Person-Centered Care for Residential Assisted Living in Practice

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By: Alexandra Cohl

Interview with Dave Risi: Evermore Senior Living, Residential Assisted Living, and Opening During a Pandemic

This week, I spoke with Dave Risi, the owner and operator of Evermore Senior Living, a residential assisted living space that opened in Lake Ridge, Virginia during 2020. Dave has been working with the JSR team to build this facility and create a space that fulfills the needs of its residents. He and I spoke about the inspiration behind Evermore, how the person-centered approach benefits both residents and staff members, and the challenges—and surprising benefits—of opening during a pandemic. This conversation was full of laughter and good humor, so be sure to insert some laughs in your head as you are reading through. You can learn more about Evermore here.  

 

 



This interview has been edited for clarity and flow.


Dave, thank you for joining me today to talk about Evermore Senior Living. As the owner, can you tell me a little bit about what you do there?

 

Thank you for inviting me. It’s an honor to be here. So I am the owner and operator of Evermore Senior Living, and I have a background in health and safety. I’ve been doing health and safety for about 30 years and decided, “You know what? It’s the right thing to do at the right time.” So, I am not there for day-to-day operations, but I’m there to make sure that our staff has everything they need to be successful.

Front Entrance, Evermore Senior Living

Front Entrance, Evermore Senior Living

 

In terms of how it all got started, what was the inspiration point behind that?

 

It’s actually a cool story. Going back probably four years ago, we were looking for a place for my father-in-law—he’s a soft, gentle, little Sicilian man who’s really not outgoing and kind of reserved—and we were looking around for a place because it just became too much for my mother-in-law and we were seeing her age from being the caregiver. It was just too much for her. So, he and I got in the car and drove around, and I took him to a couple of larger facilities. And he looked up at it, looked down to me, and looked back up at it, and he’s like, “I’ve lived in a house my whole life, you know, I don’t wanna live in a condo,” and I’m like, “That’s cool. I heard that there’s some of these smaller homes that are being renovated. Let’s go check those out.” So, on my own I went and looked at a few and to be blunt, I was appalled. Some of these homes you walked in and you would have sworn there were 50 cats living in the house. It was just disgusting. The food was bad, they just parked people in front of the TV, and left them alone. And after being appalled I’m like, you know what, I’ve done real estate for years, and I know I could do this better. That was kind of the inspiration behind the whole thing, and when we started working with Jane, it was just a God-send. She’s been fantastic to help direct us and make sure we do it right, you know?

 

I love hearing the background. So, is your father-in-law now living in one of those spaces and loving it?

 

He would. Unfortunately, he passed. The time it takes to architect, engineer, buy our land, and everything else, it just took too long. But, we kind of dedicated the place and the whole concept to Frank.

 

That’s beautiful, and I’m sorry to hear that. So, we’re definitely going to get into the work you’ve been doing with JSR, and this might actually come up in your answer to this next question, but I love that there is a 4 to 1 ratio of residents to staff members. It is very much person-centered care, and I’m wondering how have you been able to do that because I know in other assisted living spaces, that’s not always possible.

 

So with only eight residents, the goal is to have at least two caregivers around there. If one resident is in high need of help, you still have somebody watching the fort, so to speak. They are the caregivers in these smaller homes, and they’re doing more than just caregiving. They actually get involved and help serve the food. They do the laundry. They’re doing other activities that they may not be doing at the large facilities.

 

That was a little challenge when we started interviewing people. They were like, “Oh, I need to…” and I’m like, “Yeah, we’re all in it.” This is a family-type environment and everybody rolls up their sleeves, and everybody pitches in, and it is different for our CNAS and med techs because they are going to do more activities than they would normally do. But it’s really a home environment.

 

When they walk in, they’re not really reporting to work. They’re just coming into a different home. They’re only dealing with eight residents, so they know a lot more details about them, and they can get a sense if they’re even just not having a good day. The level of care is a lot higher.

 

Yeah, and I imagine the quality of life of the residents is much higher, too, because they can actually build really close relationships with the staff members.

 

Exactly, exactly.

 

Last month, I spoke to Shernise and she told me a bit about Residential Assisted Living (RAL), and how it works, and I have two questions. My first question is based on what you just said and what I learned from Shernise. The eight residents aren’t necessarily related—though they could be—but that’s not really the normal situation. So, since they aren’t, how do residents normally get grouped together? Is there a system for that or does it happen randomly, based on what’s available? I’m very curious.

 

Resident Bedroom, Evermore Senior Living

Resident Bedroom, Evermore Senior Living

It’s really random. We do have a husband and wife that’s looking at us. So, we might have a husband and wife where we might need to put two in the room, which our rooms are big enough to handle that. Or, we can bust down a wall and stick a doorway between the two. Or, they may want to be separate. You don’t know.

 

But, one of the key things that Shernise and the team brought to my attention was that it’s good to have multiple seating areas. Kind of how I relate to it now is our first couple of residents were gentlemen, which is ironic, but all these guys started moving in, and they all love sports, so they are in front of the 70-inch big screen, and they’re watching sports and their loving life and with each other, having fun. Well, then we have ladies move in, and they want to watch Hallmark. So we said, “Well, it’s good they’ve got a second seating area.” We actually have a second seating area, and it has worked out well to keep them separated that way.

Resident Living Room, Evermore Senior Living

Resident Living Room, Evermore Senior Living

 

That’s so fun. Second question, and you touched on it a little bit just now, but as the client to JSR, what was that process like from start to finish? I know Evermore is still relatively new, so were there any challenges that you learned or faced that you hadn’t initially anticipated?  

 

Yeah, I’ve got so many stories I could tell you. It was really like drinking from a firehose. It was amazing when I started getting involved in that, and they started talking about things like the right building code for the State of Virginia for Prince William County and I didn’t know. So, then they did a deep dive in and went through that analysis and meeting with the county to go through the building codes and get involved with things like the fire sprinkler systems.

The challenge with Residential Assisted Living is that there’s no black and white way to build these homes in most locations. So, every time that we met with somebody with the county or with the state, you’d have to explain what it was.

 

And they kind of shook their head and would go, “Well, I’m not sure exactly how to address that question.” So, we were literally coming up with standards of how we’re going to build out the house. It wasn’t like we were building a 200-person facility where you know exactly what to build. This is a very different process. Working with Jane’s team—if there were one extreme of level of professionalism and building out a quasi-commercial facility, on the opposite end, I had my builder and this gentleman has been building residential homes for almost 40 years. Good, old boy, you know, country boy. So, it was kind of the yin and the yang.

 

Between the two of them, what we built was perfect. Because there were some things that were starting to go down the road of a little bit too much commercial and then my builder was a little bit too much residential, and each time there were questions or issues or things that we needed to go through, and the three of us sat down and rolled our sleeves up and discussed it. We came up with great answers. But, I think it was a learning curve for all three of us to be honest with.

 

Yeah, that’s great. I love it. You also opened in the middle of a pandemic, which presents its own challenges. I wonder if you could speak a little bit to that and what you’ve learned through opening during this time.

 

Hmm, first advice I would say is don’t do it. It’s extremely challenging. So, the first thing that changes obviously is the big open house. In my head, I had a big barbecue truck come in, I had a live band, I was going to blow it out. I was going to have a really big party and get involved with the city and the county and really just have a lot of fun with it. Couldn’t do that.

 

So, our open house was spread out over two days and we had prewrapped food and drinks, and people serving it. It was a very different environment. When we did open up, we were having a lot of issues because a lot of the facilities were still in lockdown. So, people that wanted to do a tour couldn’t come in and do a tour because they couldn’t leave their facility. And then the other ones were maybe at home because a lot of these residents that were in the larger facilities, the children started taking them home and said, “Well, we’ll do home healthcare for a while until this whole COVID thing calms down,” because they were afraid of lockdowns and everything else.

Outdoor Porch, Evermore Senior Living

Outdoor Porch, Evermore Senior Living

 

A house like ours, you got to see it. I mean, it’s a very different model. It’s truly a hybrid between a regular, residential one and a larger facility. So, we really try to get people in but just getting them to tour their home was what was really tough. I mean, there’s a lot of fear out there. People were concerned about putting their parents in a facility and not being able to see them because of lockdown, especially when residents are on the second, third, or fourth story. You know, those were all the fears that went into it. A very tough time to open up. I wouldn’t advise it to anybody. It’s definitely been a challenge.

 

Salon, Evermore Senior Living

On the flip side, what we did was we came out with a COVID guide that said how we are different. So, for instance, everything’s on one story. So, even if there was a lockdown, which we haven’t had—knock on wood—everything’s one story, where you got extra-large windows. So worst-case, you could still sit outside the window and talk to your loved one. The way that we designed the house, there’s a clean area where the food and materials come in, and there’s a dirty area where it leaves. Our whole clean versus dirty and the transition on that really reduces the risk of COVID.

 

Kitchen/ Dining Room, Evermore Senior Living

We just generally have less staff, less people, less caregivers. So, that’s a lot lower risk. We don’t have a large common area. And it’s still a home. Our residents are still there in the house. They’re sitting near each other, not next to each other, but they’re not stuck in their own apartment. They’re out in the living room or watching TV together, and if they wanted to go get something to drink, they stand up and go over to the kitchen and get a drink or a cup of coffee or a little snack. It’s a home—that’s their kitchen. So, it really gives them more of a sense of being home and not in a lockdown. They’re not in an apartment where staff members are going to bring them their meal and they have to eat in their room.

 

The other interesting thing that we did was on the air filtration. I had the fans oversized, so we could use HEPA filters, which filters out 99.97% of bacteria, mold, and any kind of particulates that are in the air. When COVID came out, I did a lot of research and I found UVC filters that you can put in after the HEPA filters. So, anything that gets through there like a virus, because viruses are so small, they go right through those filters and will be annihilated. It’s the same technology that hospitals use to sterilize equipment—the ultraviolet—that’s what we use in our air ducts. Very unique and it kills odors.

 

Well, that’s great. Definitely challenging, as you mentioned, but also what has been positive about this past year is figuring out better systems. I also love that these folks are not as isolated—because as I’m sure we both know, that’s been a huge problem for memory care, in particular for people dealing with that and just general mental health for older folks. That’s awesome. I have one final question for you, and you might have multiple answers to this, but you can choose one or a couple to answer. I’d love to hear about one of the most rewarding stories or experiences to come out of this approach to senior living, whether it’s with the residents or staff, or both.

 

I have two. One is staff-related and one is resident-related. When interviewing for staff, it was almost an instantaneous selection where you found the right person. We knew we had the right people because you could tell they were into it with their heart. When they would look at our model, they would sit back and the light bulb would go off, and they would say, “Hold on a 4 to 1 ratio? So, I’m really going to get to know these residents really well? And I’m not having to run around trying to quote, unquote, put out fires, and I can actually sit down and get to know them on a personal level and provide the level of care that I’ve always wanted to do?” Absolutely.

 

And the same thing with our executive director. She’s been phenomenal. She came from a larger facility, and her biggest “aha moment” was when we were interviewing her and she said, “You know, this is going to provide the environment where I can give the level of care I’ve always wanted to give.” So, from a staffing perspective, that’s probably most satisfying—when they’re truly happy to be able to provide a higher level of care.

 

From the resident side, our first resident had his wife and kids say, “Okay, well, he doesn’t really eat breakfast and he sleeps until 10 or 11 o’clock. He takes three or four naps during the daytime and that’s how he’s been for the last 20 years.” And he was really skinny—too skinny. We have a chef in the house, so the food’s phenomenal and are basically custom meals. To me that was one of the biggest things. I want to have the best food out there and when Bob moved in, he said, “I don’t like fish,” and I said, “Fish is off there for you. What else do you like?” He goes, “I love chicken.” Great! He’s in there about a month, and he gains 10 pounds.

 

He’s getting up at 8:00 a.m. and having a full breakfast—I couldn’t even eat as much as he was eating. He’s eaten more than he’s ever eaten in a long time. He just kept asking for more. And his sleeping got better. He might pass out on the couch here and there when he’s watching sports or whatever, but he doesn’t take a long nap during the daytime anymore. A lot of that is because of our activity schedule and the things that we do are things that they want to do. My daughter will show up every week for their standing game of chess. He loves chess. He’ll be like, “Oh, your daughter kicked my butt today again.” We joke about that.

 

The other thing is that we also have what’s called circadian rhythm lighting. And so it’s for people with sundowners. It just helps them get on a normal sleeping arrangement. So, in the morning it’s a nice sunrise, it’s really calm in the daytime—a nice bright light—and then in the evening, it’s like a sunset. It really helps them wind down at the end of the day and get calm and relax.

 

So, our residents are all on a good sleep schedule. We haven’t had anyone with sundowners yet, but that’s really what the design of the product was—to help eliminate or greatly reduce sundowners. But the folks without sundowners are definitely going to benefit from it. Their sleeping schedules are normalized. That’s been the nicest thing I’ve seen over the last few months. It’s really nice to see them get on a normal sleep schedule.

 

Well, you’re really curating a space centered to their needs and their wants, which makes a huge difference.

 

Yeah, exactly. I mean, it’s been life-changing for myself, our whole family. Both my girls are involved in it and my wife is definitely involved in it, and it’s just been a great journey so far.

 

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Person-Centered Care for Residential Assisted Living Design

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By: Alexandra Cohl

Interview with Shernise Richardson: Project Design at JSR Associates, Residential Assisted Living (RAL), and person-centered approach.

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This week, I spoke with Shernise Richardson, the Project Designer at JSR Associates. Shernise explained the meaning of Residential Assisted Living and how it differs from larger scale assisted living facilities. Throughout our talk, she also explained how essential it is to take a person-centered approach to design, what one of her favorite projects has been, and the unexpected challenges that happen throughout the design and building process.

 

This interview has been edited for clarity and flow.

 


Shernise, thank you so much for joining me today. I want to jump right in and give our readers a sense of who you are and what the work that you do. Can you describe what your role is at JSR Associates and what a typical week might look like for you?

 

Yeah, no problem at all. Thanks for having me. I am the Project Designer for JSR Associates. So, typically my work week looks like a number of things—I wear a few hats. I’m often producing the drawing sets for any of the projects that we have, whether that’s for new construction or renovations. Sometimes we do a bit of consulting work, as far as reviewing some other projects to make sure they meet certain things that are related to senior living, person-centered care, and things of that nature. So, in my role, I talk a lot with clients. A project  manager is everything, so I’m basically the lead person when it comes to drawing projects and production.

 

Cool. I was just going to say that it sounds like you’re the producer of what goes on.

 

Shernise and Jane working on art install placement.

Shernise and Jane working on art install placement.

Yeah, and we’re a small family firm. When I came to this firm, I was like, “Man, this is awesome,” because it introduces you to a lot of different things that you might not get to experience at larger firms. So, getting to interact with a lot of different people has definitely been a great part of this firm.

That’s awesome. So, one of the things I wanted to ask you about today is the term Residential Assisted Living (RAL). Could you explain that term, for those of us who don’t know what that is, and what it encompasses?

Yeah, so Residential Assisted Living is your typical assisted living but scaled down to a single family-home style. So, basically, taking everything that you would normally see from a facility that’s like 64 units or something like that and fitting it into a single-family home where it’s more of a family-style oriented type of facility. With that, it’s often one main kitchen that everyone shares, not kitchenettes or anything separate, and it’s a home. You have your living room setting, your dining room, people eat together, and have fun in one common living space.

 

Gotcha. So, it’s like a separate home building, not say my grandparents’, for example, who live in an independent living residential space that is an apartment connected to others down a hallway to these other buildings. What you’re explaining is an actual home that’s separated by maybe a yard or something.

 

Right. And within that home, everybody has their own individual rooms and individual spaces. All of the resident rooms that we design have their own bathrooms. We still give the residents that amount of privacy, which is what they prefer. But it’s not apartments, nothing like that. You see all your housemates every single day. It’s literally a house.

 

And are the people who are living in the house blood relatives, or is it sometimes just other people who are living within that home. Or, is it a mix depending on the situation?

 

Typically, it’s all individuals who are not related. Like, if you had an assisted living building and it was separate apartments, instead of it being apartments, it is just people living in individual rooms. You could have a space with maybe somebody related, but they would still have their own individual room.

 

Gotcha. It reminds me a little bit of, say, the fancier suites that some people at college would get. In terms of the work that you do at JSR, how does this term specifically apply to that work and what process do you go through when you’re working with clients on something related to Residential Assisted Living?

 

The way it relates to us is we are very focused on person-centered care, and senior living is almost, I would say, maybe 95% of what we do and what we focus on. The way that Residential Assisted Living fits in is that it’s almost like a household model, and so, we do that when we’re working with other clients on larger assisted living projects. We always recommend a household setting and basically having groupings of just a small amount of maybe eight people (no more than ten) where they all share the same common space. That’s helpful from a staffing perspective, as well as the resident to sometimes have that more focused, smaller grouping of individuals rather than feeling like they’re just in a large grouping.

 

Evermore Senior Living– Woodbridge, Virginia Small Household living room

Evermore Senior Living– Woodbridge, Virginia
Small Household living room

Where that fits in for us is that we do household design for a common space with a significantly smaller staffing to resident ratio. We take all of that knowledge, and we just pack it into Residential Assisted Living based on our knowledge, the materials, spacing requirements, spacing recommendations, and getting a better understanding of how the residents would like to experience their space. With a project, since you asked about the process, we typically do programming for a project before even starting with drawings. So, we’ll meet with the client, discuss their wants and needs and what they require. If it’s a new build, of course, they are not going to have any residents yet. Meeting with the residents is not always an option. That’s when our knowledge has to come into play to let that client know, from other projects, what we’ve experienced with other residents from other facilities.

 

If it’s a renovation of one, then we will meet with the actual residents and speak with them without staffing present or their children. It’s just the residents by themselves speaking their mind about how they feel about their space: what they need, what they like, what they don’t like. We take all that into account, and a lot of projects can be made better if we just simply talk to the people who are using the space, instead of relying totally on what we’ve learned through books or something like that. When you just talk to people, it makes a big difference.

 

So, we do the programming process, talk to the client, listen to their needs, their wants, and then we basically let them know based on our knowledge level, what we think would best benefit them for their project as far as staffing or anything operational. We’ll start there, and then we’ll go into some of the design process, schematics, and space requirements. When you start to put pencil to paper, that’s the fun part. When you’re starting to really flesh out your ideas. From that process, we go from making sure that the client is happy about what they’re looking at: “Does this meet all of your needs?” Sometimes the understanding of what may be needed for a resident is not always understood. But, we sit down and talk to the client about why we made this decision or why we recommend laying a space out the way that we do. A lot of them say, “Well, I never thought about it that way.”

 

Thinking about something as simple as a nightlight. One thing I would definitely include in their rooms is a through-wall nightlight that directs you to the bathroom. It is a light fixture, and it’s recessed into the wall—it’s essentially a nightlight. We place it on the same wall or near the opening where the bathroom is. That way, if they wake up in the middle of the night, and it’s dark, they see the light and they’re like, oh, the bathroom’s that way. Sometimes that can cause a lot of issues and that helps with less incontinence issues. So, something as small as that that the client never thought about before.

 

Oh, I like that. The nightlight reminds me of the lights you would find on the outside of a front door so people can see where to enter. The person-centered approach is just so, so important. I love that you gave the simplest example because it shows how much the needs of these people can easily be missed. And so, I’m curious, out of the many projects that you’ve worked on, are there any specific ones that come to mind that stand out for whatever reason, whether it was just a certain part of the process or the end result or anything outside or in-between that?

 

I would say of all the projects—every project in itself has something within it that I’ve learned that’s helped me prepare for the next one. It’s something as simple as a small detail. As far as a specific project, I would say Evermore Senior Living. That’s one that we’ve just recently completed and the first house is actually built already in Virginia and they started getting residents in. That process was very interesting to me. I love construction site visits. You get to see the thing that you put on paper actually come to life. And so, as I was doing the construction site visits, it would just be small things that come up that you have to think about right there on the spot. Like, okay, what is the way that we can fix this? Or, what is the best way to go about this? Even though it might deviate a little bit from the drawings, like something as far as spacing might come up, I may ask myself, “How do we change this to where it won’t affect the resident that much but will essentially give us what we need?” A couple of things like that came up with that project and it allows you to go back to the drawing board and basically think about your next one. Like, let me put that in my brain bank and that’s what Evermore did for me as I continue to do those site visits. It was the most site visits I’ve ever done for a project. So, getting to experience that was very rewarding and that’s why that one sticks out the most to me.

Evermore Senior Living– Woodbridge, Virginia Construction site visit

Evermore Senior Living– Woodbridge, Virginia
Construction site visit

A rendering of a resident room. Rendering by Shernise Richardson

A rendering of a resident room. Rendering by Shernise Richardson

The completed resident room. Photo by Nicole Lowder

The completed resident room. Photo by Nicole Lowder

 

I love that you mentioned a little bit just now about particular challenges and what they have taught you for future projects down the road. Can you expand on that just a bit? If there’s any other challenges that you’ve specifically gone through while you’ve been doing this type of work, and how you overcame those challenges.

 

I don’t think a lot of people think about this, but bathrooms and kitchens are some of the most difficult things to design. If you haven’t realized in those two spaces we do so many things. So, just being able to design for a space that anything possible could happen: you know with a bedroom, you’re sleeping or you may have a desk in there, but with bathrooms, especially for senior living, we have to take into account grab bars. But not just your traditional setup of grab bars. We typically go with the drop-downs, and with the drop-downs, that allows the user to push themselves up rather than the traditional setup that’s on the side or the back wall. So the drop-downs and the grab bars that can be used by different individuals.

 

So, with grab bars, we have the ones that adjust up and down, to the side. You have to think about counters, storage, things like that. Showers! Just something as simple as the entry to a shower and making sure it is a level transition with no bumps or anything like that. You wouldn’t think about how much just that little spacing, that little bump, can cause a tripping hazard. So making sure there’s no level change or transition, but the detail of how the floor meets the shower insert. Sometimes we have one-piece showers, and your flooring has to meet right up so that water doesn’t escape into the bottom. That detail is very delicate. It has to be so specific. Especially if it’s slab on grade—that’s basically your concrete. They had to cut into the concrete in order to set the shower inserts inside the concrete and make sure it is level with the floor. It was like me, sitting at the drawing table for hours, pulling my hair out. So, that was one of the things that I experienced with one of the projects.

 

It takes a good amount of your time. Something just that finite, even if it’s off by a 16th of an inch. It can really cause an issue. So, we sat there for hours and finally figured it out. Then we just decided to put an extra detail, almost like a collapsible dam that is rubber. So, if you step on it, it flexes with your foot and doesn’t cause you to trip. You can also wheel over it. It gave a way to also keep more of the water in. We had to figure out solutions to something that small, and it can take a good amount of time just to make sure that we’re getting it right for the resident. You want them to be comfortable and also make sure it meets their needs. But also, design-wise and structure-wise, we didn’t want water getting into the flooring and things like that because that can cause issues down the line (as far as replacing materials). When it comes to bathrooms and kitchens, those are the spaces where you learn the most.

 

It’s very much clear to me, as someone who has no idea how the intricacies of this work works, how creative and innovative you have to be while you’re considering how to make this space work for the actual humans that are going to be using it day in and day out.

 

Yes, yes. When we’re thinking about the single family, we’re not just designing this space for a single family. It’s a project for a client that’s going to have multiple tenants. And, sometimes there’s going to be some changeovers. So, that’s a different person coming into that space. And, we have to make sure that that space serves everyone—not just the typical, single family.


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