​Staffing has long been one of the most pressing challenges in the long-term care industry. Chronic shortages are a persistent issue, and the new Centers for Medicare & Medicaid Services (CMS) regulations, which increase staffing requirements, have only added to the complexity. As providers grapple with these demands, one strategy gaining traction is the reconfiguration of skilled nursing facilities (SNFs) into spaces with less intensive staffing needs, such as assisted living facilities (ALFs). This approach not only reduces operational costs but also revitalizes the care offerings of long-term care campuses. Here’s a guide to successfully transition a skilled nursing facility to an assisted living model.

Step 1: Define Program Goals and Engage Stakeholders
The first step is to set clear program goals and define the elements you want to incorporate into the new environment. To ensure a resident-centered and operationally efficient design, include input from both residents and staff.

Key considerations:

• Target Resident Demographics: What level of care will the facility provide? Will it cater to residents with early cognitive impairments or focus on general assisted living?
• Licensing Requirements: Collaborate with state authorities to understand the licensing processes and requirements for transitioning your building(s).
• Operational Balance: Work closely with staff to align care and service offerings. For instance:
• How will food service staff interact with residents and colleagues?
• What meal delivery methods will be used, and will residents participate in cooking activities?
• How can efficient layouts minimize staffing needs?

Collaborating with an architect to address these elements is crucial. Owners should clearly outline expectations for critical systems such as wander management; nurse call systems; heating, ventilation, and air conditioning (HVAC); and emergency power backup. Additionally, plans for new safety procedures, including updated fire safety protocols, must be established to ensure compliance during construction.

Step 2: Assess the Current Facility

To make informed decisions, conduct a thorough evaluation of the existing facility or campus to determine its suitability for the new use. Building codes and design requirements for assisted living differ significantly from those for skilled nursing facilities.

Structural Modifications:

• Corridor Widths: Assisted living facilities do not require the 8-foot-wide corridors mandated for SNFs. Explore opportunities to repurpose this space to enhance unit layouts.
• Kitchenettes: Adding kitchenettes to units is a common upgrade. Plan how to reconfigure existing spaces to accommodate these features along with living and dining areas.
• Property Layout: Aim to move away from the institutional feel of SNFs by introducing design elements to enhance the architectural rhythm, such as wall bump-outs and accent lighting in corridors to create a warm and inviting atmosphere.

Safety and Compliance:

• Fire Protection: Unlike SNFs, community-based residential facilities (CBRFs) often require smoke detectors connected to a central alarm system in each resident-occupied space. Address any gaps to meet these requirements.
• Evacuation Standards: Depending on the physical and cognitive capabilities of a resident’s ability to self-evacuate, assisted living facilities may require residents to be ambulatory and capable of self-preservation during emergencies. Adjustments to window operation, door hardware, and resident room layouts may be necessary to meet these standards.
• Lighting and Ventilation: Evaluate the need for additional windows or daylighting to create a comfortable environment for residents in shared spaces.

Compliance with building codes is paramount. States often adopt the International Building Code (IBC) but may also have unique requirements. Engage an architect familiar with local codes to navigate these complexities and consult with the authority having jurisdiction (AHJ) early in the process.

Step 3: Avoid Common Pitfalls
Transitioning a skilled nursing facility to an assisted living model is a complex process with potential obstacles. Here are some key pitfalls to watch for:

• Licensing and Timeline Oversights: Ensure that licensing requirements are well understood and that submissions to the AHJ are timely to avoid construction and licensure delays.
• Resident Disruptions: Minimize disruptions during renovations by creating viewing areas, offering guided tours, and maintaining operational support spaces. Consider temporarily relocating residents who may struggle with the changes because of physical challenges or emotional distress.
• Mechanical, Electrical, and Plumbing (MEP) Systems: Understand how these systems are integrated throughout the building. Proper planning is essential to keep them operational in occupied areas during construction.
• Lack of Coordination: Engage with the AHJ early to confirm requirements, seek variances where needed, and secure consensus with code officials on the overall plan.
• Construction Oversights: Obtain approvals and inspections at critical milestones. For example, ensure equivalent construction ratings are maintained and avoid exceeding allowable building areas.

Step 4: Foster Clear Communication and Collaboration
Effective communication is the cornerstone of a successful transition. Establish clear lines of communication among owners, architects, construction managers, and code officials to:

• Clearly define licensing requirements and building modifications.
• Manage cost issues and set realistic budgets.
• Document responsibilities to avoid misunderstandings and overlaps.

Owners play a pivotal role in leading these efforts, ensuring all parties are aligned and focused on meeting project objectives.

Step 5: Set Yourself Up for Success
Transforming a skilled nursing facility into an assisted living model is a multifaceted endeavor that requires careful planning and execution. By defining program goals, assessing the facility’s capabilities, avoiding common pitfalls, and fostering collaboration, you can navigate the complexities of this process with confidence.

This transition offers a unique opportunity to create a modern, resident-centered care environment while addressing staffing challenges and operational efficiencies. With thoughtful planning and execution, providers can successfully reimagine their care offerings and meet the evolving needs of their communities.

Julie Heiberger, AIA NCARB LEED AP, is a senior project architect and the senior living market leader for Hoffman Planning, Design & Construction, Inc. with more than 30 years of experience. A member of the American Institute of Architects and the National Council of Architectural Review Boards, Julie received her Master of Architecture from the University of Wisconsin–Milwaukee. She can be reached at jheiberger@hoffman.net.