Unwilling to tempt fate again, the facility soon invested in new real-time location system (RTLS) technology — in this case a bracelet with an emergency call button — to replace the 95-year-old facility’s call bell system on nine linked alarms activated by pull chain.

Whether senior living residents fall or amble off during the day or at night, by accident or on purpose, their unmonitored and untethered movements are the stuff of restless evenings for so many administrators and directors today.

But thanks to RTLS and a host of innovative technology, from invisible sensors to radio frequency tags, the issue of elopement now has the potential of being a thing of the past.

“Safety and security have always been top priorities in the long-term care setting,” says James Jansen, product manager for Direct Supply Technology Solutions. “But with recent local and global events, more diagnoses of dementia and the reality of ongoing staffing challenges, security has become even more top of mind. There is also more visibility into and exposure of safety risks and breaches than ever before.”

Still, wandering remains high on the list of greatest risks in so many communities, particularly as more and more seniors fall victim to dementia. Even those without such a diagnosis can easily become agitated and confused under adverse conditions.

Memory care inspired

Approximately 60% of older adults with dementia are wandering candidates, according to the Alzheimer’s Association.

Paul Larson, vice president of new product development and engineering services at RF Technologies, believes some of the most significant innovations have sprung specifically out of the memory care industry. “Memory care has seen huge advances in safety,” Larson says. “Fully monitored solutions utilizing discrete wireless transmitters help ensure that patients with dementia or memory loss don’t elope from the community. Coverage of defined outdoor spaces now is relatively easy to achieve, and global positioning system (GPS)-enhanced solutions are one of the most significant game-changers that we see coming soon.”

Incubators in play

Engineers have been busy innovating the past few years, thanks in large part to the Internet of Things. Real-time locations, for example, is made possible because of the integration of GPS tech online.

“The senior living market has gone through a tremendous evolution in the last decade, and care communities are partnering more and more with technology companies to deliver safety and security for their residents,” adds Larson, pointing to innovations such as the wireless call pendants.

Perhaps one of the biggest incubators in senior living is the Evangelical Lutheran Good Samaritan Society, the nation’s largest not-for-profit provider of senior care services. For many years, vendors have sought out the organization (and vice versa) to test emerging technologies and, in some cases, try ideas that sprouted from inside the walls of the organization itself.

“We take on an incubator role often. It’s an interesting dance,” says Kelly Soyland, director of innovation and research, and the organization’s Vivo: Innovation for Well-being Center. The organization has long worked with various vendors, from well-known brands to startups. A major project underway at press time involved activity monitoring and wearables. Soyland says the Society has been on a remote monitoring path for more than a decade, beginning at the University of Virginia Medical Automation Research Center. Ultimately, Soyland is hopeful its work will generate federal funding for remote monitoring.

“Safety and security solutions for senior living have certainly come a long way, taking advantage of a range of new technologies,” says Steve Elder, senior marketing manager for Stanley Healthcare, which markets the RTLS device Wales Home uses. 

Elder points to three recent developments along wandering tech’s evolutionary path: mobile protection (“a far cry from the days of fixed call stations”); customized protection, which stores and analyzes movements and behaviors to shape staff awareness and allows, for example, “access to areas like an enclosed Alzheimer’s garden at certain times of the day but not others”; and tech integration, which allows things such as e-call and nurse call, wander management, fall monitors, access control and fire panels to be consolidated into a single system for easier management and reporting purposes — in most cases, via mobile phones.

Fuzzy robots, anyone?

The past several years have been a watershed in wandering tech. Recent innovations have been so effective, they have arguably hastened the drastic reduction in the use of antipsychotics while exposing some of the drawbacks of “old-school” solutions such as door alarms, restraints and even video cameras.

As Centrak Marketing Coordinator Josette Weinstein argues in a recent case study, video surveillance now permitted in assisted living facilities in six states is an outdated technology. “Unless you have a staff member watching camera feeds 24/7, it’s impossible to know in real time when hazardous situations are occurring,” Weinstein says. Centrak provides RTLS solutions.

Even as innovation continues briskly, there seems to be no end to the kinds of gadgets and gizmos — some of them quirky but effective — that are flooding the market. Among them are GPS-enabled shoes, a fuzzy robotic pet designed to ease dementia-fueled anxiety and a quarter-sized radio frequency identification button a teenager recently patented in the course of his mission to find a cure for Alzheimer’s disease.

Invisible motion sensors

Back in the year 2000, the elderly mother of Marilyn Rantz, Ph.D., RN, FAAN, fell in her home. For eight agonizing hours, the woman lay on the floor unable to move, suffering from a shoulder fractured in 13 places as she looked frustratingly at a wearable “911” alert pendant necklace she had removed and placed on a table earlier in the day. 

The event was an epiphany for Rantz, a University of Missouri professor who spent the next 16 years studying, researching and developing a plethora of remote sensor technologies to measure gait, behaviors and movements of all kinds. Earlier this year, Rantz and her team successfully proved their sensors that are embedded in the floors, beds, walls and furniture in seniors’ own homes could reliably predict falls with an 85% certainty. The Aging in Place Project also has been able to demonstrate a doubling of the length of stay with RN care coordination and another doubling with the sensor technology developed over the years.

Emergency mindset

As treacherous as the outside world is, wandering inside the walls of a secure facility can be fraught with danger, and information tech companies have been busy developing solutions that monitor and track practically every movement a resident makes. Some of the solutions employ visible, wearable tech. Others are practically invisible.

“CMS is always looking for ways to keep residents safer than just making sure they’re not wandering around outside the facility, says Maayan Wenderow, director of marketing for EarlySense Inc., which markets a continuous patient monitoring solution.

Wandering management today has evolved, in part, by adopting many of the techniques used in healthcare emergency preparedness, which uses a system of drills and sophisticated information technology to achieve around-the-clock situational awareness.

“I think the most important thing is increased awareness around the safety risks,” Wenderow says. “Most facilities have initiatives and protocols in place to assist with fall prevention, pressure ulcer prevention and wandering residents.”

One popular method is the Situation, Background, Assessment and Recommendation (SBAR) Toolkit, adapted from the U.S. Navy by Kaiser Permanente. “SBAR is an effective and efficient way to communicate important information and is used by the nursing team to communicate clinical information about a resident’s status to a physician or a nurse practitioner,” Wenderow adds.

“All new construction projects include some form of safety solution between wander management, access control and video surveillance,” Jansen says. “We also see more of our customers with existing communities looking to upgrade their current technology as the quality of offerings improve and become more financially attainable.”

The biggest benefit from today’s offerings is the ability to customize technology to fit individual residents. “Facilities can create system configurations that are specific to their needs and the needs of their residents,” says Brad Hyder, marketing manager for TekTone Sound and Signal Manufacturing Inc. “For most facilities, that includes providing the patient with the ability to initiate the call when they know that they need help. Facilities with wander management systems also maintain the flexibility to allow residents to wander freely throughout the facility while creating alerts for doors or hallways that may put the resident at risk.”

Adds Larson, “Technology plays a huge role in improving safety measures, and the level of monitoring is generally very flexible. For instance, most call pendants and wander transmitters don’t track residents unless the system has been activated. If a resident pushes their pendant button for assistance in the day room, an alarm with their identification and location will be created in the software. In another case, a memory care patient wearing a transmitter may attempt to exit through a monitored door or may loiter near a door. With a wander management system configured with ID, an alarm would be generated with the resident’s ID and the location of the alarm event.”

Larson predicts sensor-based solutions may one day become so sophisticated that they could generate predictive alerts on changes in residents’ abilities to perform activities of daily living.

The personal touch

No matter how sophisticated the technology gets, the “man or woman behind the curtain” still will be a critical part of the solution. As Wenderow asserts, “technology is only a tool in the hand of the clinicians, and to achieve safety goals, there needs to be a cultural change and teams have to work together to accomplish it.”

“It’s impossible for staff members to watch over every individual all the time, but technology can,” Elder adds. “Our philosophy has always been that it is aware and engaged caregivers who keep residents safe.”

Laura Wasson, director of business development for Tech Electronics, believes technology is one solution that works in tandem with staff to ensure resident safety. Still, “the staff is responsible for caring for multiple residents at a time, leaving room for human error,” she says. “Technology is constant.”

“The average out-of-court settlement for a wandering lawsuit is $400,000, so staff members play a particularly vital role in protecting the residents that they care for,” Hyder adds. “Technology is absolutely essential to providing resident safety, but staff members must remain ever attentive.”

“The now often-used phrase of “see something, say something” never has been more important than in the realm of resident wandering and elopement,” Jansen says. “Staff engagement is absolutely essential in creating and sustaining a truly safe environment.” 

But furnishing a community goes beyond the initial encounter. That same “wow” factor also should extend into resident rooms, dining areas, corridors, outdoor areas and even utility rooms. Furnishings also should provide more than aesthetic appeal, manufacturers say.

For instance, Anna England-Chaney, designer for Flexsteel Industries, says her approach is to incorporate a “cross-application” between form and function.

“Beautiful furniture is always important, but consideration should always be made to construction,” she says. “Three great questions to ask are: What’s safe? What’s durable? And most importantly, will residents be comfortable?”

As long-term care facilities have become more hospitality-oriented with independent and assisted living models, the role of furniture has taken on a much more prominent role in the décor and as an amenity for residents looking for relaxation and comfort. Andrew Christmann, marketing manager for Hekman Contract, says manufacturers serving the healthcare and hospitality markets tend to focus on making products for group usage, but that doesn’t mean they don’t take individuals’ needs seriously, either.

“The needs and wants differ greatly from one person to another,” he says. “The challenge and fun part of our role is to develop and introduce products that meet the needs of a larger swath of the population, then work on identifying the ever-changing solutions to be in harmony with senior residents’ individual needs.”

The contemporary movement toward person-centered care in senior living has motivated furniture suppliers to transition away from stereotypical, commercial-looking designs and toward creating an at-home experience, says Dean Jarrett, director of marketing for H Contract.

“The homelike environment helps ease the transition from living independently for many residents,” he says. “The furniture also has to be functional, in addition to achieving the right look. Manufacturers need to provide the residential styling, while also delivering durable products with value-added features required in the senior living marketplace.”

Common areas — foyers, lounges, dining areas and meeting rooms — are where furnishings are most visible and where the most pieces are required. Fully furnished common areas typically will have chairs, sofas, recliners, benches, pillows and tables, as well as lamps and other lighting fixtures. Besides beds, resident rooms need chairs, tables and case goods. Office areas need desks, chairs and tables.

At Flexsteel, England-Chaney says the company takes a holistic view of the facility in its commercial approach.

“For us, there is an equal balance placed on resident rooms and public spaces,” she says. “Since so many of today’s senior and assisted living centers focus heavily on community and interaction, we design to ensure that the comfort and durability residents experience in their private spaces is just as present in the public spaces. This means designing furniture that not only is beautiful to look at but also is easy for residents, caregivers and family members to use.”

Christmann says that if there’s one room where the “wow” factor is essential, it’s the dining area.

“Dining room furniture is a very important piece of it,” he says. “How potential residents will be fed is paramount for decision-makers. Making an impression with the dining room speaks volumes, both positively and negatively, to prospective residents.”

Fashion is fickle by nature, and what’s “in” for a time also can go “out” in a flash. The worst furnishing faux pas is to purchase a style that looks dated after a short time. To avoid falling into a “trendy trap,” manufacturers say facility operators should trust the design staff’s sensibilities on the issue.

“We don’t view this as a ‘trendy trap,’ but rather the evolution of senior living,” Christmann says. “It seems that the current style is very hospitality-oriented with specific healthcare properties. The biggest considerations a facility operator should make when furnishing a new development is to stay aesthetically relevant and functionally sound.  Never compromise the performance of senior living furniture for a less expensive but very stylish piece of furniture. It is up to manufacturers to anticipate the trends and provide quality, lasting products that satisfy aesthetics and function.”

John Martin, founder of Martin’s Chair, says the traditional style is perfect for senior living communities because it gives residents a feeling of being at home and offers them a sense of ownership.

“These people often have a history and a story and would like to feel as if the surrounding area does, too,” he says. “Furniture and furnishings can help with this. Most would prefer this over more modern furniture or the furniture that reflects the vision and decision of an interior designer they don’t know. Also, when made properly, traditional and even Early American- style wood furniture rarely goes out of style.”

When considering the design, form and function of a room, it is important to include walls and floors in the equation. Although not considered furnishings in a conventional sense, wall treatments and flooring options complete any room’s design scheme, industry stakeholders point out.

“Identifying the right type of floor covering is essential to creating that great first impression for visitors and prospects,” says Bob Bethel, director of business development for education and healthcare at J+J Flooring Group. “The right floor covering can help set the tone for the design and functionality of the space, so it’s critical to know who will occupy the space and how that space is being used. Naturally, a soft-surface flooring can greatly contribute to a sense of home. A soft-surface product, such as carpet or textile composite flooring, adds an enhanced level of warmth, comfort and noise reduction to create a quieter and more calming living environment.”

With regard to flooring, facility operators also should be mindful of other associated costs that can be unforeseen, such as slip-and-fall injuries. To reduce potential slip-and-fall events, operators should consider a flooring that is both slip-resistant and helps reduce noise in a space, Bethel says. 

“Should they occur, falls can be less severe on a soft surface versus a hard surface, as a soft surface is better at absorbing the impact of a person’s fall,” he says. 

“With a less severe fall, residents and patients spend less time recovering, reducing any medical expenses related to that recovery. Perhaps more importantly, it means people are back doing the activities they were doing before the fall.”

Wall coverings have advanced to provide bright aesthetic qualities to a room’s look as well as providing more durability than paint, says Clarence Porch, director of national accounts for Koroseal.

“Wall coverings can be tailored to a facility’s level of care,” he says. “There are a variety of colors, patterns and designs, and the durability is strong enough to resist scuffs, scratches and chips.”

Digital printing allows facilities to apply custom designs and patterns to the walls, and templates enable sections to be replaced with no discernable difference, he says.

Design themes and stylistic continuity are considered by most professionals to be unifying forces in the overall facility décor. Yet some say the rules can be bent, even broken, and that conformity shouldn’t be the overarching concern.

Brian Martin, son of the Martin’s Chair founder, is a big believer in consistency, rationalizing that “most homes have consistency in them, so why shouldn’t senior living facilities?” Creating furniture “that looks like it ‘belongs’ in the interior space is important not only to the external perception of the facility, but internally from the point of view of the residents as well,” he says. “When furniture appears like it belongs in the facility, it can give the residents a better sense of belonging as well.”

The younger Martin contends that the best way to ensure consistency is to work closely and collaboratively with the furniture manufacturer. 

“Sending specs to a manufacturer and leaving it at that can lead to serious disconnects in the overall interior design,” he says. “The less collaboration and specification occur, the much more unprofessional and disorganized the facility can appear, which can cause potential residents to choose other facilities.”

England-Chaney agrees that design consistency is important, and adds that “it has to fit the mission of the facility.” For example, she points out that if there are various wings with differing focuses, such as memory care, “it’s important to ensure the design focuses on integrating to the needs of residents in those areas.” 

Conversely, Christmann believes that design consistency is less important these days.

“There was a time when mixing wood finishes with a space was taboo,” he says. “Now it is generally accepted, if not encouraged.” 

“Design trends today are unpredictable, unscripted and very impressive. The general rule seems to be, when it comes to style within an environment, there are no rules.”

Still, despite all the science around skin pH and the plethora of innovative products and treatments today, researchers continue to be puzzled why so many cases aren’t spotted earlier.

In their recent study of more than 10,000 residents in nursing homes across 28 states, renowned University of Minnesota School of Nursing Professor Donna Bliss, Ph.D., RN, and colleagues found that only 12% who developed incontinence-associated skin damage (IASD) after
admission received prevention measures. “Knowing the risk factors of IASD and their importance will support prevention efforts and hopefully raise the percentage of prevention that is given to residents with incontinence,” Bliss said during a recent McKnight’s webinar.

Clinical practice also is stymied by bedside caregivers, too many of whom have dismissed incontinence as simply an unavoidable consequence of aging. Such attitudes, some researchers say, lead to costly delays and sometimes overlooked interventions that could have prevented skin damage and wounds.

“If you want a practice change to occur, it has to happen at the level of the professional or person who is at the bedside. They have to be knowledgeable and have skill to be able to translate that,” says Liz Jensen, RN, MSN, RN-BC, clinical director for Direct Supply Inc. Jensen, who is certified in gerontological nursing and a long-time educator, pointed to a recent study by University of Southern Indiana researchers published in Urologic Nursing.

The extensive examination concluded that most certified nursing assistants (82%) believed bladder disorders are a normal part of aging and that a knowledge gap related to urinary incontinence (UI) exists. Significant numbers of LPNs and RNs held similar beliefs. Researchers noted their findings could help explain “the lack of UI management care planning and treatment.”

“Of course, most lay people believe that the older people get, they’re going to leak a little bit and have some issues with incontinence,” Jensen adds. “But for nurses to make such assumptions could mean they’ve not been refreshed on their knowledge of late or they’ve not followed the research.” 

A stubborn condition

Its prevalence is unquestionable. Incontinence affects more than half of the elderly in senior living settings, according to the National Association for Continence. Michelle Christiansen, vice president of clinical sales and marketing for Medline, believes that figure is much higher. “Nearly 80 percent of nursing home residents suffer from urinary and bowel incontinence,” she says, pointing to a recent Centers for Disease Control and Prevention study asserting that nearly 51% of people aged 65 and older living at home reported bladder and/or bowel incontinence.

And it’s a stubborn malady that defies even the best of best practices.

Bliss and her colleagues studied more than 980 nursing home residents to explore the underlying causes and risks for IASD, which in addition to leaked body waste include irritating cleansers and, ironically, some types of adult briefs. “Why is assessing for IASD so important? For many years, it was an unrecognized and overlooked problem,” Bliss says. 

Studies have shown that even for nursing home residents on a skin damage prevention program, the prevalence and incidence of IASD never hits zero, Bliss adds. In fact, its recurrence rate can be as high as 6%. In one study that monitored nursing home residents over a 40-day period, IASD continued to recur in several residents — even after initial treatments.

Complicating matters is the fact that so many nursing home residents with chronic health issues could have underlying systemic problems that compromise the health of their skin, and those with cognitive deficits suffer from toileting challenges, Bliss says.

Sadly, incontinence also is a leading culprit in another major high-risk problem: falls. Eula Reynolds, RN, MSN, CWS, clinical education manager for DermaRite, says her experience “with some of the most severe falls in facilities have been directly related to uncontrolled urinary incontinence.”

Several years ago, Direct Supply piloted a new bladder ultrasound scanner with customers in two nursing homes to gain feedback and provide training. Jensen says that led to an epiphany.

“A resident with dementia was unable to tell staff she needed to go to the bathroom,” she recalls. “She would get up and try to go, and even after the staff would take her, she kept falling. Once they understood she actually was retaining urine, they were able to start her on some medication. They were able to help her, understand her pattern better. She went from falling two to three times a month to no falls at all.”

A wave of innovations

While educating caregivers continues to be an uphill battle, the industry has answered the call for better treatments and preventive measures. Many times over.

“The evolution of products has been spectacular,” says Jeanette Podlogar, regional clinical director for McKesson. “Ten to 15 years ago, if you were incontinent, you got a plastic-backed brief that may or may not contain your urine and may or may not keep your skin dry. Today, there are hundreds of different types of products for the educated consumer to pick from. Products have evolved to be breathable, have multiple levels of absorbency, be gender-specific with targeted wetness zones. There are even ones that look like boxer shorts.”

Brian Tripi, vice president of sales for Hartmann USA, believes the surge in dementia in long-term care has incited a lot of innovation that “allows the adult incontinence industry to help support the ever-evolving aging-in-place care continuum.” 

Tripi attributes a shift toward universal protocols to “higher-performing nighttime products that allow the resident to sleep through the night without compromising care. Additionally, instead of a one-size-fits-all approach to product selection, there is a greater practice of individualized care based on a resident’s acuity level,” he says. 

He also notes the recent innovations around a proprietary, spiral-shaped, plant-based cellulose material called “curly fibers” that significantly lowers skin pH, staving off IASD in many nursing home residents.

Innovations haven’t been limited to products. “Over the past ten years, caregivers are more aware of the importance of monitoring the nutritional status of patients in senior care facilities,” says Lisa Logan R.D., CNSC, enteral program manager/nutrition support clinician for McKesson Medical-Surgical’s Extended Care-Clinical Resource Team. It came from the industry’s long-awaited recognition of the prevalence of malnutrition in the nation’s elderly, she adds.

Christiansen also is quick to point out that ongoing research has led to some startling and useful revelations in clinical practice. “As technology continues to evolve, there’s a greater awareness around incontinence,” she says. “We now know that there are several types of incontinence, including urge, stress, overflow and bowel, and that there isn’t a one-size-fits-all approach to care. Each person must be assessed to determine their proper care plan.” 

Work in progress

No one in the long-term care environment disputes the fact that much remains to be learned as they unravel the complexities of this cruel condition that afflicts so many older people.

“Clinicians need to be armed with more than just products,” Christiansen says. “Protocols for addressing skin breakdown exist but oftentimes lack context, consistency and versatility.”

Bliss and her colleagues have done pioneering work in IASD assessments, and their findings about methods and products to lower skin alkalinity are widely known.

The field is rife with passionate and dedicated people whose work will continue to defy incontinence naysayers. McKesson’s Podlogar, for example, radiates hopefulness. 

“Being old does not mean you must become incontinent,” she says. Proof came during a series of collaborative efforts with the facilities of Ball Pavilion, part of Erie, PA-based Brevillier Village.

“Once we were able to convince them that they should apply the same [incontinence care] techniques to their assisted living as they did to long-term care — like assessment, product selection and choices — and really start to address it, they noticed a tremendous increase in residents’ participation in activities, social outings and the time people spent with their families,” she notes. 

California recently became the fifth state to enact a law allowing assisted suicide for the terminally ill. By all indications, other states will continue to pursue this option. As a result, many senior living operators may need to confront challenging  moral, religious and caregiving questions.

Roughly 20 additional states are considering legalizing physician-assisted death. Among them are Arizona, Colorado, Massachusetts, New Jersey and New York, according to Death with Dignity, a group that advocates for aid in dying.

The California law was spurred by the death of Brittany Maynard, a 29-year-old schoolteacher who had brain cancer. Maynard opted to move to Oregon, where assisted suicide has been legal since 1997. Her final weeks alive were marked by videos in which she said she should have been legally allowed to get physician-prescribed medications to end her life in California.

“The end-of-life option that Brittany supported will now become law in our home state of California. This means a terminally ill individual will not have to leave home like we did, and that individual can pursue this option of a gentle passing if it becomes necessary for them,” said her husband, Dan Diaz.

The California law mandates that two doctors agree, before prescribing the drugs, that a patient has six months or less to live. Patients must be able to swallow the medication themselves and must affirm in writing, 48 hours before taking the medication, that they will do so.

Other states with similar laws in place: Montana, Oregon, Vermont and Washington.

But if euthanasia and physician-assisted suicide are becoming increasingly legal, their use remains fairly rare, according to JAMA. 

Ezekiel J. Emanuel, M.D., Ph.D., of the University of Pennsylvania in Philadelphia, examined the legal status of euthanasia and physician-assisted suicide as well as data on attitudes and practices. 

He found that less than 20% of physicians in the United States had received requests for euthanasia or physician-assisted suicide, and 5% or less have complied. More than 70% of cases of euthanasia or physician-assisted suicide were cancer-related. 

The option remains largely used by patients who are white, wealthy and well-educated, investigators found.

Emanuel noted that fear of losing autonomy, no longer enjoying activities and other psychological concerns are the main drivers. Surprisingly, pain is not, he added. 

Preliminary results of the investigation, which was conducted by researchers at Brown University, found skilled nursing and assisted living providers are worried that placing cameras in rooms will violate the privacy of residents, their roommates, facility staff and visitors. Many operators also expressed concern  that the cameras could open them up to potential litigation if activity caught on film was misinterpreted.

The survey also highlighted less common camera-related fears. These included the possible erosion of resident and staff trust, staff demoralization and video security.

Despite worries about installing cameras, many survey respondents said filming what goes on in residents’ living areas could help with investigations into complaints and give family members peace of mind. Many also noted that facilities can use footage to help monitor staff, determine the possible cause of resident falls and reveal behavior to families.

One-fourth of the 228 operators who have responded to the Brown survey so far said they allow families to place cameras in resident rooms, while 16% said they know of at least one family that installed a camera. Just half of the facilities that allow cameras said they require signs in rooms where cameras are in use.

“This survey reveals that a large minority of respondents are aware of cameras in use in resident rooms. Most believe that privacy is at stake, and many envision potential positive effects,” wrote lead researcher Clara Berridge, Ph.D., MSW.

A: This is a three-step process.

1) Create an income statement and sheet that includes only your senior living business operation (revenue, operating expenses, profit, debt service, cash flow, etc.). If necessary, show any cash from the business operation that is needed to fund charitable initiatives as a separate financial burden below the operating profit and net cash flow line entries. The expected outcome is the execution of sound business practices while meeting industry benchmarks for financial performance.

2) Prepare another financial statement that shows other sources of cash such as charitable donations, fundraising and restricted cash used to fund your defined charitable mission, which instead might be used for reducing monthly service fees and subsidizing operating expenses to provide affordability for certain residents. The objective is executing the Charitable Mission within defined available mission resources and spending guidelines.

3) Then (and only then) prepare the more traditional consolidated financial statement. 

Jim Moore runs a national senior housing and healthcare consulting firm based in Fort Worth, TX. He has written several books about assisted living and senior housing, including Assisted -Living Strategies for Changing Markets. 

Within the category, rates for independent living properties and assisted living properties averaged 91.0% and 88.0%, respectively. When compared to the prior quarter, the occupancy rate for independent living fell 0.3 percentage point and slipped 0.4 percentage point from its eight-year high in the fourth quarter of 2015. Occupancy for independent living was unchanged from year-earlier levels. The occupancy rate for assisted living decreased 0.2 percentage point from the first quarter, but rose 0.1 percentage point from year-earlier levels. 

The project took 11 months to complete, with 33 apartments added to the 14-year-old facility, increasing the total to 102 units. The new terraced apartments include dens and open, spacious kitchens. Other contemporary amenities include gardening beds, a craft studio and woodworking shop, as well as Wi-Fi and concierge service.

Canterbury residents now have all the modern comforts of home in the renovated facility. But the  real design showstoppers harken back to the community’s post-war glory days with Emmett’s Garage and, to the more distant past, with the HMS Victory Bistro.

Emmett’s Garage — named after Canterbury CEO Aaron Koelsch’s late father, who founded Koelsch Communities in 1958 — is designed to take residents and visitors back to a simpler time when “muscle cars” ruled the road. The senior Koelsch collected antique cars, and his restored red 1955 Ford Thunderbird is parked in the garage under a vintage Texaco sign. Koelsch also is planning to add a 1956 Chevrolet Corvette to the garage once its restoration is complete.

The nautical seafarer-themed bistro and English pub, meanwhile, features a detailed model of the 1765 British battleship HMS Victory in front, and has become “quite a gathering spot for residents,” Koelsch says.

A spacious courtyard dotted with greenery and rocking chairs was added outside the bistro. The bistro itself serves complementary coffee, soup, salad and ice cream daily. Panini sandwiches, drinks and sweets are available for purchase.

The Canterbury facility is one of four Koelsch Communities operated by Koelsch and his three sisters. The Koelsch siblings all are involved in the seniors housing industry, stemming from their parents’ passion for the business.

“We started in 1958 in Longview, when my parents bought a vacant nursing home and moved into the basement,” Koelsch says. “This business is truly part of our heritage.”

The family legacy also includes Koelsch’s wife, Judy, who handled the interior design at Canterbury. The family’s own construction company built the renovated facility.

“That way if I have a problem, I can only blame myself,” Koelsch says.

The interior design “leans toward a traditional feel — a European mix that features antiques and historical items” Judy says. “It is very home-like and reflects the Longview area and its outdoor activities, like boating and hunting.”

A regional census served as the impetus for the renovation, Koelsch says, and that demographic forecast shows a 20% increase in the senior population by 2030.

“We have found just in the last five years the need for independent living,” says Kris Friberg, Canterbury executive director. “There is such a continued growth, and this is the direction Koelsch Communities is moving. The Koelsches spare no expense, so everybody can have what they had at home and feel like they’re not really leaving anything.” 

Q: In his new book, “Third Wave,” AOL founder Steve Case asserts that the Internet will become engrained in everything we do, and entrepreneurs will vastly transform major  “real-world” sectors such as health, education, transportation, energy and food — but success in the Third Wave will require a different skill set. In what ways do you agree or disagree with those assumptions or predictions as they apply to senior living tech?

A: I agree with most of these predictions. However, I believe that in the senior living sector, we will still need high-touch care delivery skills, and I believe that we will need technical competencies to enhance these fundamental skills. I also believe that such skills are becoming first nature, or instinctive, with the younger generation joining the senior living workforce. We also will need people with skills in using dashboards, examining data from different sources and contextualizing the data to turn them into information and knowledge that drive care delivery processes and quality.

Q: Is there a nexus right now where most tech innovation is coming from? Is it software?

A: Most innovations are on the software side, but innovation is driven by the need for connectivity, having information at your fingertips at the point of care, mobility and being able to coordinate with others. 

Q: Is tech underdelivering or overpromising in senior living? 

A: It can be either, a combination of both or neither. In many cases, this perception stems from either not understanding the technology, unrealistic expectations, not knowing what it takes for it to yield the expected results on the provider’s end or overpromises from the vendor. Technology implementation is a partnership, just like a marriage, and it requires the vendor and the provider working together like a hand and glove. The success of technology hinges on a number of things, the majority of which start with, and rely on, the provider, frankly. These include:

•  Having clarity on strategic direction, specific strategic goals and the enabling technologies.

•  Including proper planning and selection of the technology solution that engages all operations affected directly or indirectly by the technology, starting with understanding users’ needs, requirements and desires; a clear understanding of what the technology can or can’t do; and operational goals. The selection should not be based only on the technical specifications or functionalities, but also the service, operational, staffing, training and support needs. It is a multistakeholder team effort, and it is not the responsibility of the IT team.

•  Ensuring that the planning process includes understanding the IT infrastructure update needs. These steps should take place before a vendor is even identified.

•  Designing or redesigning workflows and operations to take advantage of technology.

•  Having a well-thought-out implementation plan with sufficient resources, including human resources for project management, implementation, training, system migration and support. The last two steps can be done collaboratively. 

You can have the exact same technology implemented differently in two very similar communities yielding drastically different results. CAST collected many success stories whereby the technology delivered results that exceeded expectations, but only because the provider had the right planning and implementation team, process and resources in place. 

Q: Is there any hesitancy among senior living operators to adopt technology?

A: Senior living has been generally behind other sectors when it comes to technology adoption and technology spending, although I have seen signs of improvement in the past few years, particularly in certain technology categories. For example, electronic health records and point-of-care are starting to get adopted. I believe this adoption was driven primarily by the regulatory requirement to submit assessments (MDS, OASIS, IRF-PAI) and by billing information electronically to Medicare. Of course, the national health IT initiatives, CMS’ EHR adoption incentive program and emphasis on health information exchange have recently raised awareness, increased interest, and accelerated EHR development and standardization.

Q: What overarching trends will shape future innovation, and adoption?

A: I believe aging in place, and the corresponding growth in home- and community-based services, regulation, health and payment reform will continue to affect and drive future innovations. Connectivity, reliance on data, information and knowledge at the point of need will be the hallmark of innovation. But ultimately, adoption is going to be directly related to entrepreneurial spirit and foresight of providers, especially among leaders of aging services; and the usability and stickiness of the technology innovations brought to bear.

“Too many hardworking men and women who tend to the most basic needs of our loved ones continue to be shortchanged for their efforts,” said Ruben Rosalez, regional administrator for the Wage and Hour Division’s western region. “We aim to put a stop to that through strong enforcement of federal labor laws along with a robust outreach and education program.”

The owners of San Miguel Homes for the Elderly of Union City have agreed to pay $425,000 in back wages and damages to 26 caregivers working at its Union City, CA, facilities after admitting they did not pay minimum wage and overtime, the labor department said.

The department had sued the residential care provider in December, saying that the owners had refused to meet with Wage and Hour Division investigators and had claimed that they were not obligated to comply with the Fair Labor Standards Act. In January, according to the labor department, the division learned that the San Miguel’s owners were threatening to sue workers suspected of cooperating with the investigation and were having employees falsify timesheets.

The consent judgment in the case also requires the company to provide adequate coverage during all shifts to eliminate the practice of employees working off the clock and to ensure that the company pays employees properly for all hours worked.

Under a separate ruling, Razel Cortez and Elizabeth Palad, who own eight residential care facilities in central California, will pay unpaid wages and damages of $643,992 after reportedly violating minimum wage and overtime provisions of the FLSA. The facilities involved are Walnut Creek Willows in Walnut Creek, Elizabeth’s Care Home 1 and 2 in South San Francisco, Samantha’s Care Home in San Bruno, New Haven Care Home in Union City, and Rayzel’s Villa and Villa San Lorenzo in San Lorenzo.

The employer misclassified caregivers as independent contractors, paid them a flat monthly salary “well below” minimum wage, provided no premium for overtime even though the employees often worked 60 hours per week, and failed to keep any records of hours worked, according to the labor department. The consent judgment in the case also requires the defendants to hire a third-party monitor to audit their compliance with the FLSA, to post copies of the consent judgment and notices of employee rights in both English and Tagalog at each of their facilities, to provide detailed pay stubs to every employee each pay period and direct them to review the documents, and to provide contact information for the Wage and Hour Division, in both languages, with every pay stub.

McKnight’s Senior Living did not receive a response to requests for comments made to the owners of the facilities.