The US Senate Special Committee on Aging is launching a review of the assisted living industry following recent articles in the Washington Post, which reported on the deaths of residents who wandered from communities, as well as the New York Times and KFF, which scrutinized an industry pricing structure that adds fees on top of basic charges to cover additional services, as well as rate increases and the for-profit status of most providers.

Committee Chairman Sen. Bob Casey (D-PA), who has scheduled a hearing for Jan. 25, sent letters dated Monday to the leaders of Brookdale Senior Living, Atria Senior Living and Sunrise Senior Living, asking them to address his “significant concerns” about costs, staffing levels and resident safety.

“Despite these high costs, residents in assisted living facilities have been put in harm’s way, leading to avoidable injuries and death,” Casey wrote in his letter to the large providers, detailing points made in the November Times/KFF articles and December Post articles. 

Assisted living communities primarily are regulated at the state level, but the committee frequently has used its authority to “examine private companies when concerns arise about potential health and safety, as well as financial risks posted to older adults,” the senator said.

“The Senate Special Committee on Aging has jurisdiction over the problems older adults face, including matters of maintaining older adults’ health, their ability to secure proper housing, and their ability to obtain care or assistance when needed,” Casey wrote. “As chairman, I have an interest in ensuring that older adults and people with disabilities are receiving high quality care, have access to proper housing and receive good value for their hard-earned dollars.”

Specifically, Casey asked the companies to provide information and documents no later than Feb. 5 detailing how they communicate the cost of services to residents and their families, rates they charge in each state, and their schedules of services and costs. Additionally, he asked them to provide information on average revenue per occupied unit for the past seven years, figures on the number of residents who have eloped or sustained injuries due to being left unattended, information about the accessibility of information about complaints and citations received by their communities, their policies and procedures for informing residents and families about accidents, applicable staffing requirements, and job titles and associated pay rates at their companies. 

“We look forward to reviewing and responding to Sen. Casey’s letter on the assisted living industry with candor and transparency,” Sunrise Senior Manager of External Communications Heather Hunter told McKnight’s Senior Living. 

Atria Senior Living provided a similar response.

“Our top priority is our residents’ well-being and safety,” an Atria spokesperson told McKnight’s Senior Living. “We look forward to providing information in response to Sen. Casey’s letter.”

Brookdale said it is aware of the letter from Casey.

“Brookdale values the relationships we have created with our hundreds of thousands of residents at communities across the country over the last decade, and we are committed to providing high quality care,” a spokesperson said. “We take seriously our mission of enriching the lives of those we serve with compassion, respect, excellence and integrity.”

Atria, Brookdale and Sunrise are some of the largest senior living operators in the country. On the 2023 ASHA 50 list issued by the American Seniors Housing Association, Brookdale topped the list of operators, and Atria came in at No. 2. Sunrise was No. 3. On Argentum’s 2023 list of largest providers, Brookdale was No. 1, Atria was No. 2 and Sunrise was No. 5.

This isn’t the first time that senators have called for an investigation related to assisted living. In one of the most recent actions, a bipartisan group of US senators, all members of the Aging Committee, in 2015 asked the Government Accountability Office to report on Medicaid oversight and quality of care in assisted living communities. Their request resulted in a 2018 GAO report.

That report contained a to-do list for the Centers for Medicare & Medicaid Services related to state reporting of deficiencies in care and services provided to Medicaid beneficiaries in assisted living communities. Some federal lawmakers and consumer advocates, however, said that they would push for changes in assisted living because of the report’s findings.

‘Isolated incidents’

Senior living industry groups have called the number of deaths reported in The Post’s story a small fraction of the total number of assisted living and memory care residents, most of whom report high satisfaction with their communities.

“The Washington Post’s reporting featured isolated incidents that assisted living communities take very seriously,” Argentum President and CEO James Balda told McKnight’s Senior Living, adding that the elopement-related fatalities highlighted in the Washington Post stories are “exceedingly rare,” occurring with 0.0015% of more than 6.2 million residents served during the timeframe of the reports.

“Our communities look forward to demonstrating to the committee that as the nation grapples to care for our aging population, assisted living provides independence and dignity for seniors,” he said.

Argentum, Balda added, “strongly supports” state regulations already in place to investigate incidents and punish any wrongdoing, and he said that any fatality is “devastating for our staff, our residents and their families.”

Calling elopements rare while acknowledging that any resident injury is “truly tragic,” National Center for Assisted Living Executive Director LaShuan Bethea said she welcomes the opportunity to engage with the committee to “further their understanding of the assisted living profession, its oversight and our deep commitment to providing quality care.”

“The assisted living profession is committed to continuing to learn all that we can about dementia and the disease process to meet the ever-changing needs of our residents,” Bethea told McKnight’s Senior Living. “Policymakers, providers and other stakeholders should come together to find ways to advance memory care while honoring why seniors and their families love assisted living — by supporting their independence and autonomy in a home-like environment.”

Assisted living will continue to evolve with the nation’s changing needs, and regulations, staffing and training requirements must evolve with them, LeadingAge President and CEO Katie Smith Sloan told McKnight’s Senior Living.

“Our elected officials and other stakeholders must prioritize policies to support older adults and the professionals working in aging services to ensure equitable access to high-quality care in assisted living, as well as other care settings,” she said.

In a response to the original package of Washington Post stories, American Seniors Housing Association President and CEO David Schless said the stories “inaccurately” suggest that elopements in assisted living or memory care settings would not occur if there were federal oversight of the setting. He also said that the articles failed to recognize the contributions of the vast majority of frontline caregivers and other senior living professionals.

Schless called assisted living “highly regulated” by states that impose strict requirements, including licensure, and cover a broad range of provisions such as those Casey asked about in his letter to providers. Schless added that states are actively involved in updating and modifying regulations and statutes on an ongoing basis.

“The states are far more responsive than the federal government in addressing the needs of residents and their families to ensure innovative services and programs are available to meet their needs and those of a rapidly aging population, including those with Alzheimer’s and related dementias,” Schless said. 

ASHA, he said, also plans to respond to the committee with a rebuttal of the Post’s “misrepresentation” of the industry, providing information he said was overlooked in the reporting as well as information about the benefits and value of senior living.

Association leaders previously submitted letters to the editor to the New York Times and the Washington Post in response to their articles. Although The Post has not published letters from the associations, it did post a letter from Andrew Carle, lead instructor in senior living administration at Georgetown University. He said that the more than 6 million Americans affected by dementia and prone to wandering would be “exponentially safer” in assisted living communities than at homes in the greater community.

Industry quality initiatives

The industry has launched several initiatives focused on building consensus around assisted living quality measures, as well as infection prevention and control efforts. NCAL last week released its 2023 regulatory review report, which highlighted regulatory requirements across all 50 states. 

The Center for Excellence in Assisted Living, known as CEAL@UNC for the past year, itself was launched in 2003 as a result of a recommendation in the landmark Assisted Living Workgroup Report, delivered to the Senate Special Committee on Aging. 

In a recent podcast interview with McKnight’s Senior Living, Sheryl Zimmerman, MSW, PhD, the center’s executive director, called on all assisted living stakeholders “to be more mindful in a pragmatic, feasible way” across all of assisted living to address resident care needs.

“Most everyone involved in assisted living is aware there are opportunities for improvement,” Zimmerman told McKnight’s Senior Living. “The Senate Aging Committee delved into assisted living 20 years ago with the Assisted Living Workgroup Report, which led to the national Center for Excellence in Assisted Living, and as the executive director, I welcome the opportunity this brings to coordinate efforts to work towards excellence while providing person-centered care and quality jobs.”

LeadingAge, Argentum, NCAL and ASHA in June announced that they had joined with the National Association for Regulatory Administration to develop guidance for the industry and resources for operators, regulators, policymakers and other stakeholders. The groups, working together as the Quality in Assisted Living Collaborative, first turned their attention to the area of infection prevention and control, an issue brought to the forefront during the COVID-19 pandemic, with plans to address other issues.

NCAL also has its own National Quality Award program, based on the Baldrige Performance Excellence Framework. It recognizes assisted living providers that meet certain goals. The organization’s voluntary quality initiative for assisted living communities also has goals related to staff stability, customer satisfaction, hospital readmissions and the off-label use of antipsychotic medications.

Life Care Services has the highest overall satisfaction scores among assisted living, memory care and independent living providers in the J.D. Power 2023 US Senior Living Satisfaction Study. Results were released this morning.

Life Care Services achieved an overall satisfaction score of 869 out of a possible 1,000 points for its assisted living/memory care providers, followed by Atria Senior Living (No. 2, with a score of 855) and Frontier Management (No. 3, with 846 points).

Enlivant dropped from No. 1 last year to No. 4, with a score of 844, and Five Star Senior Living landed at No. 5, with 841 points). Brookdale Senior Living dropped from a No. 1 tie with Enlivant in last year’s survey to No. 7 this year, with a score of 821. 

For independent living, Life Care Services achieved the highest satisfaction score among participants for the fifth consecutive year, with a score of 827, followed by Five Star (No. 2, with 744 points), Brookdale dropped from No. 1 last year to No. 3 this year, with a score of 729, followed by Senior Lifestyle (No. 4, 724 points) and Holiday by Atria (No. 5, 658 points). 

“Receiving this recognition from J.D. Power, one of the most respected consumer insights organizations in the world, demonstrates our focus on the most important part of our business — our residents and their families,” Joel Nelson, CEO of LCS, the parent company of Life Care Services, said. “For five consecutive years, nearly 40,000 residents have expressed their confidence in our company and communities.”

Overall satisfaction levels of senior living residents and family members remained flat, but staffing levels and activity offerings showed positive gains, according to the study results.

Senior living communities across the country maintained steady levels of satisfaction, despite the increasing costs of doing business. Andrea Stokes, J.D. Power hospitality and senior living practice lead, said in a statement that although staffing was a major challenge for providers coming out of the pandemic, the survey showed no declines in resident satisfaction linked directly to staff reductions or facilities management.

One challenge area, however, is resident perception of the value of independent living, according to J.D. Power. As rents increase at a faster-than-historical clip, independent living pulled in lower ratings than other senior living segments for resident satisfaction. Satisfaction with value among residents dropped 15 points over last year, according to the results. 

The average satisfaction level among families and other decision-makers for assisted living and memory care residents is up eight points from a year ago, driven by improvements in their satisfaction with community staff members (up 11 points) and resident activities (up 9 points). “Very easy” access to community executive directors drove a 118-point increase in satisfaction, but only 48% of family members and decision-makers agreed with the assessment.

Activity offerings played a key role in both independent living and assisted living/memory care satisfaction, likely due to providers continuing to reinstate many in-person group activities, according to the study. 

The US Senior Living Satisfaction Study measured resident satisfaction with the largest US providers of independent living and assisted living/memory care service. Overall satisfaction was measured across six senior living experience factors: community buildings and grounds, community staff members, dining, price paid for services received, resident activities, and resident apartment/living unit.

The 2023 study results are based on 3,838 responses collected in July and August from independent living residents and, for assisted living and memory care, family members and other decision-makers. 

Broken promises about service and care levels, attributed to “grossly understaffed” at senior living communities and skilled nursing facilities, are the driving force behind a surge in class-action lawsuits against such providers, according to two legal experts.

The Long Term Care Community Coalition hosted a webinar Tuesday that included AARP Foundation Litigation, a charitable nonprofit arm of the AARP that focuses on civil rights cases, abuse and neglect in senior living communities and skilled nursing facilities. The group advocates for systemic change in federal and state courts to “change the circumstances that give rise to poor care,” AARP Foundation Litigation Vice President Kelly Bagby said.

Benjamin Davis, AARP Foundation Litigation senior attorney, said an issue arises when operators promise to provide a sufficient level of staffing but residents and their families mistakenly believe that that promise means that their loved ones will receive individualized care. The dynamics of senior living communities and skilled nursing facilities, he said, mean that staff members are devoted to all residents, not individuals.

The result, Davis said, is that providers make promises to attract residents but then don’t meet resident needs or effectively reassess residents to determine their changing needs.

Davis highlighted a current case against Chancellor Senior Management, a Columbus, OH-based organization that manages four assisted living communities in the state. The lawsuit alleges that Chancellor used a formula to determine the hours of care that each resident needed based on their individual conditions but only applied that formula for billing purposes, not to determine staffing levels. The lawsuit further alleges that staffing decisions are made at the corporate headquarters rather than at the community level.

The Supreme Court of Appeals of West Virginia opened the door for the case to move to a class action lawsuit, Davis said. The court also further declared that the provider’s arbitration agreements in resident admission contracts were unenforceable because they were part of a larger contract rather than a stand-alone agreement. The American Health Law Association requirements incorporated into those agreements call for them to be stand-alone agreements. 

Bagby referenced a federal class action case against Brookdale Senior Living filed in 2020. The lawsuit accuses the country’s largest senior living company, based in Brentwood, TN, of “chronically insufficient staffing” at its communities, allegedly to meet financial benchmarks. The lawsuit also accuses Brookdale of misleading residents and families and of failing to provide care and services.

“Our cases are about how to force companies to change their practices around adequate staffing,” Bagby said, adding that attorneys are focusing on violations of the consumer protection statutes that allow residents to recover damages for injuries when companies do not deliver on their promises. “In every assisted living and nursing facility, the residency agreement lays out those promises to residents,” she said.

Bagby said that it is critical for providers to be transparent about their practices and to not lie about their staffing levels. 

Class action staffing lawsuits not unprecedented

Class action lawsuits against senior living providers related to staffing levels are not a recent phenomenon.

In 2021, for example, Aegis Living of Bellevue, WA, settled two class action lawsuits for a combined $16.25 million. The lawsuits alleged that Aegis based staffing levels on predetermined staffing budgets rather than on resident care needs and in doing so violated elder abuse and consumer protection laws.

Similar legal action against other senior living companies also resulted in settlements.

For instance, the former Emeritus Corp., which merged with Brookdale in 2014, settled a class action lawsuit in 2016 for $13.5 million. The suit alleged that Emeritus misled assisted living residents about the use of a computerized system to evaluate residents and determine sufficient staffing and care levels. 

Atria Senior Living settled a similar lawsuit for $6.4 million that same year, and Oakmont Senior Living settled a class action lawsuit for $9 million earlier this year. A similar lawsuit against Sunrise Senior Living is pending.

Last fall, Argentum, the American Seniors Housing Association and the California Assisted Living Association filed an amicus brief in the Sunrise case, arguing that class actions are “unnecessary and counterproductive” because assisted living communities are highly motivated to provide quality care to residents. The brief also argued that the expense and disruption of defending class action suits diverts resources from care provision.

Atria Senior Living has agreed to pay $1.3 million in a wage and hour class action settlement over its alleged misclassification of community sales directors as outside salespeople, but the company denies any wrongdoing.

The settlement covers 69 community sales directors in Atria’s California properties who claimed that the company did not properly pay for meal and rest breaks, as well as overtime. US District Court Judge William Alsup of the Northern District of California approved the settlement on Wednesday.

“We continue to believe in the correctness of our position and vehemently deny these allegations,” an Atria spokeswoman told McKnight’s Senior Living on Friday. “However, we chose to settle the suit in order to avoid lengthy and costly legal proceedings that would have served as a distraction from our main focus: providing the best experience in senior living to our residents.”   

George Stickles and Michele Rhodes filed the labor lawsuit against Atria Senior Living and Atria Management Co. in 2020. The sales directors were successful in certifying a class of former and current employees in December 2021, covering community sales directors employed at Atria’s California properties between April 9, 2018, and Sept. 29, 2019.

According to the settlement, reached in February and finalized Wednesday, Atria denies any liability or wrongdoing and asserts that the company complied with California laws and did not engage in any unfair or unlawful business practices. 

The company previously said it would “vigorously defend” itself against the claims. 

Along with the wage and hour claims, the complaint also alleged violations of California’s labor code and sought civil penalties under the Private Attorneys General Act, or PAGA. The PAGA penalties are included in the settlement and apply to 65 of the sales directors covered in the class action suit who were employed between Jan. 17, 2020, and May 2, 2020. 

Atria owns 46 senior living communities in California.

In a post-COVID world, the senior living industry is “cautiously optimistic” about its future as it experiences significant market changes driven by a combination of demographic shifts, evolving consumer preferences and advances in technology, according to Argentum, which released its 2023 list of the 150 largest senior living providers in the nation on Friday.

The report revealed a shuffling of the top 10 largest providers, but all remained at or near their 2022 positions. 

Brookdale Senior Living maintained its top spot on the list, with Five Star Senior Living — the senior living division of AlerisLife — dropping two spots to No. 6 this year, from the No. 4 spot last year. Discovery Senior Living (No. 7 this year) and Senior Lifestyle (No. 8) swapped places from last year, as did Watermark Retirement Communities (No. 9 this year) and Integral / Solstice Senior Living (No. 10).

Other top 10 providers are Atria Senior Living (remaining at No. 2), LCS (maintaining at No. 3), Erickson Senior Living (No. 4) and Sunrise Senior Living (No. 5).

Top 10 largest providers by total units:

1. Brookdale Senior Living: 55,430 total units
2. Atria Senior Living: 42,501 units
3. LCS: 31,523 units
4. Erickson Senior Living, 23,800 units
5. Sunrise Senior Living, 23,176 units
6. Five Star Senior Living: 19,554 units
7. Discovery Senior Living, 14,660 units
8. Senior Lifestyle, 14,129 units
9. Watermark Retirement Communities, 11,336 units
10. Integral Senior Living: 10,451 units

Eleven providers moved up on the list by 10 or more places, according to the association, which ranks providers in size by number of units, number of employees, types of care and services offered and more.

Topping the list of the 30 largest assisted living providers are Brookdale (30,570 assisted living units), Sunrise (13,944 units) and Atria (9,895 units). Five Star fell from the No. 3 spot last year to No. 5 this year, while Atria, which was not on last year’s list, landed at the No. 3 spot.

The three largest independent living providers changed this year. Atria (30,692 units), which wasn’t on last year’s list, claimed the No. 1 spot, followed by No. 2. LCS (22,658 units), which dropped from No. 1 on last year’s list. Erickson SEnior Living (21,765 units) landed at No. 3.

Brookdale continued to lead the list of largest memory care providers, with 8,996 memory care units. Sunrise maintained its No. 2 spot with 6,233 units, followed by Frontier Management LLC with 3,126 units.

The largest continuing care retirement / life plan community providers also changed this year. Trilogy Health Services, which didn’t make the top 15 last year, landed at No. 1, with 115 CCRCs, followed by LCS, which dropped from No. 1 to No. 2 this year, with 86 CCRCs, followed by Century Park Associates, which maintained its No. 3 spot with 31 CCRCs.

The full lists can be accessed via the Argentum website. The report, based on company-provided data via survey, also includes information on the potential effects of artificial intelligence on the senior living industry, growth in the home care market based on a preference to age in place, and information on inflationary pressures and workforce projections.

The report was prepared in partnership with Lument and sponsored by Accushield.

Brookdale Senior Living and real estate investment trust Welltower have maintained their top spots on the 2023 American Seniors Housing Association’s lists of the 50 largest senior living operators and owners, respectively, released Monday.

The two companies have appeared at the top of the respective lists since 2019, the year that Toledo, OH-based Welltower moved up a spot from 2018 to replace Brentwood, TN-based Brookdale at the top spot of the owners list.

As of the 2018 list, based on figures from June 1, 2017, Brookdale owned 65,854 units and managed 96,026 units, and Welltower owned 65,141 units. As of June 1, 2023, Brookdale owns 30,025 units (and is No. 3 on the latest list of owners) and operates 54,855 units, and Welltower owns 95,281 units, according to the 2023 ASHA 50.

Largest operators

The largest 50 senior living operators manage a total of 542,360 units, with the top five largest operators accounting for 34% of the total, according to the 2023 ASHA 50.

After Brookdale, Atria Senior Living remained in second place, with 42,501 units, followed by LCS (35,615 units) and Sunrise Senior Living (27,017 units). Discovery Senior Living (25,876 units) leapfrogged over Erickson Senior Living (No. 6, with 25,268 units) into the top five, compared with last year’s list, with its addition of 11,034 units.

Greystar Real Estate Partners added 4,308 units from 2022 to move from No. 9 to No. 7, whereas AlerisLife (parent company of Five Star Senior Living) dropped from No. 6 in 2022 to No. 8 this year. Senior Lifestyle (with 14,691 units) moved from No. 7 last year to No. 9 this year, whereas Watermark Retirement Communities maintained the No. 10 spot with 12,325 units.

Cogir Management USA, which wasn’t on the 2022 list of operators, jumped to No. 24 with the addition of 4,117 units, whereas Oakmont Management Group moved from No. 36 last year to No. 17 this year with the addition of 3,668 units.  

Largest owners

The total number of units owned by the 50 largest US seniors housing owners is 569,086, with the largest five owners accounting for 43% of the total.

Welltower expanded its owned portfolio by 5,103 units from 2022 and remains the largest owner, with 95,281 units, followed by Ventas, which retained its No. 2 spot with 67,679 units. 

Brookdale continued to hold onto the third position on the list of largest owners, with 30,025 units. Rounding out the top five was Diversified Healthcare Trust, with 25,175 units, and Harrison Street, with 24,823 units — they maintained their fourth and fifth spots, respectively.

Kayne Anderson Real Estate moved up to No. 7 after Ventas took over Santerre Health Investors’ portfolio earlier this year. National Senior Communities jumped from No. 19 to No. 8 on the owners list this year after adding 3,593 units from 2022.

Greystar Real Estate Partners jumped from No. 15 in 2022 to No. 9 this year after adding 1,980 units. Erickson Senior Living rounded out the top 10 owners by moving from No. 14 to No. 10 this year.

National Health Investors dropped one spot from No. 10 to No. 11. Bridge Seniors Housing Fund Manager dropped from No. 9 in 2022 to No. 15 this year, whereas ReNew REIT dropped from No. 11 in 2022 to No. 16 this year.

The report also includes information on a major rebuild of ASHA’s Where You Live Matters website to better serve consumers, owners and operators. The new website is expected to launch this fall.

The rankings are based on data as of June 1. Each list includes 50 companies. See the complete 2023 ASHA 50 lists on ASHA’s website.

A smart home collaboration will see Amazon Alexa devices deployed across Atria Management Co.’s entire national portfolio, which the company says is a first in the senior living industry.

The senior living management company on Tuesday announced its collaboration with Alexa Smart Properties, which will implement large-scale, nationwide installations of Amazon Echo Show 8 devices, enabling smart home automation and automated resident engagement across its various senior living brands: Coterie, Atria Signature, Atria Senior Living and Holiday by Atria.

Atria collaborated with Amazon and digital transformation company Aiva Health to develop custom Alexa “skills” for senior living residents, allowing them to use voice commands to connect with loved ones, access information, video chat and communicate with Atria staff members.

“We are fast-tracking an analog space across our portfolio to be smarter, even more efficient in social connection and resident engagement,” Atria Chief Technology Officer Chris Nall said in a statement. “After all, we know what is most important for the well-being of older adults is to remain connected to their family, friends and staff members in meaningful ways.”

The devices’ screens also display curated videos announcing upcoming Atria Engage Life events and daily menus.

Atria already has seen a 50% to 75% increase in residents attending programs at Atria communities that have Alexa Smart Properties, Nall said.

The Louisville, KY-based company manages independent living, assisted living, supportive living and memory care communities in more than 370 locations across 44 states and in Canada. Collectively, locations serve 41,000 residents and employ 13,000 staff members. 

Amazon has been moving into the senior living space over the past several years as providers have sought ways to connect residents to staff members, family members and each other.

In 2019, Amazon announced HIPAA-compliant skills for Alexa, with senior living parent companies in the mix. And in 2022, Amazon announced a technology challenge focused on easing the aging process.

Many operators have started using Amazon Alexa and Echo devices in communities as a way to increase staff efficiency and resident connectivity, with efforts expanding since the start of the pandemic.

For example, in 2021, Atria and Sacramento, CA-based Eskaton announced that they would integrate Alexa Smart Properties Amazon Echo devices at select senior living communities to keep residents connected and engaged

In 2022, Atria announced that it was installing Amazon Echo Shows at its Coterie Cathedral Hill luxury senior living community San Francisco. 

Carlton Senior Living recently partnered with software company Speak2 to implement Alexa-enabled devices. And the Radcliff Assisted Living community teamed up with senior care communication platform Serenity, using the company’s Alexa-powered devices to streamline operations and increase communication.

Serenity Engage integrated with Amazon’s senior living solution from Alexa Smart Properties to create a custom Alexa deployment serving as a personalized digital concierge in senior living. And Sequoia Living’s Viamonte at Walnut Creek partnered with technology company K4Connect during the pandemic to use Amazon Alexa-powered devices for communication, safety and smart lighting control programs.

A University of Nebraska-Lincoln demonstration project found that voice-activated technology can reduce loneliness among senior living residents and help with the design of “gerontechnology” aimed at older adults.