Lynne Katzmann, Ph.D., founded Bloomfield, NJ-based Juniper Communities 30 years ago. Today the company has 24 properties in four states and more than 1,600 employees. The CEO and president recently took time out of her busy schedule to share her thoughts about the past, present and future of senior housing. And worm farms.

Given that it is the 30th year for Juniper, could you talk about how the company began?

I was helping the board of directors at a small public company called Metrocare, and when we sold it, I left. I decided I wanted to start a fund that would invest in what I called “undermanaged” real estate, and we would not operate directly at the time. We wanted to work with small, mission-driven, regional operators. This was 1988.

The market was not enamored of our industry at that time, so raising a large fund was not happening for someone with a limited track record. So I went out and found a couple of properties and raised money around that. I raised it from a group of investors in small amounts. They were all angel investors, and most of those people remain part of Juniper today.

What worked for me — and I’ve told this story before — I learned a very powerful lesson about raising money early on, and about mission and about culture. And I learned it in a way that I never would’ve thought.

I was at the Bank of Boston, and by this point I had raised some of the equity and I was looking for debt for these two properties. And they took the meeting, I flew up to Boston, sat with them, and it was very clear early on in the meeting that they weren’t going to lend to us — or to anyone, for that matter, but there I was, making my little pitch.

And at the end of the meeting, there was a young associate there, a woman, and she turned to me as the meeting was breaking up and she said, ‘Why are you doing this?’ And I said, ‘Do you really want to know?’ And she said, ‘Yes.’ And I said, ‘Because I believe that we need to make the world for aging adults better, that what’s going on needs to improve, and if we can buy properties and improve the quality of life for people by working with smaller, quality operators, we can serve as a model for public policy. We can show that senior housing — at that time, it was only skilled nursing — is really a good option for many people.’

And I saw her transform during that discussion. To talk about doing well by doing good, people like purpose. People like believing in something, and if they believe you are true to your word and believe in it as well … I knew right then and there that if they had money to give, I would have gotten it.

And so as I started Juniper, it’s kind of like coming out. So I came out in my socially responsible self that I had been doing in many ways before in other areas, but the fact that you could be for-profit and improve lives really resonated with people. It didn’t resonate with everyone, but those with whom it resonated, you would form a relationship, a bond, and it works. And that was a really, really, really powerful lesson for me.

So the end result is that ever since that, we have been out about our commitment to doing well by doing good, and it’s been a focal point of not only what drives our company and our investors and our banking relations, our capital relations, but also with our team members. It has become the reference point of our culture, and everything revolves around it, the desire to create better lives for people while at the same time operating a successful business.

This was 1988. We started with skilled nursing. That’s all there was. And then in the early 1990s, we got into assisted living. Initially it was by converting a Section 8 housing building and an old hotel, both in Florida.

And then from there, we decided we would try design and construction. We built three buildings that are still really strong players today. And we built those to ‘green’ standards. There was no LEED at the time. We built to the city of Austin green building standards for the first building. We built to the city of Denver’s green building standards for the second, and then we did a LEED prototype for the third, in New Jersey.

And then a couple years later, we decided we couldn’t find enough small, quality regional operators, so we started our own operating company that’s been around now for almost 20 years.

How do you decide what areas to go into — product type and location?

Let me start with location. We were opportunistic.

When you’re looking for the right price opportunities, you need to take them where they are. And originally, because we weren’t operating ourselves, the different locations of our buildings didn’t matter as much. So we were in Connecticut, Massachusetts, Maine and then we went to Florida, Colorado and finally to Pennsylvania. it was more opportunistic than anything else.

Juniper’s model is based on two things: Our operating platform and our financial strategy. We buy properties in decent locations that are undermanaged. We buy them well, price-wise, and we use our equity. We often just buy with cash that we have and then refinance it out.

We can’t compete against a [real estate investment trust] except on mission, and in certain cases we have been the successful bidder because of who we are, but that’s rare. Generally, it’s price.

So we would go into properties and buy the property at a low price and then improve the operations, be able to refinance out cash and then reinvest that cash.

We have not raised any capital since 2002. Everything we buy now is via our own cash flow or internally generated equity.

You touched on the fact that 30 years ago, the industry was limited to skilled nursing. What are some of the other big ways that senior living and care has changed over the past 30 years?

The product type has changed dramatically. We went from skilled nursing to assisted living to memory care. Now we’re seeing more on the independent living side, and there’s more attention now in senior house being paid to the 55+ product line as well. So there has been a major shift there.

On the operating side, we have gone through a series of regulatory changes, initially on the skilled side and then, as assisted living has come into its own, some changes to begin to deal with the fact that assisted living now does provide care; it’s not a pure hospitality model.

I think the bigger operating changes, though, come in how one manages. Juniper has been a big proponent of electronic operating systems. In 2011, originally because of planned skilled nursing-related changes associated with the Affordable Care Act, we made the decision to go away from paper. We implemented an electronic health records system in 2012 across our entire portfolio. Our view was that if it came to skilled nursing, then it would be part of assisted living over time, and we wanted a single operating platform.

But even before we had an EHR system, we tracked all kinds of quality metrics on a regular basis. We have over a decade’s worth of quality metrics, everything from falls and psychotropics to marketing, sales, quality, clinical, demographics. We know what the trends have been and how they have changed over time in our portfolio. The EHR system makes it a little easier for us to continue to do that.

You alluded to rising acuity. You have tried to address the changing nature of assisted living and rising acuity levels through Connect4Life, staffing-related challenges through the 15×20 program and misconceptions about aging through the trip to Burning Man. What other efforts at Juniper do you think are unique or special?

I think our Green Canopy program is pretty cool. We were green before it was cool. We’ve been doing environmentally sustainable development for a very long time and had water efficiency and LED bulbs — actually they were CFL initially. We went through and changed everything from incandescent to CFL and now it’s LED. Recycling. We even considered worm farms at one point in time. I tried it at my house, and it was such a disaster that we didn’t do it. Being green was important.

And our training programs. We learned early on in associate satisfaction surveys that our associates were really hungry for learning. And so we developed a whole Juniper University around that, and that has served us very, very well.

What do you think the future holds for senior housing?

What’s happening now is monumental relative to the changes of the past. Going from skilled nursing to assisted living was a major shift in terms of consumer-driven and person-centered senior housing. Medicare and Medicaid essentially opened up skilled nursing for people without resources, and so much of what our industry has become has to do with the fact that people needed housing in addition to healthcare. And that whole idea is coming full circle, and that’s part of what my newest initiatives are working on, having service-enriched housing that support your needs, particularly as you age, and deals with chronic issues, which saves money.

The boomers are beginning to come to a point where they’re thinking about using senior housing. The industry is going to change in a number of ways: programming, communication — social media, the internet and other technology — and environment. And all of them, in my mind, are going to be to create an integrated community.

People don’t really want to live in tiny units. They want to live in a place that is not at the edge of town but that is integrated with the greater community. That can mean the greater community comes into the building and also that residents can go out. It’s a totally different model. The key word is integration — integration of care and services and housing, integration in programming with a model that is truly about continuing to experience life, which is not segregated, and an environment that supports that.

Those kind of changes are beginning. You can begin to see little pieces of those changes in the market already, and I think that evolution will continue.

I’m not sure what buildings will look like in 10 years. Senior housing is going to look very different, on a physical plant side, on a care versus non-care versus hospitality side, and on the programming side. We’re seeing a true shift in the industry occurring.

Owner-operators and their expert “engagement” partners both agree that ensuring their residents feel home again is a tall order compared to tending their health needs.

Some seniors may welcome the change, free of mortgages and yardwork and house chores while bursting with the luxuries of rest and recreation. Others are easily overwhelmed in a swirl of emotions and fear.

What makes seniors wilt when they become residents instead of homeowners?

The reasons vary surprisingly from one generation to the next. A common thread: They’re all insecure about something.

Stephea Scheurer-Melnyk, vice president of operations for Senior Living Culinary Group at Unidine, says fears in this population are very broad among the “traditionalists, boomers and Generation Xers” who comprise those they now serve.

“Traditionalists are concerned about personal and financial security, illness, injury and fear of being alone,” she observes. “Boomers share some of these concerns, but also desire to maintain independence and stimulation. Gen Xers face challenges with acknowledging they are indeed seniors now, and value customization and access to resources.”

For many, loss of mobility and strength, both physical and emotional, makes them feel vulnerable and unsure. “Outside of ‘tech-timidity,’ physical impairments play a factor,” notes Sarah Hoit, CEO and cofounder of Connected Living Inc. It’s no small irony that even as they are swimming in high technology, poor vision or hearing can make it difficult to use it, she adds.

“Seniors worry about the same things as everyone else, like how they look and will be perceived by others,” says Christopher Krauss, director of rehab for IN2L. Regardless of the core reason behind it, age often brings extra insecurities due to diminishing physical and cognitive abilities. “Some are just naturally apprehensive in groups, or maybe socially awkward by nature, and others could be upset, sad or generally unhappy about wherever they are now compared to where they were, or want to be.”

Far too often, new residents retreat toward a place of safe solitude. The visage of an aging woman sitting alone in a dining hall can be crushing, particularly to those who provide culinary services, like Tim Bouchard, senior vice president of operations for the Senior Living Culinary Group at Unidine.

“Many senior residents prefer to eat alone, as this was their practice before joining a community,” he says. “They fear changing their habits, especially when it comes to the ritual of meals. Some may view the dining room as a restaurant where you do not sit down and join whoever is at the table.”

The loss of independence can be as devastating as the loss of anything else — nearby friends and family, once good health, strength and agility. Last Thanksgiving, Laura Mock became the primary caregiver for her mother after she was placed on around-the-clock oxygen.

“She currently lives independently but her physical health is declining,” says Mock, a certified therapeutic recreation specialist and customer success manager for IN2L.

K4Connect CEO and co-founder Scott Moody says change can be difficult. “Even as children get older, they become more adverse to change themselves, an aversion that grows with time,” Moody says. “Just try to move a teenager from one school to another, or find yourself switching from an iPhone to an Android. We go along, but we’re not happy about it.”

APPROACHES THAT WORK

Every dedicated company serving senior living has its own secret sauce, its own unique and proven methods for coaxing seniors out of their shell and engaging with the community, and world at large. This is hard work, and not for amateurs. Yet they all share common sense approaches. Externally, those including Mock say facilitating family ties is critical, and “can be very helpful and reassuring.”

Internally, one successful exercise requires a thoughtful and meaningful getting acquainted period. Krauss says listening, empathizing, adapting and nurturing are key. A million questions burst forth in him that begin with “Who are you?” and end with “What fills your heart?”

THE POWER OF FOOD

One of the things that hospitality providers like Unidine and Sodexo have learned is the tremendous value of making new residents feel welcome. Think about the time you bought your first home and the neighbor next door brought brownies. Rob Bourgon, district manager for Sodexo, suggests bringing new residents a fruit and wine basket or flowers with a bottle of wine.

Sodexo Business Development Director Daniel Lucey points out that such gestures aren’t judged by grandeur, but sincerity.

“It can be as simple as bringing fresh flowers to residents, preparing a special meal for someone, providing comfort cards for families with sick loved ones, or even assisting residents with technology,” Lucey says. “There are more grand gestures such as holding a senior prom for residents to share the joy of the communities’ high school employees attending prom, providing a ‘chef stage center’ display cooking, providing vendor fairs showcasing local foods utilized in the community, or organizing a stop hunger drive for the less fortunate members in the community.”

Bourgon says withdrawn seniors’ eyes light up when the chef who prepared their meals pays a personal visit in the dining room. He also suggests courtesies such as inviting residents to participate in dining events like lifestyle food seminars and dietitian presentations that include chef prepared samples.

Bouchard suggests creating community tables in many dining rooms as a way to spark conversation, connection and inclusion.

At one Unidine client community, the dining service team established a monthly Food Club to help residents express their tastes and involve them in the creative culinary process, notes Scott Dahlin, senior district manager. “In the past, chef demos simply prepared food in front of the seniors but lacked engagement and hands-on involvement.” The effort paid off. How else can one explain “Build Your Own Pita Pizzas?”

TECH TOOLS

Its role in helping seniors feel engaged within and without is unmistakable, and the promises of technology in senior living have only now become partially fulfilled.

In a pilot with Hewlett-Packard and Brookdale, Connected Living gave tablets to 30 of the most “disconnected” seniors in one building. After using the devices for 14 days, those residents, who were not dressing, showering or socializing, lit up — actively using the CL program, on average, nine times a day. “The improved socialization increased compliance with hygiene, participation in community activities and decreased hospitalization,” Hoit says.

The possibilities are nearly endless, as evidenced by the following examples.

• Krauss recalls working with one severely withdrawn senior who rarely left her room and declined every invitation to engage in group activities. He knew she had an affinity for storytelling, particularly an experience she had with her siblings and her father when she was very young. “When she told her story she always told it with an energetic smile and she told it to anyone who would listen,” Krauss recalls. “In her story she spoke of how her father walked her and her brothers and sisters from their home near the beach a few blocks down to the water. At one point in her story I asked her, ‘Wouldn’t it be great to visit that spot again?’ Her eyes lit up as she asked, ‘Yeah. But how, that’s in New Jersey?’” When Krauss used the Google Earth app to show the woman her home town, all bets were off. “With that revelation, she was eagerly engaged, open and interested in interacting with me,” he adds.
• Mock remembers a retired Navy pilot who had become withdrawn in his assisted living quarters. Using the IN2L system, the elderly man was shown how to use a computer flight simulator, and he suddenly opened up to others in the community. “For the first time since he moved in, he was grinning from ear to ear and telling the staff about some of his memories from his flying days,” she says. The man eventually gave other residents virtual plane rides to their favorite destinations.
• After Mock showed Google Earth to one withdrawn resident, who had come to the U.S. from Germany decades ago with her husband, she started speaking in German as she pointed to the iN2L tablet screen. “I had to slow her down and ask her to take a deep breath so she could explain to me the places the iN2L slideshow was taking us,” Mock says. “We were able to see the park where they had their very first kiss! I don’t know about you, but when an 89-year-old can show you where she had her first kiss with her husband in a whole different country, that’s pretty powerful!”
• There are many stories about the emergency power of tech as well. Danielle Myers, general manager at Status Solutions, recalls one gentleman who couldn’t find cables from staff to jump a dead car battery. Using the company’s self-service tablet with its “communication and access to information everywhere” (CATIE) platform, the gentleman marshaled a slew of nearby residents, all gathering in the parking lot with their own cables in hand. Providers like Sara Hoit are quick to sing the praises the Internet of Things has produced. “Once a senior joins the online world, technology quickly becomes an integral part of their life,” she says.

But Hoit and others also emphasize the importance of using tech responsibly. That means not only being sensitive to privacy issues (Connected Living’s platform employs private social networking and informational groups), but mindfully showing both seniors and caregivers how to properly use it. The aim is to avoid dangers and mitigate the usual tech intimidation.

To that end, Connected Living employs guided learning tactics such as in-person or hand-over hand instruction, as well as remote support through virtual tech ambassadors. Its Connected Living University also provides online educational materials and video tutorials targeted to older users.

And to ensure the engagement possibilities are not missed by vision and mobility-challenged seniors, Connected Living recently added an Alexa option to its offering, so a senior can access, using their voice, community information and direct connections with friends and families along with the other features of the Alexa platform.

KEEPING TECH TETHERED?

No doubt tech’s place in senior living is permanent, yet evolving. “One of the greatest fears residents have is losing contact with the outside world. Technology and apps help them stay connected to friends and family members outside of their new home,” says Avery De Sostoa, business development executive for Sodexo Seniors.

And it continues spawning interesting relationships among the vendors themselves. For example, Connected Living’s app allows residents and their families in Sodexo client facilities to view all their meals ahead of time. The company uses another app called Bite, which is an extension of the community’s menu and includes everything from ingredients to nutritional value, De Sostoa says.

In the same breath, however, she is quick to emphasize the vital role human touch and human face-toface interaction play. Everyone agrees about the importance of keeping technology in the right perspective.

Says Connected Living’s Sarah Hoit: “The fear and apprehension we see among seniors when it comes to technology centers around confidence and education — that is, the perception of too much or too complex technology, feelings of inadequacy, lack of social interaction and communication and negative opinions of devices. Technologies aimed at seniors remind them they are old, and many are care- or health-related, which is why we feel our name and approach is so important.”

Krauss agrees. “For someone who is familiar with apps and technology, that can be a successful approach,” he says. “However, if an individual isn’t already comfortable with tech, throwing a tablet or computer at them, even if preloaded with apps and experiences they might like, could prove frustrating.”

Simply offering technology is another factor that can add to unfamiliarity and overwhelmed feelings if it’s not geared toward seniors to meet them on their level, observes Status Solutions’ Danielle Myers. “Conversely, when designed with seniors and their day-to-day lives in mind, introducing the right technology can be key to helping seniors feel engaged. Even integrations that may seem small, such as a built-in radio station that’s curated especially for them to play ‘oldies,’ or being able to send and receive pictures from friends and family, can make a big difference to a lonely senior.”

The end goal is overcoming solitude.

“One true fear people have at any age is that of being lonely,” says K4Connect’s Scott Moody. Over-reliance on apps is a very real risk today with any age group — particularly seniors, adds Moody, whose philosophy is focused on “digital inclusion to foster physical connection. To that end, we need only work hard to foster connection to family and friends outside the community, while being keenly focused on fostering connection across those living in the community.”

In spite of all this talk of social “engagement,” those who manage senior living communities would do well to remember there’s a little part in every senior that cherishes engagement in a private way that also allows for reflection and yes, “re-booting.”

“I see so many communities obsessed with getting people out of their rooms and participating in activities which sometimes are meaningful and engaging, yet too many times are almost demeaning,” says Jack York, president and co-founder of IN2L, whose tagline is “dignity through technology.”

“To me, meaningful engagement does not require attending activity programs, but only if the community invests in the experience to make it happen. I think technology can turn the narrative in a good way, but [the resident] should have the option to stay engaged in their own room, in their own space, if that is their preference,” York adds. “Maybe my perspective will change later in life, but for now, if I were in a community, I would much rather be ‘engaged’ in my own space — Skyping with my kids, listening to Springsteen, maybe a Stephen King book on tape, or watching my daughter sing over and over.”

Several factors are driving these predictions, including “highly stringent regulations governing disposal of medical waste” such as sharps and infectious and pathological waste, according to a recent Transparency Market Research report.

Senior living communities are considered small- to medium-sized medical waste generators, but they are still fully subject to the growing body of regulations and bureaucracy. Not knowing what to do, or how to do it properly, can cost big bucks.

Medical waste must be managed in accordance with myriad requirements established by federal, state and local governing bodies. Tracking, disposing and storing medical waste can be a confusing and complicated endeavor for already overworked operators, says Jan Harris, director of regulatory compliance with Sharps Compliance, a company that provides comprehensive waste management services.

“Clinical staff should be just that, clinical staff,” she says. “Having to figure out safest and most cost-effective management of waste, training, policies and regulations can take away from resident care.”

Indeed, the list of governing bodies alone is dizzying, even for a veteran administrator or director of nursing. The Centers for Medicare & Medicaid Services, Occupational Safety and Health Administration, Environmental Protection Agency, Centers for Disease Control and Prevention, U.S. Department of Transportation, state and county health departments and environmental agencies, and even the U.S. Postal Service all have a hand in how medical waste is handled, stored, disposed of and transported, although CMS regulations may not apply to senior living communities.

MANY MAESTROS

Harris, who has been working in medical waste compliance for more than 25 years, notes that when she works with skilled nursing facilities and senior living settings, she focuses first on regulations that apply to that building or campus.

“We need to know how to assist customers in compliance in all 50 states. We service customers from one location in one state, to those with 8,000 locations in all states as well as territories,” she says.

As one might imagine, compliance is a substantial concern, especially when it comes to infection prevention and control.

“What comes up a lot in senior living is the disposal of items that are put in isolation containers,” Harris says. “It’s not unusual for nurses and other direct care staff to put everything into the red bag, even medical waste that is not bio-hazardous.”

THE 15% MINORITY

Harris recounts a story of assessing a building for the first time and finding nine full tubs that were designated for medical waste.

“I went through all of it, and what started as nine 40-gallon tubs was reduced down to one-third of one tub of actual medical waste,” she says. “This demonstrates how much trash is thrown in that tub.”

If facility staff were educated about what medical waste is, “the senior living community would save a lot of time and money,” Harris explains.

In the hierarchy of medical waste, Harris says that most of what’s put in the red bag [a red-colored bag that holds bio-hazardous waste], is not actually bio-hazardous.

In fact, only 10% to 15% of waste in any facility is actual infectious waste, according to the World Health Organization, which says that of the total amount of waste generated by healthcare activities, about 85% of it is general, nonhazardous waste. The remaining 15% is considered hazardous material that may be infectious, toxic or radioactive.

OVERDOING IT

Staff might deposit everything — gowns, gloves, non-bloody dressings — into the red bag due to an overabundance of caution or because that bag is within closest reach of the caregiver, Harris says.

“That’s not necessary. Unless it’s bloody, it can be taken to the dumpster” she points out. “I’ve seen many [buildings] put everything that comes out of the isolation room into the red bag.”

In defense of direct care staff, Lisa Sweet, chief clinical officer for the National Association of Health Care Assistants, admits that CNAs may often toss gloves and protective gowns into the red bags for several reasons, the most prevalent of which relates directly to their jobs.

“A lot of it boils down to the fact that sometimes CNAs are stretched so thin that they take shortcuts in the direction of being overly cautious,” she says. “I’m sure there is probably a need for more education and retraining when it comes to knowledge of waste management. It really makes you realize how important it is to have adequate training and education,” she adds.

Sweet emphasizes that when a CNA provides hygiene for an incontinent resident, for example, “who may potentially have infectious waste or feces that could kill someone else such as C. diff [Clostridium difficile], it shows the extent of influence they have and the importance of their work.”

SUBJECTIVE CALLS

Research has found no epidemiologic evidence to indicate that traditional waste-disposal practices of healthcare facilities — whereby clinical and microbiological wastes were decontaminated on site before leaving the facility — have caused disease in either the healthcare setting or the general community. The CDC does note that the statement excludes sharps injuries sustained during or immediately after the delivery of patient / resident care before the sharp is discarded.

“Therefore, identifying wastes for which handling and disposal precautions are indicated is largely a matter of judgment about the relative risk of disease transmission, because no reasonable standards on which to base these determinations have been developed,” the CDC notes.

TRAINING AND EDUCATION

Harris explains that, in her experience within a hospital setting, the infection preventionist or IP department are also those responsible for medical waste management.

“Facilities don’t have that [yet] and so it’s sometimes more difficult to stay on top of education and training with regard to proper waste management,” she speculates. “In addition, the high turnover among staff adds to this complication.”

In an effort to alleviate this issue for clients, Sharps provides its clients with a training and education portal on its site. The trainings are aimed at helping staff put processes in place that will help to ensure better compliance, Harris notes.

CMS TRAINING COURSE

Not necessarily affecting stand-alone assisted living or memory care communities, all skilled nursing facilities soon should have infection control specialists in place, thanks to the CMS final rule on requirements of participation. The agency announced recently that it is collaborating with the CDC on the development of a training course on infection control and prevention for nursing home staff.

Slated to be available in spring 2019 as an online on-demand course, it will be free of charge, the agency said in a memo in March. It will take approximately 16 to 20 hours to complete and will include a certificate of completion following the online exam.

The announcement comes in the midst of the implementation of CMS’ new infection control and prevention requirements for skilled nursing facilities. The deadline to have them in place is November 2019.

Assisted living communities may benefit from the training as well and also should check with their state regulatory agencies to ensure they are in compliance with infection control policies in the states in which they operate.

“When caring for the elderly, skin-related issues can certainly present unique challenges, particularly in the hot summer months,” says Mitchell Manway, D.O., PGY-2, dermatology resident at Affiliated Dermatology. Those skin challenges can be compounded by many chronic illness and conditions, such as diabetes or vascular disease as well as certain medications that increase photosensitivity and dryness.

Proactive planning and proper care is essential for maintaining skin integrity and comfort. That involves assessing each resident’s specific risks, consistently applying the right products and ensuring proper care practices are adopted community wide.

A DELICATE BALANCE

A common caregiver mistake is assuming skin moisturizers aren’t necessary during hot months because of humidity and sweating; on the contrary, experts say excessive dryness is the most common skin problem seen in the elderly during summer. Not only does skin thin with age, oil production also diminishes, especially when skin is exposed to sun and heat.

“Air conditioning also is drying because it decreases the amount of water in the skin,” explains Peggy Brenner, MSN, RN, Northeastern regional director of nursing at Acts Retirement-Life Communities.

The same is true of overly hot water used during bathing, she adds: “This should be avoided because it can further dry skin and make it more susceptible to damage and irritation.”

Dry skin is not only uncomfortable, it can lead to eczema, rashes, excessive scratching, skin breakdown and subsequent infection. Yearlong, skin-care products that are free of dyes, perfumes and harsh detergents should be used. Daily moisturizing is prudent regardless of the season, but Manway recommends lighter lotions and creams instead of thick, barrier-restorative creams and ointments. Although heavy moisturizers commonly are used in cooler months, they can trap heat, cause sweat to accumulate and create a perfect environment for bacteria and yeast to grow when used in warmer months. Bacteria and yeast overgrowth most commonly are seen in skin folds where moisture from sweat more readily retained, such as underarms, underneath breasts, in-between digits or in leg or groin creases. These areas must be thoroughly cleaned and dried, and an absorbent antifungal powder can be applied twice daily, according to Adrienne Haughton, director of clinical & cosmetic dermatology at Stony Brook Medicine at Commack. “If that does not resolve or prevent infection, then a dermatologist should be seen for prescription medication,” she adds.

EXTRA PRECAUTIONS

Whenever residents will be outdoors or exposed to sunlight, liberal sunscreen use becomes critical to prevent skin damage.

“Sunburn causes ultraviolet damage to skin cells, resulting in thinning of the skin. This thinning may lead to bruising of the skin and increase the risk of developing skin cancer,” says Ellen Thompson, BSN, RN, CWS, wound and product specialist for Gentell Corp.

Sun overexposure also damages DNA, collagen, proteins and lipids, adds Dan Beecher, RN, BSN, WCC, account manager and clinical educator for DermaRite Industries.

Caregivers routinely should check for any medications being used that might have a sun-exposure contraindication. They also should observe for any adverse reactions to sun exposure or products used on skin to prevent over-exposure.

“Several medications can cause sun-induced skin reactions, [so] check prescription drug bottles. The label may have a warning to avoid excessive or prolonged sun exposure,” says Steven Antokal, RN, BSN, CWCN, CCCN, DAPWCA, director of clinical education for DermaRite Industries. He warns that sunburns can lead to blisters and open areas, and healing may be delayed or complicated for someone with an acute or chronic medical condition such as diabetes.

Applying a broad-spectrum sunscreen of at least SPF 30 to all exposed areas of the body — including hands, feet, chest, face and ears (which sometimes are overlooked) — is essential, and some physicians recommend an SPF of 50 or higher. Neil Brody, a board-certified dermatologist in Manhasset, NY, prefers a zinc-based sunscreen that contains antioxidants and comes in a spray bottle for easy application. The introduction of antioxidants has been critical, he says, because some of the molecules in sunscreen are injured by ultraviolet light, which can render the product ineffective and add to oxidative damage from sunlight. “Having an antioxidant present protects both the skin and the sunscreen,” he says.

For Acts Retirement-Life residents, Brenner recommends using a water-resistant sunscreen with zinc oxide or titanium dioxide. She also educates employees on the importance of liberal and frequent application — approximately one ounce (two tablespoons) that then is reapplied at least every two hours or immediately after swimming or at times of profuse sweating. To protect delicate skin on lips, she says SPF 30 lip balm should be applied frequently and immediately after drinking.

Full-body hydration plays a pivotal role in skin health and its especially crucial any time residents are outdoors. Not only does dehydration decrease skin elasticity, making the skin more fragile and increasing the risk of skin breakdown, it also affects residents with wounds. According to Eula Reynolds, RN, MSN, CWS, director of clinical education for DermaRite Industries, dehydration can decrease the amount of oxygen and nutrients being delivered to the wound site and affect the skin’s ability to heal.

“On average, an individual needs eight to 10 glasses of water to remain hydrated, and warm weather increases that demand for seniors,” Reynolds says.

RISK FACTORS

Caregivers should be aware of any constraints related to existing comorbidities that may limit fluid intake, Thompson adds. At Acts Retirement-Life Communities, hydration stations with fruit-infused water are strategically placed and easily accessible to all residents. Walks and other outdoor activities also are discouraged during prime time for sun and severe heat, typically between the hours of 10 a.m. and 4 p.m., Brenner says.

Proper attire plays a key role in sun-smart skin care. Brenner reminds employees, residents and their family members that lightweight, breathable cotton clothing is best in the summer because it is cooler, more comfortable and helps wick away moisture. Broad-brimmed hats that cover face, neck and ears offer additional protection from the sun and heat, and residents are encouraged to sit under umbrellas whenever possible.

CLOTHES CALL

Clothes should be changed as needed to prevent sweat accumulation, and skin should be observed and assessed throughout the day to proactively pinpoint irritation at its onset and prevent further skin damage. Incontinent residents are especially vulnerable to moisture-related skin irritation and require highly absorbent briefs and frequent changes to keep them dry. Acts Retirement-Life Communities recently trialed three new incontinence briefs, and Brenner says the difference in fluid absorption across the three products in the test pilot was surprising. Due to the successful pilot, a high-quality brief was selected that could hold a large amount of fluid. “This is so important, especially when we are encouraging more fluid intake,” she says.

Furnishing specialists have various ideas about how operators can make a splash with first-time visitors as well as create interior environments that provide comfort and safety.

“I think the ‘wow factor’ is created by the entire space, not just the furniture,” says Troy Rabbett, marketing manager for Flexsteel Industries. “However, seating plays a huge role in this experience. The ‘wow factor’ might be created by aesthetic interest or even by the implementation of a product with innovative technology such as USB ports, tablet tables or theater seating.”

Open Road President Carl Kennedy agrees that seating provides the biggest “wow factor” for interior décor.

“The lobby area is generally the first impression of a senior living community and its seating is the main attraction,” he says. “The style of seating, selected finishes and fabric can set the scene and mood for the entire facility. Seating is also where color and patterns can be incorporated to provide that ‘wow factor.’”

Although the lobby is the point of visitors’ initial contact, Sarah Wishau, design consultant for Direct Supply, says the lobby and dining room also provide a “high impact” view.

“The lobby needs to make a great impression as guests walk in. It’s important to have newer or stylish furniture that has stopping power and makes the space feel like home,” she says. “The dining room is also a big focus when showing prospective residents around, so consider having stylish, newer chairs that your residents will love and be comfortable in. It’s also important to have senior living-specific dining chairs; family members want to ensure that furnishings are ideal for seniors, and residents will appreciate easier ingress and egress.”

Melissa Lallas, national account manager for senior living at LG Electronics USA, says strategically placed flat-screen TVs in each common area and resident room “provide the same platform and linear look throughout the community, saving maintenance and IT teams from having to know multiple TV brands and configurations.”

Moreover, she says, using LG’s Electronics Pro:Centric server in each room provides community information, events, menus and local area information for residents and guests.

REGIONAL TASTES

From an aesthetic standpoint, furnishing specialists say styles and themes can make strong and appealing statements about the community. Interestingly, tastes are broad within the senior living industry, favoring a wide range of styles.

“We are seeing a lot of contemporary requests,” Rabbett says. “Things like quilted backs and tight, crisp upholstery with sled base legs. These are design elements that lend to a lighter look but are still engineered to meet the needs of properties and residents. Most of the trends we’re seeing are very heavily influenced by geography and climate, which dictate the type of aesthetic desired. However, functionality and comfort are expected to be a part of the product as well.”

In upscale senior living spaces, mid-century modern furniture has been a popular choice, Wishau says.

“It’s common right now in the residential and hospitality settings, but many other communities feature more of a transitional style,” she says. “It used to be more traditional with Queen Anne legs, but now it’s moving toward modern design.”

Geography plays a key role in design, Wishau agrees, because it conveys familiar images to residents.

“We do quite a few local artwork pieces for communities to help residents feel at home, and it can even evoke memories,” she says. “Using regional patterns in fabrics is big, too. You wouldn’t do a Southwestern design in the Northeast. Geography is a huge part of our design because it helps residents feel comfortable.”

‘HAVE IT ALL’

Form is important, but so is function when it comes to furnishings. Durability, sustainability and strategic placement are essential elements of a safe environment for residents, furnishing specialists say.

“Benches, statement chairs and upholstered items can be used to foster socialization or serve as a place for residents to comfortably sit while waiting for visitors or transportation,” Rabbett says. “These are not only beautiful additions to the aesthetics of a property but also serve a function.”

Wishau maintains that form and function need to be balanced equally.

“In the past, you had to choose between stylish and durable furniture, but now you don’t have to choose — you can have it all,” she says. “If you’re marketing toward residents, comfort and durability are big. Staff members also appreciate durable furniture that stands up to wear and tear. At the end of the day, the space is for the residents. When we design, we always have residents in mind, so it’s important the furnishings are comfortable and feature the proper dimensions for seniors.”

With regard to strategic placement, Kennedy says certain furnishings can be used in corridors to prevent falls.

“Tables and chair arms should be able to hold the extra weight of a senior who is walking through the halls and needs to use furniture for support,” he says. “Chairs are also included in corridors as a resting point for seniors. Common areas include a variety of seating options and seating arrangements that encourage interactions between residents and their guests.”

With the growing rate of obesity in the United States, bariatric-grade seating continues to be of importance in senior living communities, Kennedy says.

“Many furniture offerings, such as dining chairs, seating and benches, now come with a bariatric option,” he says. “It’s important that the style, fabric and finishes complement the other furnishings in the senior living community, but they should not stand out. Seating in public areas — dining, living, waiting and activity rooms — should all accommodate larger individuals.”

Selected finishes on seating and tables can help create a relaxing atmosphere — specifying seating for seniors to provide them with the most comfortable and safe experience, Kennedy says.

“For example, seating for seniors is higher from the floor than average, making it easier to sit and rise from the chairs and sofas,” he says.

“Arms on sofas and chairs should be full length from the front edge of the seat to the back to provide more support. Seniors also require a firm cushion and less depth in seating. Furniture should also be easy to clean, inhibiting the transfer of illness,” he adds.

TYING IT TOGETHER

Often overlooked in the interior design picture is the importance of flooring — especially for buildings under construction, says Jamie Thorn, national sales manager for Forbo

“Flooring is the last thing to be considered and is commonly sacrificed in the budget,” he says. “By the time you go over everything, lowbudget flooring goes in with the idea that it will be replaced later.”

Yet nothing takes as much wear and tear as the floor, Thorn says.

“Consider how much foot and wheel traffic the floor has to endure, especially in higher-acuity assisted living, skilled nursing and memory care,” he says. “In higher-acuity areas, your concern for function is more important than independent living, because the risk of falls is higher.”

Luxury vinyl tile and luxury vinyl plank are popular flooring alternatives to carpeting for senior living communities, Thorn says.

“Many facilities have gravitated toward it because they can’t keep the carpet clean, and this is easier,” he says. “Unfortunately, the product is noisy, it scratches and scuffs and gets sticky and slippery.”

Forbo is promoting its Flotex flock textile surface as a suitable alternative because it is designed to minimize sound, reduce slips and falls, and is durable and easy to clean.

“There is a place for carpet, but not in the high-acuity sector, because it absorbs liquids,” Thorn adds.

So first impressions are usually … impressive. But they also continue to dazzle with a classic water fountain, outdoor courtyard and garden, grand ballroom, theater, billiards room, library with fireplace and a mansion-like ambience throughout the common areas of the community.

With room for 117 independent living and 64 assisted living residents, Alamo Heights is the fifth Franklin Park community in the San Antonio area, a district that CEO Luke Classen concedes has become highly competitive. Attracting prospective residents requires a truly distinctive feature, and he believes Crescendo is it.

Offered through FLIK Hospitality Group, Crescendo is a food service program designed to elevate resident dining beyond the ordinary, says FLIK Division President Jack Silk.

“Today, elevated experiences with a restaurant-style approach are a must,” he says. “High-quality, white-glove service from the dining staff is no longer ‘nice to have,’ but a ‘need to have’ to remain competitive.”

Crescendo — an exclusive program for Franklin Park — is named after a musical term because its designers want to create “a symphony for the senses” with its special meals. Classen reasons that if décor’s purpose is to provide a sensory experience, then food service also should be a critical part of that environment.

“We know that dining is not what most companies dedicate extra resources to, so to beat the competition, we focused on the sensory experience of dining — what does the resident see, taste, smell and hear?” he says. “Food is the common denominator of all our services — if we get the food right, the rest falls into place.”

Professional chefs prepare the gourmet-level meals, and FLIK’s team of food service experts includes nutritionists and clinicians familiar with the special dietary requirements of each resident. FLIK’s food philosophy is to make all meals from scratch, sourcing sustainable ingredients from local purveyors, with “nothing out of a box or can,” Silk says. “This is a food-first approach. We operate restaurants inside senior living communities.”

Interior design serves as a platform for the elevated dining experience, as guests can relax on couches, have a cocktail at the bar and socialize in a comfortable atmosphere. It is precisely the type of experience baby boomers appreciate, Classen says.

“They may not be quite ready to move in yet, but they are key influencers on their parents’ decisions,” he says. “This is a generation who changed society, and they won’t be happy with meat and potatoes.

They want the best-of-class level of food.” In implementing Crescendo, Franklin Park wanted to make a good food program a great one that matches the high-class aspirations of its properties, Classen says.

“Our food service program wasn’t broken,” he insists. “We just wanted to make it exceptional and Crescendo does that.”

A: Here are three reasons:

1. The management function must now deal with a very complex business model. Due to senior consumer preferences and increasing acuity, the senior living continuum is blurred and subject to extensive overlap.
2. Third-party management companies are developing or acquiring increasingly complex resources. These resources include state-of-the-art software, systems and procedures, and sophisticated intellectual property.
3. Regulation and licensing issues are presenting future challenges. Management must strike a delicate balance between operating in an increasing regulatory environment, optimizing resident satisfaction and clinical excellence and avoiding litigation while dealing with increased resident acuity within a blurred, overlapping living continuum.

These three are just a sample. There are many more, including covering increasing costs and sustaining economies of scale.

Jim Moore is president of Moore Diversified Services Inc., a national senior housing and healthcare consulting firm based in Fort Worth, TX, that has been serving clients for 46 years. He has authored five books about senior living and healthcare, including Assisted Living Strategies for Changing Markets and Independent Living and CCRCs. Jim Moore can be reached at (817) 731-4266 or jimmoore@m-d-s.com.