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Assisted Living Facilities Facing New Strain as Residents Become Older, Sicker

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For decades, assisted living has been seen as the ideal bridge between independent living and skilled nursing care. When mom or dad needed a little extra help with activities of daily living, such as assistance getting dressed or reminders to take prescriptions, assisted living facilities were designed to meet the need. One industry source pegs the current U.S. assisted living population at 810,000, with demand expected to top 1 million beds by 2040.

But are assisted living facilities and staff up to the challenge of caring for older, sicker residents? According to a comprehensive report spotlighted in a late-2022 article from KFF Health News, the answer is no – and the concern is growing among industry experts that the crisis in assisted living will only get worse as an aging population and rampant staffing shortages put a growing strain on a woefully overtaxed system.

The KFF Health News article was written by the excellent reporter Judith Graham. It’s a powerful early warning to families searching for the ideal living situation for seniors in need of extra aid.

Assisted Living Facilities Aren’t Meeting Resident Needs

A recent report published on the JAMA Network by a diverse panel of experts has found that assisted living communities too often fail to meet the needs of older adults. In her sobering Kaiser Health News article, Graham calls this, “a clarion call for change inspired by the altered profile of the population that assisted living now serves.”

She writes, “Residents are older, sicker, and more compromised by impairments than in the past: 55 percent are 85 and older, 77 percent require help with bathing, 69 percent with walking, and 49 percent with toileting, according to data from the National Center for Health Statistics.”

The litany of health concerns doesn’t stop there. “Also,” Graham continues, “more than half of residents have high blood pressure, and a third or more have heart disease or arthritis. Nearly one-third have been diagnosed with depression and at least 11 percent have a serious mental illness. As many as 42 percent have dementia or moderate-to-severe cognitive impairment.”

Assisted Living Care Standards are Inadequate

According to the experts, assisted living facilities have not kept up with the changing nature of their clientele and have adopted no widely accepted standard of care. To this end, the experts provided 43 recommendations in the report for what they hope will be a new set of standards.

One such set of recommendations addresses staffing. Graham writes, “The panel proposes that ratios of health aides to residents be established and that either a registered nurse or a licensed practical nurse be available on-site.” (Graham notes that the panel did suggest further research on staffing requirements was necessary before they could advocate specific recommendations.)

Assisted Living Facilities Struggle to Hire, Retain Staff

This warning about staffing is especially timely, the article states, since assisted living operators are still struggling—like so many in their field—to hire and retain staff in the aftermath of the COVID-19 pandemic, with a majority reporting a “moderate” or “high” level of staffing shortages.

KFF Health News reports that inadequate staffing has in turn led to very poor handling of sensitive problems. Residents are often left without help when they fall and need assistance, or cannot get someone to aid them with toileting or other crucial functions.  The article includes anecdotal evidence of substandard care bordering on neglect.

Pandemic Deaths Point to Staff Training Inadequacies

The COVID pandemic had other effects on the industry, as reflected in the panel’s findings. Graham writes, “The panel also recommended staffers get training on managing dementia and mental illness, on medication side effects, on end-of-life care, on tailoring care to individual residents’ needs, and on infection control — a weakness highlighted during the height of the pandemic, when an estimated 17 percent more people died in assisted living in 2020 compared with previous years.”

Dr. Helen Kales, a department chair at UC Davis Health, urges facilities to focus on training their staff members properly and thoroughly, remarking that “the better trained staff are, the more likely they are to provide high-quality care to residents and the less likely they are to feel frustrated and burned out.”

Memory Care Facilities Receive Special Scrutiny

This urgent need for training is especially acute in memory care, whether it is offered as a stand-alone facility or as a wing in a larger community. The experts discovered that so-called “memory care” can often cost extra, up to thousands of dollars more per month, and yet the only difference can sometimes be a locked door to prevent residents from leaving the unit. This is a far cry from the sensitive and personalized care that these facilities often advertise.

“Because dementia is such a pervasive concern in assisted living, the panel recommended that residents get formal cognitive assessments and that policies be established to address aggression or other worrisome behaviors,” Graham writes.

Assisted Living Facilities Need “More Enlightened” Approach

Kales suggests that, as part of a more enlightened approach to memory care, non-pharmaceutical strategies might be worth exploring, such as aromatherapy or music therapy. Another strategy could be closer observation of resident behavior, to catch early signs of deterioration and call for pre-emptive medical or psychiatric evaluations.

Graham notes that the personal touch so essential to effective senior care is often ignored. “Further recommendations from the panel emphasize the importance of regularly assessing residents’ needs, developing care plans, and including residents in this process,” she writes.

The Assisted Living Industry Agrees – but Worries About the Cost

The industry has so far been cautiously open to the panel’s recommendations, and spokespeople say that many facilities are already following them. But according to LaShuan Bethea, the executive director of the National Center for Assisted Living, the issue is practicality and cost.

“We need to understand what the feasibility would be,” she says, and has suggested that a broad study could look into this. “In the meantime,” she adds, “states should examine how they regulate assisted living, taking into account the increased needs of the residents.”

Assisted Living Facilities Lack Federal Oversight

Graham explains, “Because the nation’s roughly 28,900 assisted living communities are regulated by states and there are no federal standards, practices vary widely and generally there are fewer protections for residents than are found in nursing homes. Some assisted living facilities are small homes housing as few as four to six seniors; some are large housing complexes with nearly 600 older adults.” As noted above, over 800,000 individuals live in these communities.

Gaining a better understanding of the different “flavors” of assisted living, their proper names, and who they are best suited to care for, would go a long way toward moving the industry forward, according to the panel.

Future of Assisted Living is Unclear

Graham points out that the original idea of assisted living was supposed to be a social rather than a medical model, “a home-like setting where older adults could interact with other residents while receiving help from staff with daily tasks such as bathing and dressing.” But sadly, this doesn’t reflect the reality of the greater need, anymore, and has become outmoded.

Tony Chicotel, a panel member, thinks that assisted living should roll with the times, but still hopes it doesn’t become more of a medical model, like nursing homes. 

“What’s interesting is you see nursing homes pushing to get to a more homelike environment and assisted living needing to more adequately manage the medical needs of residents,” Chicotel says. “That said, I don’t want assisted living facilities to look more like nursing homes. How this all will play out isn’t at all clear yet.”

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(originally reported at

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