1. For every additional occupied memory care unit (for occupancies in excess of 80%), one could assume approximately 30% of the additional monthly service fee would go for new, incremental expenses. That is because at relatively high existing occupancies, most operating costs already are incurred and paid.

2. Approximately 70% of the additional monthly service fee results in a very high incremental profit margin, new cash that drops right to the bottom line.

3. For a single-facility memory care operator with a typical baseline monthly service fee of $6,050 per month, the 70% incremental profit margin results in new cash flow benefit of $4,235 per month, or an annual cash increase of $50,820 for each additional occupied unit.

With a 7% cap rate, this could increase the value of each additional occupied unit by over $725,000.  

With the acuity shift in long-term care driving patients from hospitals to the long-term care sector, rehab is no stranger to assisted living. These communities have long been welcoming residents in need of clinical rehab services. Rehab just hasn’t been part of assisted living’s identity as it has for skilled nursing.

But David Tate, chief strategy officer for Reliant Rehab, says rehab is indeed becoming more associated with senior living.

“It is common for senior living operators to promote the availability of onsite therapy services,” he says. “Whether in a small skilled nursing unit, memory care unit or in a dedicated outpatient therapy gym, therapy services are increasingly available to senior living residents. For senior living communities without dedicated therapy space, an approved therapy facility may offer ‘off-premises’ services in a patient’s room. Home health is another provider commonly offering therapy services to residents of senior living communities.”

Although short-term rehab infrastructure may not yet be universal in senior living, Tate says it is more commonplace to see senior living communities with dedicated therapy gyms that occupy prominent locations and can be accessed by residents and potential residents.

“Short-term rehabilitation provides senior living residents an opportunity to receive therapy services in an ideal environment for restoring optimal functional abilities,” Tate says. “While the convenience of onsite outpatient therapy is a definite plus, the more important advantage is receiving functional rehabilitation services in the actual home environment.”

The clinical dynamic

Rockland Berg, architect and principal with the Dallas-based architectural firm three, has witnessed the acuity shift and rehab migration trend over the course of decades. If skilled nursing has owned the rehab component, it is because the facilities have a more clinical focus (and image) than senior living, he says.

“It’s because skilled nursing has been closely identified with hospital environments and institutional settings, and it’s a highly regulated environment,” Berg says. 

“Also, skilled nursing in the past seemed to be a competitor for the hospital environment, but that fundamentally changed about 10 to 15 years ago as hospitals needed to shed patients as required by new regulations.”

Even so, post-acute care and senior living are evolving in their identities, approaches to care and overall environments and are gaining more influence over public policy, so the migration of rehab into assisted living is a natural result of that evolution, Berg says.

“Today, we’re seeing operators getting more creative with licensing regulators, so that they can provide better care in less restrictive environments,” he says. “I think certain states are no longer requiring skilled nursing as part of the continuum, such as Arizona, I believe, and that will continue to change the dynamic.”

Nevertheless, senior living is a different care setting and faces an alternate process of adopting rehab.

“They are less institutional, less encumbered by regulation, and potentially less expensive to the resident,” he says. “All these qualities make it very different to add short-term rehab, and it aligns well with the dynamics of today’s senior living environments.”

The EdenHill experience

Five years ago when EdenHill of New Braunfels, TX, cut the ribbon on its Fischer Rehabilitation Center, industry observers may have considered it to be a novel approach for a continuing care retirement community.

As the local newspaper reported in 2014, EdenHill management decided that a CCRC should provide rehab “to ensure that continuity of care.” 

The center has made services accessible throughout the New Braunfels’ community, including wellness and fall prevention as primary objectives. Therapists have developed programs to assess and improve residents’ mobility, balance, safety, strength, cognition and swallowing abilities.

Among the center’s rehab and clinical services are post-surgical recovery, wound care, pain management, cardiac and orthopedic programming, incontinence management, and programs about cognitive and physical impairments.

Berg is familiar with EdenHill — three designed the 2015 renovation and expansion — and holds it up an example of forward thinking in senior living.

“They strategically reduced their skilled nursing complement, replacing it with contemporary assisted living and memory care and a robust PT/OT component to improve services and drive revenue,” he says.

The rehab strategy

As the rehab migration continues to gain momentum in senior living, Berg says it has come at the expense of skilled nursing in the communities that offer it. 

For-profit and nonprofit designations also make a difference, he says.

“I would like to stress that all of the for-profit senior living providers we know or that are working with our firm have ceased to provide skilled nursing as an option, and they now stop at memory care,” Berg says. 

“As for the not-for-profits we see, they are cutting down their skilled nursing offerings. As a means to satisfy opportunities for short-term rehab, they are now providing solutions in these hybrid environments that are licensed under assisted living. As this is taking place, the footprints for physical therapy and occupational therapy are enlarging, sometimes doubling what they have provided in the past,” he adds.

To be a viable part of the post-acute rehab network, senior living communities have to establish strong relationships with hospitals and referring clinicians. Berg says that is happening.

Good neighbors

“Some communities are strategically locating in close proximity to the hospital output environments and tailoring their physical therapy and occupational therapy services to align with prospective residents’ needs,” he says. “In fact, we see that they are actually advertising their affinity to the larger community with these healthcare networks.”

If there is reluctance among senior living communities to accommodate short-term rehab, Berg hasn’t seen it.

“I can’t say that I have,” he says. “We’ve found that most of the operators see it as a need to be filled, an economic opportunity and an opportunity to market to a new group of prospective residents who might not have considered their community otherwise. Some of those potential residents are even younger and staying in their communities longer.”

Textiles and fabrics such bed linens, bath towels, resident clothing and employee scrubs and uniforms may become contaminated with urine, stool, blood, skin and other body fluids and tissue. If not properly handled and laundered, these materials potentially can transmit infection to employees and residents.  

“Improperly laundered linens and clothes can become a reservoir of micro-organisms that cause bacterial, parasitic, fungal and viral infections,” says Christine Sanders, vice president of campus administration at United Hebrew of New Rochelle, an elder care campus in Westchester County, New York. Sanders oversees the operations for United Hebrew’s campus, which includes independent living, assisted living, memory care, skilled nursing, rehabilitation and home care.

Because linens are reusable commodities, she stresses the need to diligently follow laundry-related guidelines, including those from the Centers for Disease Control and Prevention, the Department of Health and the Occupational Safety and Health Administration. 

When soil and pathogens are properly removed and inactivated and practices are followed to prevent hygienic laundry from becoming inadvertently recontaminated before use, the CDC says risk of cross-contamination and infection transmission to employees and residents becomes negligible.

Sorting the risks

Regardless of whether a senior living operator runs its own in-house or offsite laundry facility or outsources the function altogether, experts agree that safe and effective laundry care involves more than just proper washing and drying.

“It encompasses a much larger process, including linen collection, transport, sorting, folding, storage and return to point of use,” explains Katie Hurley, Ph.D., lead chemist for Ecolab. “Each of these steps is an opportunity to help or hinder the spread of infection.”

Employees should treat all unclean items as if they are contaminated, according to the CDC and OSHA. Some operators allow only designated environmental services employees to collect laundry, while others allow nurses and other designated employees to manage the task so contaminated laundry can be addressed more quickly. Whatever the case, all employees who handle any steps in the laundry care process must be well-trained on proper policies and procedures to keep themselves, their co-workers, residents and visitors safe. To prevent microorganisms from becoming airborne or settling on other surfaces, linens and textiles never should be agitated or shaken during removal or collection, and they should be carefully bagged and transported. United Hebrew of New Rochelle requires clean delivery carts with plastic protective coverings to be used when transporting soiled linens.

Employees also should be trained to hold linens and textiles away from their bodies during collection and handling. Doing this helps prevent cross-contamination and minimizes the risk of coming in contact with sharps that accidentally may have been left in linens. For laundering of employee scrubs and uniforms, the CDC recommends either making provisions to have them laundered by the facility or its contracted laundry service provider or providing employees with detailed instructions on how to launder their uniforms safely and effectively at home.

Experts warn sorting or rinsing of laundry never should happen outside the designated laundry area, and no employee should handle dirty laundry without use of proper personal protective equipment that is changed in-between collections. Hands also should be washed in-between each collection and before new PPE is donned.

Healthcare Services Group, a housekeeping and laundry services provider for skilled nursing and assisted living communities, provides thorough employee training to ensure full understanding of policies and procedures, including proper use of PPE. “It’s imperative all EVS workers are equipped with and wear proper neoprene aprons and gloves, in addition to using goggles to prevent the spread of infection,” says Mike Irrizarry, director of operational excellence at Healthcare Services Group.

Keep it separated

Using color-coded laundry bags with room numbers helps keep residents’ personal items sorted and can identify laundry items by unit, such as long-term care, rehabilitation, assisted living or memory care, which can help ensure clothing is returned to its rightful owner. 

“This helps prevent cross-contamination and reduce complaints,” assures Daniel Gravatt, LNHA, T-CRCT, business operations manager for ServiceMaster Clean.

In laundry areas, it’s essential that dirty and clean linens and textiles remain separated. Bill Brooks, North American sales manager for UniMac, says a U-shaped design is ideal because it allows soiled linens to come in on one side and leave as clean linens on the other – without risk of the two contacting one another or becoming intermixed. Even the smallest laundries should be partitioned into two separate areas — a “dirty” area for receiving and handling soiled laundry and a “clean” area for processing washed items, according to the CDC’s Guidelines for Environmental Infection Control in Health-Care Facilities. 

“Color-coded carts can also help employees keep clean and soiled linens separated,” Brooks says. 

Sorting loads by like item and soil level is equally critical for helping to ensure that items receive the proper treatment and cycle. Typically, all flat linens, such as sheets and pillowcases, are laundered together, Irrizarry says. HCSG also recommends washing items such as blankets, towels, wash cloths and other heavier cotton items together. Tablecloths typically are washed separately and not usually dried to prevent wrinkles, he says. 

When loading a washing machine and starting a wash cycle, parts of the equipment — including the door, keypads and controls — come in contact with contaminated linen and gloved hands that touched the dirty items. To avoid cross-contamination, Hurley recommends sanitizing the washing machine door, handle and controller after loading dirty linen, and changing PPE in-between loads. 

“That way, when clean linen is removed from the washing machine, opportunities for contamination are minimized,” she says.

Chemistry counts

Sources agree that even the best infection control strategies for laundry care will fall flat if operators lack high-quality, commercial-grade washers and dryers. Often, these units not only offer higher capacity but also have advanced programming and automatic dilution settings and temperature control to ensure each load receives the proper treatment.

“Water must be 160 degrees for at least 25 minutes to kill pathogens,” Gravatt says. 

Although under-loading machines can lead to costly inefficiencies and, perhaps, overuse of chemistries, overloading them can prevent proper mechanical agitation, wetting and chemistry dispersal required for effective cleaning. Filling to 80% of machine capacity is a good rule of thumb, according to Hurley. Chemistry containers also should be checked routinely to ensure wash loads aren’t running without solution.

“An extra level of infection prevention can be added by using a registered sanitizer or disinfectant during the laundry wash process,” she says. Ecolab offers several of these solutions, ranging from sanitizers with 99.9% kill to disinfectants effective against even tough bacteria such as Clostridium difficile.

Cloud-based laundry management systems that network laundry equipment can give managers pertinent data to ensure proper processes and cycles — including correct water temperature — are being consistently followed. These laundry management systems can present performance data in easy-to-read charts for proactive monitoring, even when managers are offsite. 

“This will arm managers with the information they need to ensure processes are being followed to drive infection control efforts, quality and efficiency,” Brooks explains. 

Any suspected equipment malfunctions should be reported promptly for immediate service and repair. Washed and dried items should be folded on the clean side of the laundry room and then transported in clean, covered containers.

This in part explains why the average age of move-in across the various levels of senior living has risen considerably in recent years, according to Majd Alwan, Ph.D., senior vice president of technology for LeadingAge and executive director of the Center for Aging Services Technologies, or CAST.

It’s happening right now in more than 250,000 independent facilities alone, according to Jerry Wilmink, chief business officer for CarePredict.

“Independent seniors like to be around their peers and family, and they value safety and security,” he says. “They typically are able to perform most activities of daily living, like eating, bathing, dressing, grooming, and toileting. They also may be able to perform most instrumental activities of daily living, which … let a senior live independently in a community or in their home.”

Wilmink asserts that although seniors value their independence, many don’t want to bother with many IADLs, such as yard work, cooking, cleaning and securing and taking their prescription medicine. “This is where technology can provide a safety net,” he says. Examples include wearable tech that monitors vital signs, provides med alerts and summons help at a button-push with real-time location.

Owner-operators can thank baby boomers for fueling resident security tech. “Many already wear smart watches or fitness monitors and use home automation to keep their residences comfortable and secure,” says Mike Webster, director of senior living, fall management and security solutions for Stanley Healthcare.

Safety over autonomy

Still, owner-operators and their residents, respectively, recognize and welcome giving up a little autonomy now and then in the interest of personal safety.

Senior living providers are called on every day to make difficult decisions that subjugate residents’ autonomous desires for security.

An easily adoptable safety feature “without much loss of privacy or autonomy” includes things such as automatic shutoff mechanisms on stoves and ovens, Alwan says.

Another includes various kinds of elopement safety tech, such as emergency notification and response  systems and location tracking and access control technologies and software, Wilmink says.

Such tech not only saves lives but staff time.

“By using technology like access control and wander management systems or mobile devices for communications, a facility can drastically reduce the amount of time it takes to respond to a wide range of urgent situations,” notes Micahele York, product marketing manager for Secure Care. “By using technology to help manage specific situations, a facility can free up its nurses and other caregivers to focus on providing care.”

Real-time location systems also can help stem aggressive behavior and prevent resident conflicts from occurring, says Syed Ahmed, senior living segment leader for Philips Aging and Caregiving. Systems can notify community staff when residents with past incidents are close to each other, or when one resident tries to enter the room of the other.

A complementing technology is video surveillance.

Aside from its obvious benefits, video monitoring also can vindicate a staff member when resident-on-resident violence occurs, observes Patricia Howell, RN BSN, WCC, CFCS, clinical support manager for McKesson Medical-Surgical Extended Care. Video surveillance, however, requires a great deal of privacy assurances and can give overworked caregivers a false sense of security, she warns.

Cybersecurity issues are on the rise, and facilities find themselves grappling with balancing their needs to protect their own operations against residents’ demands for online privacy.

“While cybersecurity historically hasn’t been a big area of concern for senior living, that’s changing as systems and technologies become more sophisticated and collect more data,” Webster says. “In some ways, the more advanced systems make senior living more of a target for data breaches and other attacks.” Webster and others believe assisted living rapidly is becoming an easy target for cybercriminals simply because the infrastructure needed to thwart them isn’t quite good enough. 

Patrick Hardy, LL.M. CEM, MEP, CRM, president of Hytropy, a continuity and disaster preparedness solutions provider, believes some cybersecurity vulnerabilities are self-inflicted.

“Many of the breaches we hear about today result from risky behaviors that employees are engaging in on the computer, such as opening phishing e-mails and accidentally providing passwords to cyber belligerents,” he says. “Employees need to be informed and trained on digital applications, and common ways that cyber criminals are accessing sensitive information.”

Balancing ACT

Still, senior living managers must continue to grapple with a host of weighty decisions when it comes to crossing the fine lines between independence and security.

“There are different security and privacy expectations in independent and assisted living,” says Laura Wasson, executive director of sales for Tech Electronics. “Residents in independent living would have to request a certain level of security. However, there is a fine line between providing the level of security a resident in assisted living needs to be safe while not invading their privacy.”

Owner-operators would do well to heed the advice of vendors that absorb many of the tech gripes residents volunteer during facility visits. “In addition to cameras, residents complain about obtrusive exit door lock systems with pin pads,” Ahmed says. “Seeing staff members use a code on the pin pad to unlock the door often makes residents feel trapped.”

Webster agrees. “The most common complaint I hear is that devices — whether wearable or mounted on a wall — just look too institutional,” he says. “Sometimes communities treat seniors like patients, and they really don’t want to be treated that way.”

Floor and mattress-based sensors can alert staff every time a resident leaves his or her bed to void to develop better protocols to treat incontinence, and imbedded sensors can analyze urine in toilets and saliva on toothbrushes to inform better decisions around diet and infection. But what if you’re the one whose bathroom habits are being analyzed?

Similarly, although video surveillance has become the new norm in facility common areas, different rules apply in more private areas, Webster cautions. Ahmed suggests facilities deploy location systems that achieve what video does in a less obtrusive way because they “allow staff to see the general location of a resident relative to a floor plan, without seeing a live visual of what the resident is doing.”

It’s easy to see why privacy issues are top of mind.

And with the cacophony of bells and whistles and beeps comes alarm fatigue, and false alarms — a dangerous condition in which both caregivers and seniors themselves become so jaded that they ignore, or worse, disable them.

In late 2016, serious privacy gaffes with video surveillance prompted the Centers for Medicare & Medicaid Services to develop stringent rules to protect resident privacy and prohibit photos and video/audio recordings without residents’ permission. Protections even extend to residents’ personal space and clinical records for covered facilities.

When a major healthcare tech vendor’s nurse consultant placed her mother in an assisted living memory care facility several years ago, “she lost her sense of modesty and our family’s peace of mind,” she said on condition of anonymity. Once, when left briefly unsupervised in an activity room with other residents, a caregiver returned to find the woman “with her hand down the front of the pants of the man sitting next to her, and his hand was over hers.”

In the end, attaining balance requires technology that is “thoughtfully deployed,” James Jansen, product manager for Direct Supply Technology Solutions, points out. 

“It needs to provide a joint benefit for residents and caregivers, typically in a discrete, non-threatening way,” he says. “The right mix of security technology changes depending on the location. In a public space, you’re providing safety measures for everyone.”

Jeremy Falke joined Dallas-based Capital Senior Living in early 2018 as senior vice president of human resources, having previously served in HR roles at Tenet Healthcare. He recently spoke to McKnight’s Senior Living about the role human resources plays in an organization and new developments at the company, which has 6,600 employees nationwide.

What originally attracted you to human resources?

I started my career in logistics and supply chain management and have more of a fiscal or analytical mind, but I love people. I had an opportunity early on in a small, national, startup hospital system. After about 100 days working in materials leadership, they asked me to lead HR, and I said OK. And then from there, I’ve learned two things that are really important to me, personally and professionally. One is that human resources is a space of the business that allows me a chance to leverage my spirit of servant leadership and just how much I care about people. And the second thing is, I want to be a part of a company that makes a positive impact in someone else’s life. Those two things keep me tied into HR.

How do workforce issues in the acute care setting compare with workforce issues in the senior living setting?

There are lots of similarities. Probably the most common when it comes to people is the continual search for people with that caring spirit, the “it” thing. The people who do the greatest in roles in a care setting are people who have some intrinsic motivation or mission spirit to care for others. The biggest difference is probably just the acuity level, and that impacts the folks that you need in your staffing mix.

Could talk a little bit about how success in the HR area affects overall company performance?

We are really privileged to be in a business where, when you take all the bricks and mortar away and you take all the pieces of the business away, it is literally one human being who’s caring for another human being who needs some level of care. The people are your business. So I’ve always been a really strong believer that the better we are at human resources, the better we’ll be at our mission of that one human being caring for another, and that company performance follows that. We’re really focused on creating an organization with the greatest consistency around pieces and programs and processes to engage our people across the company. In doing that, it both gives people additional benefit to be a part of the Capital Senior Living family and also gives us positive financial returns, whether it’s through expense savings through centralization or it’s just in the fact that we have great people who provide great care to our seniors, which drives our business forward.

Capital is one of 12 participants in a new, four-year, $12 million apprenticeship grant from the Department of Labor being administered through the Dallas County Community College District.

Yes. Over the four years of the grant, we’ll be helping to train 400 apprentices. We’re still working on the details, but apprentices may be on site at some of the local community colleges, with even more online education. The program will focus on CNAs, licensed practical and vocational nurses and registered nurses. It’s a full career ladder, from a dietary aide or a server who could work through the apprentice program and become a CNA and then from there move right into the next step of becoming an LPN or RN and all the way to wellness director or executive director. That’s something the Department of Labor is really excited about, too — getting people into higher living wage roles and improving entry level workers’ education and professional growth in the country.

We initially will start with current colleagues who are in roles, and then it’ll be a huge recruitment piece for us, too. All of the academic components will be funded through the grant, and we will provide the apprenticeships and that time and flexibility for them to be working for us in their current roles and also going through this educational program.

We’ll have the chance to leverage this program into several of the other states where we operate, and we’ll have the opportunity to show some of the other grant participants in acute care hospitals and health systems more about what senior living is and how it works. On the hospital side, people think of senior living as skilled nursing and that’s it. We’re having chances to talk about the differences in assisted living and independent living and the incredible quality of life and care that can happen in those communities at such a low cost. This also is a great opportunity for senior living to be around the table to talk about what CNAs look like in senior living — how they work, how they’re used, what competencies they need that might be different from a hospital. And the same thing with registered nurses.

In addition to this grant and the initiatives that will stem from that, what other initiatives has Capital Senior Living implemented in the area of human resources?

Our HR programs and processes are tied into our strategy of Stabilize, Invest, Nurture and Grow, or SING, and we’re starting to see a lot of very positive indicators of what that will do for our business. This is a very competitive labor market, so we are making sure we have an excellent benefits program that has a modern design and that is available to all benefit-eligible employees across the company. We’ve done a lot of work on that. In 2019, through August, we have increased our participation of our employees in our benefits plan by 40%. That’s something that I’m really proud about, because we’re creating a better life and better benefits for the colleagues that are part of our family.

With approximately 90% of its residents drawn from Ludlow and the surrounding area, the Mill 10 community “offers a compelling case study of how agencies and development teams can strategically employ preservation and adaptive reuse to help keep aging residents within their communities, contributing to continued positive economic impact,” says Michael Binette, architect with TAT in Chelsea, MA.

Opened on the building’s 110th anniversary in 2017, Residences at Mill 10 has 75 independent living units — 63 one-bed and 12 two-bed apartments. Fifty-one units are reserved for households with incomes at or below 60% of area media income, 15 are restricted to households with at or below 30% of AMI, eight qualify as project-based subsidized housing and nine units provide market-rate housing.

The estimated total cost of the project is $19.3 million, with much of that figure made possible by federal and state Low Income Housing and Historic Tax Credits, Binette says.

“The availability of these tax incentives goes a long way toward  making an affordable senior living project viable, and Residences at Mill 10 is a good example of why historic structures are a smart choice for this kind of use,” he says. 

Originally built in 1907, the four-story Mill 10 structure had fallen into decline in recent years and became the focus of preservation and renovation. Together with Winn Development and a team of architects, historic preservation consultants, engineers and contractors, the TAT team conducted an intensive rehabilitation of the former factory, replacing more than 280 single-pane windows with double-pane aluminum historic replicas.

Another major thrust in the renovation centered on carefully stripping hazardous materials, including decades’ worth of lead paint, and replacing hundreds of worn-down stair treads with old-growth Southern yellow pine lumber treads from another mill on the property.

Historic elements punctuate the entire property. For instance, all units feature wood flooring that complements the exposed wood beams and steel columns, giving a respectful nod to the building’s industrial past. The building also features a spacious common room and resident lounge with refurbished sawtooth skylights that transport natural light deep into the space, illuminating the exposed original brick, structure, decking and arched doorways.

Modern elements provide a contrast to the building’s historic character, including a fitness center, resident lounge, reading nook and computer lounge. Residents also have access to the adjacent re-established Riverwalk on the Chicopee River and co-location with commercial and retail businesses, a microbrewery and a rehabilitation hospital.

Because the building is landmarked on the National Park Service’s National Register of Historic Places, any renovation or restoration work must be completed to exacting standards of historic preservation, upheld both by the National Park Service and by the state’s historic commission. The Mill 10 project required close collaboration with the Massachusetts Historic Commission and the National Park Service, Binette says.

• Construction has started on the North Star Georgetown (TX) community for active adults age 55 and older. Located on a 12-acre site, North Star Georgetown will include 298,800 square feet of active adult living, including 210 resident apartments and community space.

• The Blake Management Group in Jackson, MS, is set to open three new communities — all between 90,000 and 110,000 square feet — expanding its regional footprint into Tennessee, South Carolina and Virginia simultaneously.

Inside:

• Opportunities ahead
• Here’s what I’m telling my members: Insights from the leaders of the National Investment Center for Seniors Housing & Care, the American Health Care Association / National Center for Assisted Living, LeadingAge and Argentum
• SNFs and PDPM, ready … or not?
• Yellen to be heard at NIC
• Middle muddle: Investors eye margins, developers explore affordable options
• Three tips to secure financing for a successful community turnaround