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.

While still a state legislator in the mid-1990s, Parkinson and his wife, Stacy, founded the first of their 10 eldercare communities in Kansas and Missouri, an assisted living community. 

The lanky lawyer particularly distinguished himself in recent years as the most visible spokesperson for the long-term care sector — the segment of society most devastated by infections and deaths during the COVID-19 pandemic. He has been the president and CEO of the 14,000-member American Health Care Association / National Center for Assisted Living since 2011, the year after he declined to run for another term as governor of Kansas.

“Mark doesn’t just talk the talk. He walks the walk. During his years at the helm of AHCA/NCAL, he has helped guide the industry through some of the most challenging times we’ve ever faced,” said McKnight’s Editorial Director and Associate Publisher John O’Connor in making the announcement of Parkinson as this year’s top Pinnacle honoree. “This he has done with amazing skill, wisdom, grit and grace. He is deserving of this honor, and we are truly fortunate to have him among us.”

When not touring the country to visit members and affiliates, Parkinson spends most of his time lobbying on senior living and care operators’ behalf from his home in Washington, DC. 

He and his wife started their chain of facilities in 1996 while still working in their private law practice.

A Republican state legislator dating back to 1991, he switched parties in 2006 to become Kathleen Sebelius’ running mate when she ran for governor of Kansas. They won, and in 2009, he became governor after Sebelius became secretary of Health and Human Services in the Obama administration. He declined to seek another term and instead accepted the top AHCA/NCAL post before he left office in January 2011.

In 2020, McKnight’s named him one of long-term care’s most notable figures of the past 40 years.

Before becoming especially prominent as an industry point person during the pandemic, one of his biggest accomplishments was stitching back together a fractious AHCA/NCAL constituency, convincing major chains that had set up their own alliance to come back into the fold. The number of AHCA and NCAL state affiliates also has grown under his guidance.

Recognition is not a stranger to Parkinson. He also has been selected as one of the “100 Most Influential People in Healthcare” by Modern Healthcare multiple times and was named a Top CEO in the Washington Post’s 2019 Top Workplace survey in the small-employer category. He was named a Top Association CEO by CEO Update in 2013 and has appeared on The Hill’s list of top lobbyists every year since 2013.

A former No. 1 graduate of the University of Kansas Law School and champion college debater, he leads a list of 31 McKnight’s Pinnacle Awards honorees who will be celebrated at a gala ceremony open to all March 21 at the Ivy Room in Chicago.

A full list of 2024 winners, spanning the senior living, skilled nursing and home care professions, can be found at the McKnight’s Pinnacle Awards website. The program honors industry veterans who are setting standards, driving change and providing guidance to others in their field.

The McKnight’s Pinnacle Awards are a joint effort of McKnight’s Senior Living and sister media brands McKnight’s Long-Term Care News and McKnight’s Home Care.

Assisted living regulations, statutes and policies in 20 states (31%) were updated between July 1, 2022, and July 1, 2023, according to a new report from the National Center for Assisted Living.

The 2023 edition of the report, “Assisted Living State Regulatory Review,” released Wednesday, has added information about infection control and emergency preparedness regulatory requirements, which were in place in almost all 50 states as of July.

The report noted that 44 states (86%) have infection control requirements in place, 45 states (90%) and Washington, DC, have emergency preparedness requirements established, and 24 states (47%) have quality measurement, data collection or quality management requirements.

“NCAL added these additional categories to the 2023 report because it is important to understand how states are working with assisted living providers to protect residents overall, but especially in preparation for future public health emergencies,” NCAL Director of Policy and Regulatory Affairs Jill Schewe said in a press release. “States are making changes as they determine how to best serve their specific resident populations in the years ahead, and we anticipate this trend will continue.

Although some federal laws and regulations apply to assisted living communities — the Department of Labor Fair Labor Standards Act and Occupational Safety and Health Administration requirements, for example — NCAL maintains that state-level regulation of the sector “ensures an efficient, comprehensive licensure system,” allowing states to effectively coordinate a full range of housing and service programs. Varying state philosophies, NCAL said, enable “provider innovation and piloting of new models of housing plus services that respond to local consumer demand.”

“Assisted living providers are dedicated to delivering high-quality care to their residents every day, and state oversight and support helps them achieve this,” NCAL Executive Director LaShuan Bethea said in a statement. “NCAL supports ongoing collaborative efforts between these providers, state regulators and all stakeholders to ensure accountability, while encouraging innovation all in an effort to honor residents’ unique needs and desires.”

According to NCAL, approximately 48% of assisted living communities are Medicaid-certified as home- and community-based services providers, and almost 17% of residents rely on Medicaid to cover their daily care in assisted living. One in five of all assisted living providers has a unit, wing or floor designated for dementia care or only serve adults living with dementia.

The report provides summaries of select state requirements for assisted living licensure and certification, including information on the state agencies that license assisted living, and recent legislative and regulatory updates affecting assisted living, scope of care, limitations of service, staffing, training and more. In addition, some states refer to assisted living as residential care or personal care, and the report has information on these settings as well as information about person-centered supportive services or healthcare services for older adults and people living with disabilities.

The report is available on the NCAL website.

Increasing COVID-19, influenza and respiratory syncytial virus vaccination rates in older adults is going to require a village to battle vaccine reluctance in the form of misinformation, hesitancy and fatigue, according to senior living experts.

The Centers for Disease Control and Prevention recently released two reports on vaccination coverage and treatment for respiratory viruses. The agency found that vaccine fatigue, inaccurate health information and vaccine hesitancy contributed to lower vaccination rates in older adults. 

A significant challenge is that many people now tend to equate COVID-19 with catching a cold, Argentum Vice President of Government Relations Paul Williams told McKnight’s Senior Living. 

“We need to continue to emphasize how serious these respiratory viruses can be for our residents, who tend to have multiple comorbidities and chronic conditions, putting them at greater risk for serious complications, and even death,” Williams said. “At this point, so many people have made up their minds on vaccination, and trying to get folks to reconsider is an uphill task.”

Many people are “done with COVID” and any discussion of vaccines, he added.

“Vaccine fatigue is real, even though it remains a threat to the older adults we serve,” Williams said.

Raising vaccination rates

According to the CDC, uptake of the updated COVID-19 vaccine is approximately 37% in adults aged 75 or more years, compared with the national average of 19% among all adults. The statistics aren’t much better for the flu and RSV vaccines — only 34% of adults aged 65 or more years had received the flu vaccine as of Oct. 28 and only 17% of adults aged 60 or more years reported receiving an RSV vaccine as of Dec. 23.

Nursing homes have national reporting requirements for resident and staff member vaccination rates, making statistics more readily available than in assisted living, which does not have such requirements. And not all states are mandating or tracking vaccination in senior living community staff members for COVID, RSV or flu.

Williams said that Argentum is hearing that communities with strong leadership often have higher vaccination rates, and that staff members who trust and respect community leaders are more receptive to calls for vaccination and the importance of helping to protect residents and colleagues in the community.

“Communities that involve trusted nurses and clinicians to educate residents and answer questions on the risk and benefits of vaccines have higher rates,” he added. “The use of toolkits and talking points have proven to be helpful but the main barrier to increasing compliance remains ‘vaccine fatigue.’”

Challenges of vaccine reluctance

The challenge in battling vaccine reluctance is not unique to senior living or nursing home providers; it is systemic among the US population at large, according to the American Health Care Association / National Center for Assisted Living.

“As a country, we face significant challenges with vaccine reluctance that require a collective endeavor by public health officials, other healthcare providers and the public,” an AHCA/NCAL spokeswoman told McKnight’s Senior Living. “Assisted living providers remain persistent in talking to family members and residents about their vaccine concerns and appreciate the partnerships of the larger healthcare system to help reinforce the importance of the vaccines.”

Last week, US Department of Health and Human Services Secretary Xavier Becerra met virtually with representatives from LeadingAge and AHCA/NCAL to express concerns about low vaccination rates among residents of nursing homes, which are supported by federal dollars through the Medicare and Medicaid programs. LeadingAge said in a statement after that meeting that it had urged HHS to help ease logistical issues that have slowed vaccination rates and to encourage hospitals to offer vaccines on discharge. 

David Gifford, MD, MPH, chief medical officer of AHCA/NCAL, writing in a column in McKnight’s Senior Living sister publication McKnight’s Long-Term Care News last week, discussed the need for the nation to collectively combat vaccine reluctance. He opined that strides in the right direction since the pandemic have been taken with vaccines, especially in the long-term care industry, but much collective work remains to be done by the healthcare profession to combat widespread hesitancy.

Vaccine fatigue and hesitancy, Gifford said, are “rampant,’ but especially so when it comes to COVID-19 and RSV vaccines. And although vaccine uptake in skilled nursing facilities is higher than in the general community (a number easier to know for nursing homes due to federal reporting requirements), he called for a doubling down on efforts to increase those numbers.

Gifford called for the ready availability of vaccines for residents through on-site vaccine clinics, provider reimbursements and consistent public health messaging. He said many new admissions arrive at an assisted living community or nursing home without being offered or having received the vaccine during visits with physicians in other healthcare settings.

AHCA/NCAL created a #GetVaccinated website last year with resources for providers to secure and administer vaccines on site, as well as resources to help encourage residents and staff members to receive vaccines.

The persistence of a pandemic-associated increase in antipsychotic, antidepressant and anticonvulsant medication use in assisted living residents — and a greater increase in antipsychotic use in dementia care settings — raises concerns about the risks for residents, say the authors of a study published in the January issue of JAMDA–The Journal of Post-Acute and Long-Term Care Medicine.

Prescriptions for antipsychotic medications in assisted living communities increased during the first two years of the COVID-19 pandemic, especially in residents living with dementia, according to the researchers. They examined the proportion of assisted living residents in Alberta, Canada, who were prescribed an antipsychotic, antidepressant, benzodiazepine, anticonvulsant or opioid medication between January 2018 and December 2021. 

Antipsychotic medication use prevalence increased to a larger degree than antidepressant use and was approximately 8% higher for memory care compared with other assisted living residents during the latter two pandemic waves — wave 3 (March to May 2021) and wave 4 (September to December 2021). Assisted living residents not living in memory care settings also showed a statistically significant but small increase in anticonvulsant use during the pandemic waves 2 (September to November 2020, and December 2020 to February 2021) through 4. 

For both assisted living and memory care residents, the pandemic was associated with a statistically significant decrease in benzodiazepine use and no significant change in opioid use, they found.

The study results revealed that the increase in antipsychotic use among assisted living residents in dementia care (3.5% to 7%) was larger than estimates previously reported for nursing home residents living with dementia (more than 1.7%). 

“The significantly greater increase in antipsychotic use among residents of dementia care was surprising given our hypothesis that the presence of specialized dementia care staff and environments might mitigate behavioral changes and antipsychotic use in this population,” the authors noted.

Lead author Colleen Maxwell, PhD, a professor in the University of Waterloo School of Pharmacy in Ontario, told McKnight’s Senior Living that she and colleagues believe that the substantial challenges and losses faced by assisted living communities and nursing homes during the pandemic partially explain the increase in use of the medications. Those challenges included staffing shortages, declines in services and comprehensive integrated care, loss of family caregivers, an increase in resident pain and mental health conditions due to pandemic-related restrictions, and difficulties in implementing nonpharmacologic interventions to address pain, sleep, mental health concerns and responsive behaviors among residents. 

The researchers also said that the increased use of antipsychotic medications in assisted living likely was “inappropriate.” Although they acknowledged that the mental health distress that assisted living residents likely experienced, as well as the lack of nonpharmacologic alternatives early in the pandemic, might have supported the short-term use of antidepressants and antipsychotics, their use remained elevated throughout the pandemic. 

“Prior to the pandemic, there is strong evidence that once started, these medications tend to persist beyond what might be considered an appropriate period of treatment, leading to an increased risk of polypharmacy / hyperpolypharmacy and medication-related adverse events,” Maxwell said. 

She added that when faced with public health crises, it is important that the senior living industry direct careful attention to implementing strategies for the appropriate oversight and administration of high-risk medications, particularly among at-risk residents and those living with dementia. 

A spokesperson from the American Health Care Association / National Center for Assisted Living told McKnight’s Senior Living that the groups have been active partners in a national effort to reduce the unnecessary use of antipsychotics in assisted living and skilled nursing and has made progress in the past decade, including focusing more on nonpharmacologic interventions.

“Along with prescribing physicians and family decision-makers, we must continue to educate ourselves about these conditions and the proper use of medications, as well as explore and promote innovative memory care techniques to help individuals with dementia thrive,” the spokesperson said.

A continuing challenge in assisted living

More than two-thirds of assisted living residents have dementia or cognitive impairment, and antipsychotics commonly are prescribed off-label for behaviors that include aggression, agitation, anxiety, delusions, hallucinations and sleeplessness, according to a 2023 study also published in JAMDA, by researchers from Brown University and the University of Michigan. 

In the early 2000s, studies showed that the off-label use of antipsychotic medications for older adults living with dementia was associated with a higher risk of early mortality, leading the US Food and Drug Administration to issue a “black box” warning on the use of the drugs in this population.

The Centers for Medicare & Medicaid Services, through the National Partnership for Quality Dementia Care, developed quality improvement efforts related to the use of antipsychotics in nursing homes. But evidence was lacking about antipsychotic medication use in assisted living / residential care facilities, staff training and use of nonpharmaceutical interventions and potential discrimination against older adults whose behaviors were deemed challenging, according to a study published in early 2023. 

Reducing the off-label use of antipsychotics in assisted living communities has been a goal of the senior living industry. One of the performance measures used by an assisted living community accreditation program launched in 2021 by The Joint Commission is medication management, specifically, off-label antipsychotic drug use. The National Center for Assisted Living’s Quality Initiative also lists antipsychotic medication use among its goals. 

Improving health-related quality of life for people living with disabilities and chronic conditions is the goal of a new center that will train scientists to address access and quality inequities in rehabilitation and long-term services and supports.

The American Health Care Association/National Center for Assisted Living is part of the effort. 

The Learning Health systems training to improve Disability and chronic condition care (LeaHD) center at Brown University is being launched with a five-year, $5 million grant from the Department of Health and Human Services’ Agency for Healthcare Research and Quality as well as the Patient-Centered Outcomes Research Institute, an independent, nonprofit research organization based in Washington, DC. 

With chronic conditions affecting more than half of US adults, Linda Resnik, PT, PhD, FAPTA, principal investigators said, efforts to address inequities have never been more important.

“A learning health systems approach offers potential solutions by embedding knowledge and best practices into care delivery, thereby supporting improvement, innovation and equity,” Resnik said in a release.

The goal of learning health systems is for patients to receive higher-quality, safer and more efficient care, and for healthcare delivery organizations to become better places to work. The model engages institutional and clinical practice partners in the generation, adoption and application of evidence-based research. 

The effort is a collaboration with the Brown University School of Public Health, the University of Pittsburgh and Boston University, along with nine health system and health organization partners, including AHCA/NCAL. Together the collaborative will identify and develop questions focused on rehabilitation and LTSS for persons with disabilities and chronic conditions.

Research priorities for AHCA/NCAL include evidence-based clinical and functional care approaches for long COVID, efficiency in functional change outcomes and workforce issues affecting care and service delivery in assisted living communities and nursing homes. 

“We’re a proud partner of the LeaHD Center and pleased to hear about this multi-year grant to further improve training and research for rehabilitation and long-term care services,” an AHCA/NCAL spokeswoman told McKnight’s Senior Living. “We look forward to working with the center in future research projects related to disability and chronic condition care to best assist in achieving our mutual mission.”

The LeaHD center is expected to prepare clinician and research scientists for independent research careers in patient-centered outcomes research, or PCOR, and clinical effectiveness research, or CER. 

CER compares the effectiveness of two or more interventions or healthcare approaches. PCOR compares two or more medical treatments, services or health practices and addresses questions and outcomes important to patients and other healthcare stakeholders. 

Senior living operators will continue to face inflationary pressures and capital market challenges in 2024, but some effects may lessen before the year is out, according to industry experts. Expect the workforce-related issues that have dogged providers for years to persist, however, they said.

“The elevated interest rates driven by the Federal Reserve efforts to bring down inflationary pressures had a profound impact on the sector in 2023,” National Investment Center for Seniors Housing & Care President and CEO Ray Braun told McKnight’s Senior Living.

Noting the “significant demographic wave on the horizon,” he said that the past year also saw record absorption of new senior housing inventory as it hit the market. “At the same time, we experienced a marked decline in new construction as well as transaction activity in 2023,” Braun said. “The lending environment and overall cost of capital has been prohibitive and has been a definite headwind.”

Capital still will be constrained early this year, he said, “but we are also hopeful that as the year progresses, we will start to see some improvement on this front.”

National Center for Assisted Living Executive Director LaShuan Bethea singled out inflation as the top issue faced by the industry over the past year.

“Inflation has caused soaring labor costs, in addition to other expenses, and made it difficult for assisted living providers to compete for caregivers,” she told McKnight’s Senior Living. “As a result, assisted living communities have been forced to use more contract nurses and staffing agencies, many of which are charging two or three times more than they charged prior to the pandemic.”

As 2024 dawns, Bethea said, the financial challenges will continue.

“Inflation makes all other expenses in assisted living more expensive, from food to cleaning supplies,” she said. “Additionally, the entire industry is still facing the ongoing ripple effects of skyrocketing costs from the pandemic.”

Assisted living providers, Bethea said, managed their COVID-19 response with little support from the government. According to some estimates, assisted living communities collectively received approximately $1 billion in relief funds, compared with the $12.5 billion received by nursing homes, despite the fact that assisted living providers serve about the same number of older adults and incurred more than $30 billion in pandemic losses and expenses.

“Federal and state policymakers provided little support to these communities in terms of personal protective equipment, testing and staff support,” she said. “Those COVID-related expenses continue today.”

Senior living providers, American Seniors Housing Association President and CEO David Schless said, continue to be confronted by “inflationary pressures across several key expense categories and a significant and rapid increase in interest rates.”

“Ultimately, the top challenge in 2023 was related to the capital markets and liquidity challenges,” he told McKnight’s Senior Living, adding that he expected those issues to continue this year.

“While inflationary pressures appear to be moderating somewhat, the interest rate environment and overall capital market environment for all real estate-based assets will likely remain challenging,” Schless said. “And we know there are many owners facing debt maturities in the upcoming year, which may prove to be extremely challenging with an ongoing liquidity crisis.”

NIC believes that the industry will reach an inflection point this year and that a “reset” will occur, Braun said.

“There will be some distressed inventory and underwater loans that the market is going to have to work through,” Braun said. “We think this reset is going to force a narrowing of the bid-ask spread and some reconciliation around equity contributions to stabilize outstanding debt.”

A ‘patchwork’ system

From a broader perspective, LeadingAge President and CEO Katie Smith Sloan told McKnight’s Senior Living, operators are challenged by “the shortcomings of our current patchwork system of delivering and financing long-term care.”

The association for nonprofit providers across the continuum of aging services is “doing all we can to raise up and urge policymakers and other stakeholders” to address the issue, she said.

“America is experiencing a massive demographic shift with implications for every aspect of society,” Sloan said. “Accessing quality long-term care is very often challenging, for many reasons. There is little political will to address these issues systemically, but policymakers are quick to criticize. Too often, aging services and providers are the scapegoat.”

Policymakers and members of the public must be educated about the industry as a whole as well as the differences between provider types, Sloan said.

“Ensuring that the public understands how long-term care is delivered and paid for — in a patchwork, inefficient system — and that the public appreciates the support that is needed, is critical,” she said. “And then advocating for long overdue change. We’re committed to doing everything we can to achieve that goal.”

Issues related to access and affordability also are on NIC’s radar screen, said Braun, who called them “an ongoing challenge for the sector.”

“NIC has been committed to defining and finding solutions for the middle-market consumer segment, and this work is more important than ever,” he said. “We need to be creative in finding solutions and models that are scalable and will bring forth greater access and options for the wave of baby boomers ahead.”

NIC funded a 2019 study by NORC at the University of Chicago that found that 54% of the 14.4 million middle-income older adults in 2029 in the United States will lack the financial resources to pay for senior housing and care, and a combination of public and private efforts will be needed to address the looming crisis.

More recently, Braun noted, NIC provided funding for the Housing for America’s Older Adults 2023 report, prepared by the Joint Center for Housing Studies of Harvard University. According to findings shared in that report, only 13% of adults aged 75 or more years who are living alone across 97 US metro areas can afford to move into an assisted living community without starting to cash in their assets.

NIC also has partnered with CVS Health to support a soon-to-be released report from the Milken Institute, “Innovative Financing and Care Models to Scale Affordable Housing Solutions for Middle Income Older Adults,” Braun added.

Intertwined with staffing issues

Access and affordability issues are intertwined with senior living’s perennial challenges related to staffing, Braun indicated.

“​​Staffing-related expenses continue to pressure margins, and there is sensitivity to how much of this expense can be passed along to the consumer,” he said, noting that in the first quarter of 2023, the percentage of assisted living rent increases surpassed the percentage of wage escalation.

“We went several years where wage increases consistently exceeded rent increases,” Braun said. “This is an ongoing challenge for operators, who need to ‘read the tea leaves’ and determine how far they can go in rent increases to cover some of these expenses without pricing themselves out of the market.”

Sloan cited labor issues — specifically, recruiting and retaining workers — as the top challenge that has faced senior living owners and operators over the past year. And those issues affect access, she said.

“These challenges are particularly acute in senior living communities that provide skilled nursing and home healthcare,” such as continuing care retirement / life plan communities or assisted living communities where home- and community-based services are provided, she said. “Insufficient reimbursement rates, coupled with a highly competitive labor market, make for a very tough operating environment. Members are having to make hard choices — which service lines to continue, what to reduce — in order to maintain operations. That prospect of limiting older adults and families’ access to much-needed care is really antithetical to our members’ mission. Yet without staff, there is no care.”

NCAL’s Bethea noted that assisted living providers and those they could serve are feeling the pain as well.

“While the assisted living workforce has recovered in many areas, workforce shortages still remain a top challenge, especially in rural areas,” she said. “ Rural areas do not have as many people in general, let alone the qualified caregivers needed to support the communities’ seniors. As a result, assisted living providers are having to compete with other healthcare sectors for new hires or make the tough decision to limit admissions.”

Limiting move-ins, Bethea said, “leaves vulnerable residents displaced from their long-standing communities, as well as reduces their options for quality care. …Families are left scrambling to find new care options and often must travel farther to visit their loved one.”

NCAL, she added, is working with its state affiliates and individual providers to try to find solutions to address workforce challenges so that older adults’ access to assisted living is protected.

Mandate effects outside of nursing homes

Both Sloan and Bethea cited the federal government’s proposed minimum staffing mandate for nursing homes as a potential challenge for other types of providers along the long-term care continuum.

“There’s a bit of irony here. I’ve spent my career in this sector and finally — a true first in a long time — the federal government is focused on aging services and older adults’ access to quality care,” Sloan said. “But the Biden administration is not making the right choices.”

At LeadingAge’s annual meeting in November, Sloan said that even though the staffing mandate proposed by the Centers for Medicare & Medicaid Services directly would apply only to nursing homes, senior living and other providers would be affected because they are “fishing from the same pool” of workers and “there are just not enough people to hire.”

In December, she told McKnight’s Senior Living that “decisions are being made that will have far-reaching impact and potentially negative unintended consequences.”

Bethea predicted that the proposed mandate will be senior living’s top challenge this year.

“With the impending Biden administration’s staffing mandate for nursing homes, assisted living communities are at risk of losing staff,” she said. “No matter where an assisted living community sits on this continuum, a federal minimum staffing mandate threatens to take away the essential staff on which these communities depend to provide high-quality care for millions of residents.”

And because labor shortages can lead operators to curtail admissions, Bethea said, another top challenge for the industry will be to rebuild the capacity to accept new residents.

“As [the] workforce slowly recovers, assisted living providers must do everything they can to effectively communicate that they are willing and able to accept new residents,” she said. 

ASHA continues to pursue a variety of legislative solutions to workforce challenges, including immigration reform, Schless said. “Of course, the politics of immigration reform are extremely challenging,” he added, noting that, with 2024 being an election year, “getting any significant legislation enacted is unlikely,” although “ASHA will continue to look for any opportunities that may add new foreign workers to the workforce.”

Although the situation has improved from the previous two to three years, Braun said, labor issues continue to be a “pressure point” for operators.

“We have seen year-over-year wage increases come down from record highs, and a number of operators are reporting reduced agency dependency, but the challenges have not gone away,” he said.

Operators, Braun said, “need to be better about reducing turnover and ultimately improving the experience of our workforce, which in the end will pay dividends.”

Workforce issues also are a primary concern for affordable senior housing providers, Sloan said.

“Congressionally appropriated funds are critical to both meet rising demand for homes and support the programs for service coordinators, whose work helps residents to age in place,” she said. “Research — and the experience of our nonprofit members who provide federally assisted homes to seniors with low-incomes — show that residents are better able to age in community with improved health and overall well-being thanks to service coordinators’ work, yet for the past  decade, these programs hadn’t received support, until only recently.”

In December, the US Department of Housing and Urban Development released $40 million in new funding for service coordination programs in affordable senior housing. LeadingAge said it was the first service coordinator funding opportunity in 10 years.

A 2015 study by LeadingAge and the Lewin Group found that the availability of an on-site service coordinator, such as a social worker, at federally subsidized seniors housing reduced hospital admissions among residents by 18%. More recent studies found that service coordinators improved affordable senior housing resident resilience during the COVID-19 pandemic.

But “even with recent support, there are still significant unmet needs,” Sloan said.

Looking to the future

Looking toward the future, Braun said that the industry is “going to have to refine the owner-operator relationship in some cases.”

“We remain a fragmented space with many different owners and operators, and those relationships can be complicated depending on experience in the sector and generally a limited set of industry standards for measuring and defining quality,” he continued. “NIC is working with some others on this very topic. We think it will be critical to advance the sector in this regard as we prepare for the wave of new development that will come once the capital starts to free up.”

Look for the topics to be covered in educational sessions, forums and networking opportunities at the 2024 NIC Spring Conference, Braun said.

Meanwhile, Sloan said that LeadingAge members “are laser-focused on reimagining themselves for the future.”

“We know that the majority of Americans want to age in community, in their homes. That’s an opportunity for providers across the spectrum,” she said. “The big question for our members is determining the path that is consistent with their mission and sets them up to be successful well into the future. It’s really about making the smart and strategic choices and executing on them while at the same time navigating workforce shortages and other pressing issues.”

To educate potential residents and their families about senior living options, Schless said, ASHA will be re-launching a “completely overhauled” version of its consumer website, Where You Live Matters, this year.

Bethea said that quality will remain a top focus for NCAL and its members in 2024.

“Assisted living continues to deliver high-quality care in a safe, homelike setting that offers the ability to meet residents’ needs,” she added. “The only thing the current labor shortage has impacted is access to care, not quality. The caregivers in our assisted living communities are dedicated individuals who are committed to continuous quality improvement.”

According to the Post’s research, more than 2,000 residents wandered away from or were “left unattended for hours outside” of senior living communities from 2018 to 2023, and 98 of them died. (Read this article to learn more about the response of industry advocates.)

It isn’t the first time the industry has been scrutinized by the national lay press, of course, and it won’t be the last.

In fact, the Post articles follow the November publication of a package of articles by the New York Times and KFF. That report, titled “Dying Broke,” scrutinized an industry pricing structure that adds fees on top of basic charges, to cover additional services such as help with activities of daily living, insulin injections and blood pressure checks. It also cited the growth of rate increases, the for-profit status of most providers, and the operating margins they see.

Other examples of somewhat recent unflattering coverage of the industry include a 2017 report by CNN that counted more than 16,000 cases of sexual abuse in assisted living communities and nursing homes since 2000 and, on a more local level, articles about the senior living industry in the Minneapolis Star Tribune and Atlanta Journal Constitution in 2017 and 2019, respectively.

Although such attention can lead to efforts to try to increase state regulation of operators, in a recent interview I conducted with Nexus Insights and National Investment Center for Seniors Housing & Care founder Bob Kramer (not about these media investigations), Kramer said he believes that the government’s “desire to invest the money to set up a federal regulatory apparatus is still going to be lacking,” although “there will be a lot of noise” about it.

A 2018 report by the Government Accountability Office certainly generated some “noise” when some federal lawmakers and consumer advocates said they would push for changes in assisted living because of the report’s findings. But the report’s to-do list primarily was for the Centers for Medicare & Medicaid Services and state Medicaid agencies related to state reporting of deficiencies in care and services provided to some assisted living residents.

Still, at a time when demographics mean that a larger number of older adults will be in the market for senior living in the coming years, operators can expect the scrutiny to continue.

As Kramer told me: “The reality is that there are good operators and not-so-good operators.” Even well-intentioned providers may find themselves challenged by staffing shortages, although many have limited move-ins in an effort to better align staffing and resident needs.

“The more the industry can articulate and, in a sense, hold itself accountable for higher standards of care, the better off the industry will be, because we don’t want to go the direction of skilled nursing,” Kramer said as I interviewed him on the occasion of McKnight’s Senior Living’s 20th anniversary. (If you haven’t seen the cartoon of him on the first-ever cover of our print magazine in 2003, you can see it here.)

And therein lies the opportunity.

Possible solutions are suggested in the Post coverage, among them training, increased vigilance and more accurate risk assessments. Industry advocates also point to their efforts to attain and maintain quality among providers.

“Our association has participated in multiple efforts to build sector consensus on assisted living quality measures and other topics,” LeadingAge President and CEO Katie Smith Sloan said Sunday in response to the Post’s coverage.

For instance, LeadingAge, Argentum, the National Center for Assisted Living and the American Seniors Housing Association 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. Infection prevention and control was the initial focus of the effort, called the Quality in Assisted Living Collaborative. The work “will help the sector collaboratively address the most urgent issues,” Sloan predicted at the time.

On top of that effort, NCAL offers its National Quality Award program, and Argentum offers several certificate and certification programs, just to name a few quality-focused initiatives. And providers can pursue efforts outside of those offered by industry membership associations, such as assisted living accreditation and memory care certification through The Joint Commission.

Keep it up. The Post is. The media outlet promises to continue to report on the assisted living industry and is soliciting information from readers about their “experiences with elder care, assisted living and dementia care.”

Lois A. Bowers is the editor of McKnight’s Senior Living. Read her other columns here.

Senior living industry leaders stressed their belief in the importance of quality, safety and accountability Sunday in response to a package of articles in the Washington Post titled “Memory Inc.,” about assisted living and memory care community residents who had eloped and died. Many communities are “dangerously understaffed,” an article in the report alleged.

“Since 2018, more than 2,000 people have wandered away from assisted-living and memory-care facilities unnoticed or been left unattended for hours outside,” according to another article in the report, published Sunday, which counted 98 deaths among whom the authors described as “walkaways.” The writers said that their calculations were based on an “exhaustive search of inspection results, incident reports and media accounts nationwide” but that because they were unable to obtain records in all states, “the data … is certainly an undercount.”

“The bulk of the official records came from 29 states that make current reports public online. Two additional states said they had no incidents; 10 did not provide records nor do they make them available online; some provided only partial records,” they wrote. The article detailed several instances of residents wandering outside and subsequently dying after spending too much time in excessive cold or hot temperatures or under other circumstances.

“In case after case examined by The Post, inspectors cited evidence of too few people on duty to care for the number of residents, of staff ignoring alarms, of skipped bed checks and staff sleeping on the job, of general neglect and, in a few cases, falsified records,” the authors said.

‘Nothing more important than safety’

Argentum President and CEO James Balda told McKnight’s Senior Living: “Nothing is more important than our residents’ safety, and any fatality is one too many. Any community in which an incident occurs is subject to appropriate state regulatory penalties, up to, and including, loss of license.”

Argentum was one of the major national associations that advocates on behalf of providers and was quoted or mentioned in the report. The National Center for Assisted Living, the American Seniors Housing Association and LeadingAge also were included.

“To be clear, LeadingAge has no tolerance for bad care, and quality is a top priority for our nonprofit, mission-driven members,” LeadingAge President and CEO Katie Smith Sloan told McKnight’s Senior Living.

Older adults and their families, she added, “deserve a strong national aging services system that supports and sustains providers of high-quality assisted living, including adequate and well-trained staff,” and elected officials and other stakeholders should “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.”

The report shared factors known by those active in the field — that assisted living mainly is regulated at the state level, that care and services primarily are paid for via residents’ private funds, that retaining staff members remains a challenge and that pay for aides averages “less than most Starbucks baristas.”

It also maintained that, in elopement cases, “[f]acilities and senior managers largely have not faced serious consequences,” that “regulatory fines seldom exceed $10,000,” and that “[t]he biggest financial risk facilities face usually comes from lawsuits,” which are “typically covered by operators’ insurance.”

‘Multiple efforts’ related to quality

State oversight of the industry “is often weak in several areas,” the authors wrote. For instance, they said, their analysis found that only 13 states mandate a minimum number of on-duty caregivers per resident, that only nine states require caregivers to obtain at least six hours of training about caring for residents living with dementia, and that information about violations is incomplete or not available to the public online in 21 states. Overall training requirements, the authors added, vary from five to 90 hours across states where an amount is specified, although many states mandate training but do not specify an amount.

“Our association has participated in multiple efforts to build sector consensus on assisted living quality measures and other topics,” Sloan said. “Our engagement in those, as well as our advocacy, educational and research efforts to improve care throughout  aging services, are ongoing and, given the stresses of our country’s current approach to long-term care financing, increasingly urgent.”

In one effort this year, 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. Infection prevention and control was the initial focus of the effort, called the Quality in Assisted Living Collaborative. The work “will help the sector collaboratively address the most urgent issues,” Sloan predicted at the time, and Balda said that the initiative ultimately could lead to greater consistency across the states.

“Assisted living will continue to evolve with our country’s changing needs. Regulations, staffing needs and training requirements must evolve with them,” Sloan said Sunday.

In a statement to McKnight’s Senior Living on Monday, NCAL said: “The assisted living profession remains steadfast in constantly improving and adapting to meet the needs of their residents, including those living with dementia. We will continue to seek out opportunities to work with policymakers and stakeholders to advance high-quality, personalized assisted living care.” 

‘Overwhelmingly popular’

Balda pointed out Sunday that “[a]ssisted living and memory care communities are overwhelmingly popular with residents and their families. Our communities offer choice and dignity to 1.4 million seniors each day, and surveys find that 94% of residents report good or great satisfaction, and 91% say they feel safer than living on their own.”

In a recent J.D. Power satisfaction study, he added, assisted living and memory care communities were found to be “overwhelmingly popular with residents and their families,” scoring 837 on a 1,000-point scale.

“Professionally managed communities have security procedures such as exit/entry logs, wearable tracking devices, and cameras in place to keep residents safe, and unless an independent physician has deemed them a risk for their own safety, they are free to come and go from their home as they choose,” Balda said.

The association, he added, has “serious concerns about the validity of the Post’s data,” but “even taking it at face value, fatalities due to wandering are 0.0015% of the more than 6.2 million assisted living residents served in the last five years.”

In its statement, NCAL said that the stories in the Post report were “tragic,” and the association expressed condolences to those affected. “However, these rare incidents are not indicative of the life-affirming experience that 99.9% of assisted living residents typically receive,” NCAL said. “Caregivers make the safety and well-being of every resident their utmost priority, and their passion for serving seniors is evident through the high levels of satisfaction that residents and their family members report each year.”

ASHA President and CEO David Schless told McKnight’s Senior Living that the association had not yet issued a statement on the Post’s report.

On Monday, Argentum posted on its website additional information about its reaction to the series as well as links to all of the Washington Post articles.

REITs a focus as well

Senior living organizations were not the only focus of the report. Another article in the story package concentrated on real estate investment trusts, especially Toledo, OH-based Welltower, which, according to the 2023 ASHA 50 list, is the largest owner of senior living properties.

Many assisted living communities, the Washington Post authors wrote, “are now held by investors under pressure to produce profits for shareholders. In some places, a bare-bones approach to staffing and pay has produced a chaotic environment where medications are missed, falls and bed sores go unnoticed, residents are abused and confused seniors wander away undetected.”

One former Balfour Senior Living executive, who was not named in the report, told the media outlet that Welltower, which owned the operator’s buildings, would not let the company give raises “to hire and train more and better workers to improve safety” because it was concerned about the potential effect on profitability.

A Welltower company spokesperson told McKnight’s Senior Living that “[c]ontrary to the allegations … Welltower did not oppose wage increases for Balfour employees at the property in question.”

The Washington Post report, the spokesperson said, “contains numerous inaccuracies, hearsay from anonymous sources and demonstrates a general lack of understanding of the industry.”

The Welltower spokesperson said that the REIT “has continuously supported the investment by its operators in human capital and did so throughout the pandemic and the extreme staffing crisis that the world was navigating. In fact, since 2019, compensation expense per resident has increased over 23% across the Welltower portfolio with compensation at the Balfour properties increasing by a comparable amount.”

The REIT also “is innovating and investing in technology and tools to improve the resident and employee experience,” according to the spokesperson.

“We operate in the competitive private-pay seniors housing market,” the spokesperson said. “Ensuring that our operating partners are able to provide residents with high-quality care and a fulfilling experience are the key factors that result in residents choosing to move into our properties, in turn driving our long-term success.”

A source close to the Washington Post reporting told McKnight’s Senior Living that “well before publication,” the REIT was sent Welltower-related details that were planned for the article and that spokespeople for the REIT “repeatedly” declined to provide a comment. Additionally, the source noted that the article reported that Balfour and Kisco representatives did not respond to “numerous” requests for comment and that a Lavender Farms manager declined to answer questions from a reporter from the media outlet who visited the site.

A Washington Post spokesperson told McKnight’s Senior Living that the publication stands by its reporting.

Another report

The Washington Post articles come on the heels of a package of articles published in November by the New York Times and KFF. That report, titled “Dying Broke,” scrutinized an industry pricing structure that adds fees on top of basic charges, to cover additional services such as help with activities of daily living, insulin injections and blood pressure checks.

The package also had cited the growth of rate increases, the for-profit status of most providers, and the operating margins they see. And it reported the results of a survey that in part found that 66% of Americans aged 50 or more years are “mostly” or “somewhat” anxious about being able to afford the cost of an assisted living community or nursing home if they need to move to one.

In response, association leaders submitted letters to the editor to the New York Times.

The Washington Post’s “Memory Inc.” package of articles:

Dozens of assisted-living residents died after wandering away unnoticed

Senior homes left dangerously understaffed amid assisted-living boom

How your state regulates assisted-living facilities

Questions to ask before choosing an assisted living facility

Facilities where seniors died after walking away or being left unattended

A coalition of senior living, healthcare and veterans organizations collectively provided their continued support in a letter sent Thursday to House and Senate leadership for an assisted living pilot program geared toward serving veterans.

The American Seniors Housing Association, Argentum, LeadingAge and the National Center for Assisted Living signed a letter advocating for the Expanding Veterans’ Options for Long Term Care Act. The bill would establish a three-year pilot enabling some veterans to have their care needs met in an assisted living community rather than a Veterans Affairs home.

The associations previously voiced their support for the bill, which was reintroduced earlier this year after going nowhere last year. The House Committee on Veterans’ Affairs Subcommittee on Health held a hearing this summer on the bill, which received the support of the US Department of Veterans Affairs — with conditions. 

The VA indicated that having the authority to provide assisted living services would help the agency find a place veterans who need such services but don’t qualify for nursing home care. But a VA representative testified that the agency would need more time and resources to implement the program. 

In its letter to House and Senate leadership as well as Veternas’s Affairs Committee leaders, the coalition called the proposed pilot program an “economically sound and sensible approach to demonstrate the benefits” of assisted living, and that the bill gives the VA the authority to offer additional options in its long-term care programs.

“It provides VA the critical flexibility to address the needs of a rapidly growing population of aging or disabled veterans who are not able to live at home, and future cost savings will help more veterans receive the assistance they need,” the letter read. “The timing is right for such action given what we know about aging and the increasing demand for supportive services.”

Pointing to statistics from a 2020 VA report, the authors noted that the number of veterans eligible for nursing home care will increase 535% over the next 20 years. The letter also noted that costs to the VA for nursing home care alone are not sustainable and that assisted living offers “significant cost savings” for those who don’t require a high level of medical care.

Additional signers of the letter were the AARP, the Alzheimer’s Association and the Alzheimer’s Impact Movement, DAV, Iraq and Afghanistan Veterans of America, the National Association of State Veterans Homes, the National Rural Health Association and Paralyzed Veterans of America.