SAN DIEGO — Senior living operators and association officials discussed major trends facing operators in a Monday session at the American Health Care Association / National Center for Assisted Living annual convention, and it didn’t take long for clear themes to emerge.

Not surprisingly, recruitment and retention of workers was a powerful concern.

“We’re at like 3.7 or 3.9 [percent unemployment nationally],” noted session moderator Ed McMahon, vice president for quality for Sunrise Senior Living and an NCAL board member.

“For all intents and purposes, there are no people out there to work,” he said. “Plus, we have an immigration crisis. We’re having a hard time even finding folks.”

Increasing wages, worsened by metro areas such as a San Francisco either moving or having moved to a $15 per hour minimum wage, have further squeezed operators, McMahon said.

“The wage pressure is on us — and the people we can’t find to work for us,” he added. “It makes for an interesting conundrum.”

Another one of the trends pinching senior living operators is increased regulatory pressure, panelists said.

“Twenty-nine different states had changes to their regulations [over the past year],” McMahon noted, a fact NCAL recently shared in its Assisted Living State Regulatory Review. “What we’re seeing is, they’re pulling a lot of info from what [the Centers for Medicare & Medicaid Services] is doing” on the skilled nursing side. “Even though we’re not federally regulated, federal regs are seeping into the state regs.”

Another trend, rising acuity, was linked to the way assisted living nurses have to coordinate more clinical care than ever before. Sometimes, what they’re doing is far beyond their historic scope, he said, and sometimes it pushes legal boundaries.

“Nurses are now having to stage pressure ulcers, providing dressing changes, but they’re not the direct providers of that care, by law,” McMahon noted. “There’s a real blurring of the lines here [between assisted living and skilled care]. Some states say if you have a Stage 2 pressure ulcer, you cannot stay in assisted living. You have to go to skilled care.”

Increasing substance abuse and drug use is another contentious trend McMahon identified, and it circles back to staffing challenges. Medical and recreational marijuana, as well as the opioid crisis, have hit resident and worker populations alike.

“In the state of Colorado [where marijuana use is legal], we had a problem finding anyone who could pass a drug screen. No one,” McMahon commented. “So do we change [standards]?”

Lisa Erwin, executive director at The Sequoia Assisted Living in Olympia, WA, said that decision already has been made at her community.

“We have zero tolerance [for non-clinically indicated drug use by staff] but will change it,” she said with an air of resignation. “If we had to enforce it now, we’d probably lose 50 percent of them. It’s legal, like drinking wine at night, but we’re not treating it like that, so it’s difficult.”

She also identified resident-on-resident bullying as a major challenge for operators. The intransigence of some bullies, whether or not it might be fueled by dementia, can cause emotional and physical harm to fellow residents and tie directors and managers in knots due to government reporting requirements, Erwin said.

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