Administrator Responses to COVID-19

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study assessed how the early COVID-19 pandemic (Feb-Aug 2020) affected 40 assisted living administrators in Oregon. Three resulting themes from the interviews were emotion and burnout management (e.g., monitoring staff reactions), information management (e.g., monitoring latest recommendations and safety protocols), and crisis management (e.g., decision-making, emergency planning).

“What Keeps Me Awake at Night”: Assisted Living Administrator Responses to COVID-19

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study assessed how the early COVID-19 pandemic (Feb-Aug 2020) affected 40 assisted living administrators in Oregon. Three resulting themes from the interviews were emotion and burnout management (e.g., monitoring staff reactions), information management (e.g., monitoring latest recommendations and safety protocols), and crisis management (e.g., decision-making, emergency planning).

Factors Associated With Assisted Living Facility Closure

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study analyzed almost 2,000 Florida assisted living communities to understand factors related to assisted living closure between 2013-2015. During this time, 7.3% of communities closed; those with increased odds of closing had fewer beds, did not accept Medicaid, and had more regulatory deficiencies.

Factors Associated With Assisted Living Facility Closure

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study analyzed almost 2,000 Florida assisted living communities to understand factors related to assisted living closure between 2013-2015. During this time, 7.3% of communities closed; those with increased odds of closing had fewer beds, did not accept Medicaid, and had more regulatory deficiencies.

Staff Reports of Behavioral Expressions of Persons with Dementia in 250 Assisted Living Communities 

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study included health care supervisors from 250 assisted living communities in 7 states to understand how staff respond to behavioral expressions of residents with dementia. The most commonly reported expressions were combativeness and anxiety. A thematic analysis found that in about 25% of cases, staff recognized the events preceding behavioral expressions (antecedents). Staff in smaller and memory-care only communities were more adept at identifying antecedents; additional training to anticipate expressions may help prevent them.

Staff Reports of Behavioral Expressions of Persons with Dementia in 250 Assisted Living Communities 

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study included health care supervisors from 250 assisted living communities in 7 states to understand how staff respond to behavioral expressions of residents with dementia. The most commonly reported expressions were combativeness and anxiety. A thematic analysis found that in about 25% of cases, staff recognized the events preceding behavioral expressions (antecedents). Staff in smaller and memory-care only communities were more adept at identifying antecedents; additional training to anticipate expressions may help prevent them.

Assisted Living Residents With Dementia: Being Out in the World and Negotiating Connections

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This year-long study observed 33 individuals and their caregivers in 4 assisted living communities, focusing on the significance of outdoor and offsite activities for persons living with dementia. Data included 1,560 observation hours, 114 interviews with residents, staff, family, and visitors, and resident record reviews. Qualitative findings suggested that engaging with others and with nature is important for better quality of life. Most residents were able to at least occasionally go out, and those who went outdoors generally had positive experiences, but not all experiences were positive.

Assisted Living Residents With Dementia: Being Out in the World and Negotiating Connections

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This year-long study observed 33 individuals and their caregivers in 4 assisted living communities, focusing on the significance of outdoor and offsite activities for persons living with dementia. Data included 1,560 observation hours, 114 interviews with residents, staff, family, and visitors, and resident record reviews. Qualitative findings suggested that engaging with others and with nature is important for better quality of life. Most residents were able to at least occasionally go out, and those who went outdoors generally had positive experiences, but not all experiences were positive.

Impact of Function-Focused Care on Psychotropic Medications and Opioid Use among Assisted Living Residents

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study evaluated the impact of function focused care (which trains staff to evaluate residents’ functional capacity and physical activity to optimize their participation in activities) on the use of psychotropic medications and opioids. The study observed 794 residents across 85 communities over 12 months. There was a reduction in opioid use in the treatment group after four months; in the full sample during the overall study period, there was an increase in the use of benzodiazepines and antipsychotics.

Impact of Function-Focused Care on Psychotropic Medications and Opioid Use among Assisted Living Residents

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study evaluated the impact of function focused care (which trains staff to evaluate residents’ functional capacity and physical activity to optimize their participation in activities) on the use of psychotropic medications and opioids. The study observed 794 residents across 85 communities over 12 months. There was a reduction in opioid use in the treatment group after four months; in the full sample during the overall study period, there was an increase in the use of benzodiazepines and antipsychotics.

COVID-19 in Assisted Living: Protecting a Critical Long-Term Care Resource

Feb 16, 2022
WHAT THIS MEANS FOR YOU: This literature review explores how COVID-19 created challenges for both residents and staff in assisted living by providing an overview of its impact and suggesting actions to improve outcomes. Studies showed that residents experienced a decline in their health and happiness because of infection control measures, which made them feel lonely and isolated. Staff faced problems such as staff shortages, feeling overwhelmed and stressed, and dealing with emotional struggles. The article suggests solutions such as improving infection control, giving better training to staff, introducing Essential Caregiver programs, and encouraging residents to socialize more.

COVID-19 in Assisted Living: Protecting a Critical Long-Term Care Resource

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This literature review explores how COVID-19 created challenges for both residents and staff in assisted living by providing an overview of its impact and suggesting actions to improve outcomes. Studies showed that residents experienced a decline in their health and happiness because of infection control measures, which made them feel lonely and isolated. Staff faced problems such as staff shortages, feeling overwhelmed and stressed, and dealing with emotional struggles. The article suggests solutions such as improving infection control, giving better training to staff, introducing Essential Caregiver programs, and encouraging residents to socialize more.

“Uncivilized Children” or “Victims of Dementia”: Interpretations of Aggression in Older Assisted Living Tenants

Feb 1, 2022
WHAT THIS MEANS FOR YOU: Researchers interviewed 13 AL residents and 19 care workers in two communities about resident aggression. Care workers reported physical and verbal aggression, while residents reported relational and sexual aggression from peers. Both groups often attributed aggression to communal living, aging, or dementia, suggesting that they normalized the behavior and often did not report it. Underreporting of resident aggression was more common for workers than residents.

“Uncivilized Children” or “Victims of Dementia”: Interpretations of Aggression in Older Assisted Living Tenants

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Researchers interviewed 13 AL residents and 19 care workers in two communities about resident aggression. Care workers reported physical and verbal aggression, while residents reported relational and sexual aggression from peers. Both groups often attributed aggression to communal living, aging, or dementia, suggesting that they normalized the behavior and often did not report it. Underreporting of resident aggression was more common for workers than residents.

The Impact of Cognitive Impairment on Clinical Symptoms, Physical Activity and Care Interactions among Residents in Assisted Living Settings

Feb 1, 2022
WHAT THIS MEANS FOR YOU: This study included 550 AL residents from 59 communities, and assessed how cognitive impairment relates to physical activity, pain, and willingness to receive staff-assisted function-focused care. It found that cognitively impaired residents were less active, experienced more pain, and were less interested in staff-assisted function-focused care activities.

The Impact of Cognitive Impairment on Clinical Symptoms, Physical Activity and Care Interactions among Residents in Assisted Living Settings

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study included 550 AL residents from 59 communities, and assessed how cognitive impairment relates to physical activity, pain, and willingness to receive staff-assisted function-focused care. It found that cognitively impaired residents were less active, experienced more pain, and were less interested in staff-assisted function-focused care activities.

Storage Issues in Assisted Living Facilities and Senior Living Communities

Feb 1, 2022
WHAT THIS MEANS FOR YOU: During the COVID-19 pandemic, AL communities faced hurdles obtaining vital supplies including masks and gloves; AL communities were often considered lower priority than other healthcare settings, leading to delays in receipt. When supplies were obtained, the quantity often overwhelmed available storage space, leading to unsafe supply storage. Solutions include improved emergency management, emphasizing proper storage, and optimizing delivery schedules.

Storage Issues in Assisted Living Facilities and Senior Living Communities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: During the COVID-19 pandemic, AL communities faced hurdles obtaining vital supplies including masks and gloves; AL communities were often considered lower priority than other healthcare settings, leading to delays in receipt. When supplies were obtained, the quantity often overwhelmed available storage space, leading to unsafe supply storage. Solutions include improved emergency management, emphasizing proper storage, and optimizing delivery schedules.

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

Feb 1, 2022
WHAT THIS MEANS FOR YOU: There are significant differences in the quality of end-of-life care in AL. Research on 37,668 deceased Medicare beneficiaries who lived in AL found that 1 in 5 experienced challenging transitions including frequent hospitalizations before their death. Burdensome transitions, especially in the last three days of life, varied widely among states, which may be associated with state-level regulations.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: There are significant differences in the quality of end-of-life care in AL. Research on 37,668 deceased Medicare beneficiaries who lived in AL found that 1 in 5 experienced challenging transitions including frequent hospitalizations before their death. Burdensome transitions, especially in the last three days of life, varied widely among states, which may be associated with state-level regulations.

Assisted Living Administrators’ Approaches to Advance Care Planning

Feb 1, 2022
WHAT THIS MEANS FOR YOU: Interviews with 27 AL administrators revealed different approaches to advanced care planning (ACP). They all acknowledged the importance of ACP and often discussed topics like “do-not-resuscitate” orders when new residents arrived. Challenges included insufficient ACP training for staff and administrators and some reluctance from residents and families to discuss ACP. Most communities lacked a systematic, structured ACP approach.

Assisted Living Administrators’ Approaches to Advance Care Planning

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Interviews with 27 AL administrators revealed different approaches to advanced care planning (ACP). They all acknowledged the importance of ACP and often discussed topics like “do-not-resuscitate” orders when new residents arrived. Challenges included insufficient ACP training for staff and administrators and some reluctance from residents and families to discuss ACP. Most communities lacked a systematic, structured ACP approach.

Model Testing of the Factors that Influence Performance of Function Focused Care and Function among Assisted Living Residents

Feb 1, 2022
WHAT THIS MEANS FOR YOU: A study of 550 AL residents from 59 communities found that factors such as better physical and cognitive health, positive care interactions, and supportive environments were associated with increased participation in function-focused care. Additionally, for-profit communities had higher levels of function-focused care despite having residents with lower functioning.

Model Testing of the Factors that Influence Performance of Function Focused Care and Function among Assisted Living Residents

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A study of 550 AL residents from 59 communities found that factors such as better physical and cognitive health, positive care interactions, and supportive environments were associated with increased participation in function-focused care. Additionally, for-profit communities had higher levels of function-focused care despite having residents with lower functioning.

Implementing Large-Scale Data-Driven Quality Improvement in Assisted Living

Feb 1, 2022
WHAT THIS MEANS FOR YOU: A quality improvement initiative implemented by 810 Wisconsin assisted living communities serving over 20,000 residents found that most communities (88%) were able to comply with membership requirements and 71% remained enrolled for more than 2 years. This model could be reproduced in other states to improve quality.

Implementing Large-Scale Data-Driven Quality Improvement in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A quality improvement initiative implemented by 810 Wisconsin assisted living communities serving over 20,000 residents found that most communities (88%) were able to comply with membership requirements and 71% remained enrolled for more than 2 years. This model could be reproduced in other states to improve quality.

Reimagining Medical Care in Assisted Living

Feb 1, 2022
WHAT THIS MEANS FOR YOU: Three industry-wide proposals were recommended to enhance medical care quality for AL residents: regular on-site medical visits; employing experienced professionals in long-term and end-of-life care; and the introduction of an AL medical director role to establish rules, staff qualifications, and collaboration. The researchers acknowledge that adaptations may be necessary to adhere to these recommendations due to community size and availability of resources.

Reimagining Medical Care in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Three industry-wide proposals were recommended to enhance medical care quality for AL residents: regular on-site medical visits; employing experienced professionals in long-term and end-of-life care; and the introduction of an AL medical director role to establish rules, staff qualifications, and collaboration. The researchers acknowledge that adaptations may be necessary to adhere to these recommendations due to community size and availability of resources.