Some, like Melinda Avila-Torio, associate managing interior designer for THW Inc., Atlanta, believe the sheer diversity among senior living residents makes it difficult to move people in a singular design direction.

“It’s difficult to say because ‘homelike’ means different things to many groups,” she says. “This can be different in socioeconomic, cultural, regional and vocation.”

Her colleague, Senior Design Architect Dustin Warmus, believes it’s sometimes not good to mess with what some residents see as perfection.

“The only time I would be concerned about taking the homelike theme too far is when the spaces do not take into consideration the needs of the senior residents living there, such as the furnishings not meeting the specific seat height, depth and firmness that we typically provide,” Warmus says. “That old comfortable recliner could be a real problem getting in and out of.”

In 2014, John Knox Village in Kansas City, MO, was hunkering down after weathering the housing and economic slump of 2007-2009. As with so many in senior living, occupancy levels were stalling and portions of the village were looking dated and out of step with the market, Vice President of Senior Living Maria Timberlake recalls. Surveying the landscape, it was readily apparent that a fresh coat of paint would accomplish little.

A bold plan was needed. One that reflected an infectious yearning among current and incoming clientele to be part of something bigger and vibrant.

In late April, Timberlake and staff unveiled their massive plan to the hundreds of residents and workers “on how we were going to redefine the living experience,” she recalls. “That meant not only major capital investment but a culture change toward more hospitality and a service excellence focus to meet the changing expectations of the people we serve.”

It was invigorating and rejuvenating.

A competitor’s grand opening a few years before showcased a spectacular community festooned with fine art, chandeliers and exquisite furnishings. Timberlake knew immediately what not to emulate. “I knew right away that, for the clients we’d been serving for decades here, pretty buildings alone weren’t going to cut it,” she says. She instructed the designers at Austin, TX-based StudioSix5 that John Knox’s new “neighborhood,” The Meadows, was not going to be a “frou-frou,” or fancy, community.

“When you elevate, you sometimes think you want to make it fancier,” she says. “Not us.” The Meadows had all the niceties, such as stone countertops, but furnishings alone weren’t going to define it.

Entire apartment buildings were either gutted or torn down. It looked more like a resort than anything that had come before. Seven restaurants — no longer called “dining halls” — each with their own special cuisine, staff and theme, as well as bars and pubs, dot the new independent living campus. Nearly every week, the city manager of nearby Lee’s Summit, MO eats lunch there.

One day, months after the project was completed, an elderly resident approached Timberlake. He and his wife had entered The Meadows fairly healthy months before but since had experienced serious issues.

“He looked at me and said, ‘You know Maria, when we moved here, it was so important to us to pick out just the right kind of granite and secure the best view, but now that we live here, the sense of community here is what really mattered, and we didn’t even know it at the time.’”

At the same time, some in the industry say the term “homelike” has become ambiguous. Like other buzz words, there’s a fear it’s being overused to the point of becoming meaningless.

“The term ‘homelike’ reminds me of processed cheese food product, which is only about 10 percent real cheese,” says Margaret Calkins, Ph.D., board chairwoman of the IDEAS Institute, which provides solutions designed to improve the lives of older adults through rigorous applied research.

“Some of the ‘homelike’ environments are also only about 10 percent real. I can work to help a care community create a setting where a person can feel ‘at home,’ but the organizational /operational aspects of the environment also have to support this approach.”

And although minions of incoming residents covet the hotel and hospitality look and feel in their soon-to-be senior living digs, no one is giving last rites to the comfort-food dining and homelike ambience that continues to characterize so much of today’s senior living inventory.

“It is so important to have visual cues, and the ambiance of home as skilled nursing built environments are so critical to the quality of life,” Avila-Torio observes.

“It is still important for the adult children to know that the visual cues of home will provide a smooth transition into the next level of care,” she adds.

Nowhere is that more evident than in memory care, where connections to the comforts of home are a critical component of therapy, according to Jacki Zumsteg, director of interior design for Invacare Interior Design.

Although assisted living and independent living communities are gravitating toward more hospitality features, many are finding residents still bring those mementos from home to create that “safe space” in their private rooms, says David Sullivan, business manager at Flexsteel Healthcare.

Although many small or rural communities still lean heavily toward homelike ambience, it’s common to see demand for “stunning new hospitality themes” in urban areas, says Jim McLain, general manager for the Eldercare Interiors division of Construction Specialties.

“Aesthetic choices for materials and finishes must be supported by high-quality selections that will not compromise safety, performance and durability for the long term,” he adds.

As tempting as it might seem to the untrained eye, most design experts and vendors believe owner-operators have shown remarkable and mostly tasteful restraint. Says Jamie Thorn, national sales manager for Forbo Flooring: “It’s all about allowing the resident to be comfortable. What do your focus groups or consumer surveys tell you?”

“No matter how attractive the design may be, for many seniors, it will never replace the home they left behind, where they raised their children and grandchildren and celebrated countless birthdays and holidays,” McLain says.

“There is no place like home, and today’s designers and owners are sensitive to this as they seek to create an attractive and welcoming design that will bring comfort, peace and a sense of belonging to the resident regardless of their commitment to a design theme,” McLain notes.

The lure of city life

New York’s New Jewish Homes’ communities are a perfect example of how embedded and successful the hospitality and hotel trends are. Recently, the organization opened a luxurious new short-term rehab facility and suite with beautiful contemporary design and some spa-like amenities.

“It’s more like the home you want to live in as compared to the one you remember,” quips James Dale, director of marketing and communications.

Although the comfort and familiarity of home always holds a special place in the hearts of most seniors, they are looking for their new home to be just that — new.

“Most of our residents want to have mementos from home in their rooms. But the reality is, they generally don’t want to bring much of anything else they consider ‘old,’” says Sandra Mundy, administrator of the Sarah Neuman in Westchester, a New Jewish Home community. “They want high-end, new furniture. They want something fresh and new.”

An avid proponent of the “small house” concept closely modeled after the Greenhouse project, Sarah Neuman is building a cluster of the facilities on its campus, each with a dining and commons hub with 13 apartments lining the outer rings.

It’s all a reflection of what makes today’s seniors different from their predecessors.

“The generation upon us now is more sophisticated. They travel more. They eat out more,” Mundy says. “My grandparents didn’t travel or go out to eat. The new ones coming on board don’t even want to think this is going to be their last home. Even if they know they’re not in a hotel, they want to feel like they are.”

In its most radical departure from the homey “small house,” Sarah Neuman’s latest completion hosts a commons that conjures the seating areas of places like the Plaza Hotel and Ritz Carlton. Couches are nowhere to be seen.

“We are seeing more and more benches, wingbacks and other lounge chairs and occasional tables designed in the mid-century modern style,” says Michael Zusman, CEO of Kwalu.

“In new builds and remodels, the trend is toward stylish spaces filled with seating and occasional tables that promote conversation and light dining — all designed to support an active lifestyle,” he adds.

Of course, some of the hospitality focus in senior living stems from the fact that more and more seniors are being discharged from hospitals earlier now into short-term, post-acute care, Calkins observes.

“People perform at their best when socially, emotionally and physically engaged. When we match personal interests and clinical intervention needs, we are more likely to make a connection that motivates people to work for longer and more thorough treatment sessions,” says Christopher Krause, OT/L, director of rehabilitation for It’s Never 2 Late.

More than ever, therapy providers recognize that the days of relying on standard or routine therapy techniques and modalities for all residents are a thing of the past. A one-size-fits-all approach no longer works in healthcare, as a whole, and in the long run is detrimental to the patient or resident, explains Tim O’Malley, president of EarlySense.

“Personalized care carefully assesses each patient and ensures the therapy meets their needs,” he says

Tapping the team

“When our therapists begin to work with a new patient, the first question they ask [is about their personal goals],” says Mary Van de Kamp, chief clinical officer at RehabCare. “The answers we get are not clinical answers. We often hear things like, ‘I want to be able to dance at my granddaughter’s wedding’ or ‘I want to be flexible enough to be able to play with my great-grandchild.’ ”

Many residents can verbalize specific goals and clearly communicate their hobbies, interests, personal preferences and occupational histories — critical information that can serve as a valuable motivator when creatively woven into therapy sessions. Those with cognitive and/or functional impairment, however, may struggle to provide that information, but their need for individualized care is no less diminished.

“Residents need their voices to be heard, and they need to know their opinions about things matter,” explains Lisa Milliken, MA, CCC-SLP, FNAP, educational specialist and ASHA CE administrator for Select Rehabilitation. The therapist often is the perfect person to listen, and when residents can’t speak for themselves, family members and the collective care team can help communicate for them so the best therapy approach can be determined. 

The interdisciplinary care team approach is essential not just within the walls of the senior living community, but also at different points in the care continuum. Stroke rehabilitation, for example, often involves healthcare professionals from several disciplines, because a stroke can affect many functions, including paralysis and weakness, gross and fine motor skills, speech and language, cognition, vision, and emotions, notes Liz Barlow, RN, senior director of quality for RehabCare.

Greater benefits

Computer-based technology is playing a greater role in rehabilitation, allowing therapists to reach residents in meaningful ways to improve motivation and session engagement.

“Therapists utilizing various computer technologies can do some amazing things that are not at all possible without the technology,” Krause says, adding that computer-based solutions can be especially reliable tools for engaging those with dementia and other forms of cognitive impairment. “By presenting various stimuli that may include pictures, videos, music, cognitive content and gradable activities that match each individual’s personal preferences, we find we’re reliably capable of reaching people at their level, in that moment.”

Technology also can help therapists find the most appropriate level of challenge for each resident. Tapping into a patient’s or resident’s intrinsic motivation is extremely powerful, but it’s often difficult to do, says Mark Evin, co-founder and CEO of Jintronix. “People are most energetic when they’re doing something that’s not too easy but not too hard, and there is a lot of clinical research to back this up,” he says. “Patients achieve their goals while family and friends cheer them on. They can see their loved one’s progress through the app and can send notes of encouragement,” says Jason Zachariah, president of Kindred Rehabilitation Services.

Physicians especially appreciate therapy providers who communicate progress and updates related to transitioning to the next level of care, adds Jodi Despoy, senior vice president of HealthPRO Heritage’s Senior Living Division. “Garnering the support of the physician is an element that will additionally strengthen the trust between resident and therapist.” n

Overall, the laundry operation is the nerve center of the senior living community. So much of the material that is critical to environmental hygiene and cleanliness is collected, processed and distributed properly and professionally. Still, laundry specialists say there is more senior living operators can do to optimize process improvement, enhance throughput and increase resident satisfaction.

“Generally speaking, I think laundries in senior living facilities do a quality job and are focused on delivering the best possible results,” notes Bill Brooks, North American sales manager for UniMac. Yet at the same time, he contends that “many managers are severely handicapped by equipment and system limitations. We are all expected to do more with less these days.”

What that means, Brooks says, is that “it is incumbent upon management to employ technology and systems to increase productivity, lower operating costs and maintain high levels of quality.” This is where the new generation of laundry management systems can help, providing over-dry prevention technology, high G-Force extraction and washer-extractor programming flexibility combined to achieve better results and efficiency.

To be sure, a vast amount of technology is available to increase productivity and efficiency in laundry room operations, agrees Nathan Gaubert, manager of research and new product development for Spartan Chemical Co. — so much so, it’s easy to get overwhelmed by it.

“Advances in laundry room equipment, from the machines to chemical dispensers, allow laundry room managers to track much more information about their operations than ever before,” he says. “You can monitor virtually everything that is going on with your laundry machines and the chemicals being used with the right equipment. Advances in radio frequency identification tracking can allow laundry operations to know where each piece of linen in a facility is located, when it was laundered, and even help with sorting.”

The biggest challenge to a laundry operation is providing clean, soft and fresh linen in a timely manner, Gaubert says.

“The soil loads and staining in senior living facilities can fluctuate greatly,” he says. “Some items are cleaned easily and quickly, while others are heavily soiled or stained and take a lot of effort to get clean. Proper, diligent sorting is the best way to ensure that your operation is maximizing throughput while maintaining high quality standards. Sorting items and doing necessary pre-treatments will help to prevent rewashing that decreases productivity, decreases linen life, and increases costs.”

‘At home’ feeling

Laundry operations have a direct effect on residents’ quality of life, not unlike caregiving and other support services. And the best way to contribute to that comfort and contentment is by providing residents with an “at home feeling,” Gaubert says.

“Providing your residents with soft, fresh and clean linen should be the number one job of your laundry operation, and it should show you care about their day-to-day quality of life,” he says. “No one wants to sleep on scratchy, rough sheets or eat on stained tablecloths.”

Indeed, “There’s nothing quite as pleasing as fresh, clean linens,” Brooks agrees. “In the senior living environment, this is especially true, where a freshly made bed can improve a resident’s mood.”

Similarly, quality processes in the laundry also ensure resident comfort by helping eliminate pressure ulcers – which can be caused be an inefficient rinsing that leaves chemical residue and high pH level in the linens, Brooks says.

“Having a high percentage of this condition often is a reflection of poor equipment or process breakdowns — undoubtedly contributing to a lower quality of life of these residents, he says.

When purchasing equipment, operators should consider the proper amount of throughput for their operation, determining which items are washed the most and which items are the hardest to wash. 

“You need equipment that can launder your toughest items but will not put a time burden on your operation,” Gaubert says. “The two biggest faults I see in senior living laundry operations is a lack of dryer capacity and trying to get by with household washing machines in the place of commercial or industrial-grade equipment.”

Washing residents’ personal items in a homestyle washer “is perfectly fine,” Gaubert says, but washing bed sheets, bed pads, diapers, table linens and other heavily soiled items requires an industrial-strength machine.

“For these jobs, a homestyle washer or washers, will not suffice,” he says. “The steps needed to ensure that these items are completely clean cannot be accomplished in a standard homestyle washer. Trying to adequately wash these heavily soiled items in homestyle washers often results in several rewashes, decreasing throughput, decreasing linen life and increasing costs.”

Using the right-sized dryer also is paramount for an effective, efficient laundry operation, Gaubert says.

“Undersized dryers, or even dryers that have the same rated capacity as its counterpart washer, can often take too long to dry the washed linen, creating a bottleneck in the wash process,” he says.

“Purchasing dryers that have a rated capacity 10% to 25% higher than your washers will help ensure that the drying times are the same, or ideally, shorter than your wash cycle times. This should help with throughput and prevent a bottleneck in your process,” he adds.

A programmable industrial or commercial-grade washing machine is best, Gaubert says. 

“These machines allow you to control all the variables in the laundry process to ensure that the linen comes out hygienically clean in as efficient of a cycle as possible,” he says. “This maintains or increases throughput, decreases the wear and tear of the linen, and lowers the overall cost of the load of laundry.”

UniMac’s Brooks concurs about the value of having the right equipment in laundry operations.

“Quite simply, the lowest-priced equipment often comes with the highest operating costs,” he says. “It’s important that managers understand the difference between price and cost.”

Process control

In the past, the laundry just operated with no real eye on whether it was running efficiently or even well, Brooks says.

“The only measurement was based solely on daily throughput with occasional quality reviews,” he says. “Today’s technology eliminates that data gap and gives detailed insight into operations. Some of today’s laundry management systems are able to keep managers up to date on operations virtually in real time and provide daily or weekly reports to share with management.” For senior living communities with multiple facilities, Brooks says reports can compare the facilities to identify which ones are operating well and which ones need improvement.

“It’s all about process control,” he says.

And it’s personal to Cheryl Field, chief product officer for Prime Care Technologies, a leading data warehouse and claims clearinghouse in long-term care.

Her company offers providers hosting, managed services and cloud software — the conduits needed to facilitate the exchange of vast amounts of data known collectively as the electronic health record.

The irony isn’t lost on Field, whose high-tech career stands in such deep contrast to her other job as custodian of a large, bulging manila file folder full of paper and compact discs, which she dutifully brings along while serving as driver and devoted companion for a loved one needing transportation to important healthcare appointments.

“If you’re not convinced where assisted living is with EHR, look no farther than the ambulance driver who takes that big manila folder with him every time there’s an emergency,” says Field, who unbegrudgingly carries that ever-growing paper folder in one hand and her relative’s hand in the other during each 100-plus mile drive to a hospital, doctor’s office or lab, and back to the assisted living community her loved one calls home.

Stakeholders in assisted living have long supported EHR, and all have varying degrees of patience. But as providers are quickly beginning to realize, EHR adoption is the new price of admission to a world that demands seamless transitions and accurate diagnoses. To turn a phrase, a world where everyone — from clinicians, caregivers and residents to information technology companies themselves — are all on the same digital page.

Slow but steady

As recently as a year ago, the National Study of Long-Term Care Providers concluded that more than 75% of assisted living communities were not using EHRs. Yet two years earlier, a survey of assisted living providers by LeadingAge and PointClickCare revealed almost half had invested in EHRs, compared with 80% adoption rates among skilled nursing providers.

For now, it’s safe to say, at least anecdotally, that assisted living owner-operators have received the message loud and clear.

For some, rising acuity levels are enough to push adoption, as Brett Meyers, M.D., vice president advisory services for Stratus Interoperable observes.

“I believe that the combination of increasing acuity in ALFs and other settings, along with truly mobile and portable record systems, is driving the need and adoption for electronic health records,” says Meyers, who also serves as a long-term/post-acute case business and clinical operations analyst. “It is increasingly important to have a clear understanding of a patient’s care plan and share it with staff and with clinical resources quickly when required.”

Other vendors say assisted living companies tend to be EHR converts when a compelling business case presents itself.

“The assisted living market is definitely seeing an increase of awareness regarding the necessity of technology tools to manage the increasingly complex assisted living environment,” says Trisha Cole, chief operating officer of Medtelligent. “This increase seems to be driven by the need for efficiency in operation.”

Prime Care Technologies’ Field senses that organizational heft and presence also is a factor in adoption. “The organizations that are part of larger entities are much more accepting and readily adopting because their business lines are attached to other parts of the post-acute care continuum, where they have seen how critical it is to have standardization of data,” she says. But among the smaller independents, “I don’t see them ramping up as quickly,” she  adds.

For those on the fence, it’s often a matter of underestimating the level of sweat and commitment needed to make an EHR work, according to Patrick Hart, who leads the senior living business unit for MatrixCare. Although many are convinced that an EHR platform is the path toward providing better care and measurable outcomes, “their hesitation lies in understanding the impact it will have on staff as they learn to document, while still being front and center with their residents and patients and providing care.”

“In short, there is very much a willingness to adopt, but not necessarily the experience or sophistication to do so fully,” adds Nickolo Villanueva, vice president of engineering and client services for vcpi. “In their rush to transition and adopt, it is often easy to overlook the requirements associated with such an endeavor. This includes the simple infrastructure transition, including devices, network connectivity, wireless and the security around proper implementation and management of this now critical service. Even more basic is the proper adoption of the processes around the use, retention, training and support of them.”

Needs less unique

With acuity levels rising in assisted living, there seems to be very little that makes their needs unique from skilled nursing.

“Many still want something that is easy to use and implement, offers affordability and is current technology,” says Hai Le, vice president of sales for BlueStrata EHR. “There may be some workflows that are specific to assisted living, such as the med-pass and assessments, but that is something most traditional SNF EHRs can accommodate.”

Of course, cloud computing has made cost even less of an issue, according to Meyers, who asserts that “current cloud offerings that run completely on a tablet and are implemented and trained in minutes instead of months make the use of EHRs more appealing.”

Priorities, meanwhile, are different from the skilled side for obvious reasons.

“Robust features are just as important,” Meyers says. “However, in that environment, the patient care plans revolve more around long term goals and quality of life and less on the measures of rehabilitation progress.”

Cole believes that although skilled nursing facilities need robust software as a gateway to receiving payments from the government and to being a preferred facility with a high star rating, “assisted living communities are not beholden to these same standards as they are predominately private-pay environments, so [they] are more motivated by the need to run a profitable and sustainable business.”

In sum, assisted living priorities can change as quickly as the level of acuity in their resident population, and thus, their priorities are an EHR solution that’s “extremely efficient and user friendly for staff while meeting each state’s specific requirements,” Cole adds.

The return on investment argument also is a bit different, says David Carter, LNHA, vice president of advisory services for Stratus Interoperable.

“Many are still using a manual system or a light version of an EHR compared to skilled care facilities,” he says. “Cost should not be an issue, since many facilities enjoy a higher margin than a nursing home.” And so, the ROI arguments usually revolve around issues such asimproved workflow, risk mitigation, justifiable service levels and the biggest one of all — improved overall resident care; Carter adds.

Although the level of sophistication EHR systems provide make it a simple ROI argument, it’s not always the case, Cole says.

“Generally speaking, paper and basic electronic software seems ‘good enough’ for most practices, and a large number of popular software providers fall short of addressing the workflow needs of assisted living communities, because many technologies were born out of skilled nursing, have rigid formatting based on federal regulations, and do not allow for flexibility assisted living requires,” she adds.

What’s the holdup?

Firms such as MatrixCare have compelling reasons for assisted living to invest: maximizing occupancy and profitability, improving care and minimizing risk.

And firms such as CareMerge tout things such as improved resident engagement, seamless reporting, more accurate assessments and lower staff turnover.

So why are some still holding back?

One compelling reason: They aren’t required to. Yet.

Although operators can more easily leverage cash flow, many operators still struggle with all the myriad costs, Villanueva says.

Prime Care Technologies recently partnered with the National Center for Assisted Living to develop the AL Cost Calculator, which allows providers to assess how costs are allocated across residents. It’s no surprise EHR costs are front and center, Field says.

“I think it’s harder for independent operators to take on the expense to have electronic health records,” she says. “The intent of it was to help them understand the overall cost of getting into EHR and help some of those sites that haven’t yet fully embraced EHR through alternative means.”

According to Doron Gutkind, chief software architect for Lintech, two key issues are the main reason holdouts still exist among the assisted living community.

One is the lack of standardization. “Over the years, most facilities have developed their own internal set of unique assessments and care plans,” he says. “The lack of any industry-wide standards for assessments and care plans, and the resistance of staff to change, has caused frustration to staff and a ‘tendency’ to remain paper-driven.”

The other barrier is variations in levels of care. “Assisted living facilities currently serve residents with a wide spectrum of needs and levels of care,” Gutkind adds.

“These range from residents who function mostly independently to residents who require some assistance with most of their daily activities.”

Interoperability

There is no doubt that EHRs will be broadly embraced and implemented in this ever-changing business called assisted living.

The biggest hurdle of all remains interoperability, Field says. “From a security perspective, interoperability becomes an issue on technical standards and practice,” she says. “It is a challenge and remains so. I think we’re about five to 10 years out from being fully interoperable across the continuum.”

That’s not to say the industry can’t take the requisite baby steps to get there.

“For now, we just need to find ways to modernize that manila folder,” Field says. “We’re trying to solve some of those interoperability issues one customer at a time.” n

Seriously — they have a tugboat. It forms the centerpiece of the community’s memory care courtyard and has a connection to the locale and to Aegis CEO Dwayne Clark.

The Norene has sailed the waters of Washington’s Puget Sound for the better part of a century and amazingly is still active today after an extensive renovation. It is the namesake of Clark’s mother-in-law, Norene Ott, whose father worked on the boat more than 80 years ago.

“He was a man of the sea and loved the water,” Clark says. “My mother-in-law lives near the community and was surprised and happy to see the boat in our courtyard.”

Because the “real” Norene is still navigating the waters of Puget Sound, the Aegis boat comes from Minnesota, where it had been in drydock after years of sailing the Great Lakes. Placed onto a flatbed truck and shipped to Seattle, the new Norene landed in its resting spot after being offloaded by a crane.

The tugboat — as novel as it is — is just part of the waterfront theme at Aegis Living of West Seattle, which has the capacity for 50 assisted living and 33 memory care residents. Incorporating a sapphire blue and soft white color palette, the two-story entrance hall features blown glass chandeliers, sunbaked stone and décor inspired by the blue ocean water. Ocean-themed artwork and pottery from seafaring Mediterranean ports of Capri and Mallorca are prominently showcased.

Other noteworthy aspects of the Puget Sound-inspired design include a salt-water aquarium shaped like a submarine so that residents can feel as if they are looking out of a sub’s portals; water tanks containing live jellyfish in the main lobby; a movie theater shaped like a ship’s bow; an Admiral’s Lounge that features a ship’s wheel and other nautical memorabilia; and blown-glass depictions of 33 squid in a glass case.

One of Clark’s favorite segments is a rooftop bar that sports nine flat-screen TVs and a huge fire pit. It includes cameras that take live shots of the cityscape, so patrons can get a panoramic view from the figurative crow’s nest.

As a serious student of architectural design, Clark enjoys devising themes for each Aegis community. For instance, others are modeled after Seattle’s Pike Street Fish Market and the popular Downton Abbey television show.

Grand openings are special occasions, in which special celebrity guests, such as Linda Evans and Loni Anderson, take part in the festivities.

“It’s our disruptive thinking that leads us down this path,” he says.

A: There are many. Here are just three achievable priorities to address:

1. Revenue enhancements – For many, stabilized occupancies have dropped from 90% to as low as the 85% range. The good news is that even with lower occupancy, many owner-operators have covered their fixed and variable costs. That means that if these owners can achieve relatively modest occupancy increases over the next few months, many could experience substantial increases in operating profit margins and cash flow.
2. Operating expense reductions – A typical 180-unit life plan community – also called a continuing care retirement community – at 89% occupancy currently will experience approximately 58,470 resident-days (180 units x .89 x 365 days).  For simplicity, this excludes considerable second-person occupancy. Operating expenses for this life plan community likely will be approximately $130 per resident-day (PRD).  =With just a 3% reduction in operating expenses to $126 PRD allocated over the 58,470 annual resident-days, this would result in an annual cash flow increase of more than $233,000. 
3. The challenge of achieving at least 2.5% to 3% increased net operating income spread – Simply stated, many experienced operators ideally try to sustain at least a 2.5% to 3% positive annual net operating income by reducing their operating expenses versus achieving modest revenue increases for mature, stabilized properties. The best way to achieve and sustain this favorable spread is paying very detailed attention to the aforementioned item No. 1 and No. 2.

The key survival strategy for the remainder of 2018 and beyond is: Focus on basic fundamentals.

Q: You’ve been with Capital Senior Living for 21 years, 19 as CEO. What are the accomplishments during that time of which you are most proud?

A: I’m most proud of the team we’ve developed. Our caregivers, our staff and the regional corporate staff do such a fine job and serve the residents so well. We score 95% or greater in resident satisfaction. It’s been an honor to have led this company and our dedicated team of employees.

Q: How has Capital Senior Living changed over the years?

A: When I joined Capital, it was a small company. Back in 1996, 75% to 80% of our properties, maybe even more, were independent living. Today, 60% of our residents live in assisted living and memory care, and 40% live in independent living. The age of the resident has probably increased by a decade from when we started back in 1996.

We were developing properties and stopped development in 1999. We navigated through another rough patch in the industry with overbuilding in the late 1990s and were able to develop great institutional relationships with strong financial partners that helped us build our portfolio and our balance sheet and eventually allowed us to monetize real estate investments to start to have the ability to be the owner of real estate.

The capital structure with the ownership of the real estate has continued to deliver very attractive returns to our company and has allowed us to invest in people and technology and systems to provide excellent care to our residents. We’re now one of the largest owners in the country, as a percentage of our portfolio, and we also transformed the service levels of care we deliver to our residents to meet the needs of an aging population that we’re serving.

Today, there’s a much greater level of sophistication in the approach of the industry. I think we’re at this inflection point where, going forward, the senior housing industry will play a much more important role in the whole healthcare continuum.

Q: You mentioned a period of overbuilding in the 1990s, similar to what’s going on now. What were the lessons learned from that time?

A: One of the lessons learned for the industry is that owning real estate gives us equity and access to cash to weather difficult times. As we came out of that difficult period, and as our operations improved and the real estate values increased, we were able to rebuy or monetize again the real estate at very high returns, which gave us a much strong balance sheet.

It was the cash from those transactions that ultimately allowed us to seed the equity investment in the $960 million or so of real estate we’ve acquired over the past eight years. We’ve increased our ownership from 25 buildings in 2010 to the 83 communities that we own today.

Capital Senior Living developed back then, so we were also impacted by slow lease-ups that were costing us money. A lesson learned was that we no longer develop.

Other lessons learned are to be patient, to manage expenses well and that this industry has always been resilient. It recovered from the overbuilding of the late 1990s. It recovered from the 2008-2010 recession and the housing downturn, and it’s always rebounded much stronger than it had been prior to a downturn.

Q: Capital Senior Living and other operators face many challenges right now. What do you think are the biggest ones?

A: I think the industry’s challenges today are dealing with work competition, dealing with labor shortages in parts of the country, and increases in wages.

Capital Senior Living has very focused action plans, and the vast majority of our properties still perform at a very high level. We’re implementing a lot of initiatives to continue to improve our delivery of care and services, including moving toward a more centralized operating platform.

Q: What does the future hold for you?

A: I will continue to lead the company for the balance of the year, and then I will be available as a consultant after that. I hope to enjoy some time in retirement and pursue personal and other business interests at the same time.