Senior Living Update: Flooring solutions for memory care facilities - Mar 2016

By Ruth Simon McRae

The face of senior care is changing. From new support for aging in place to naturally occurring retirement communities, our society is becoming more creative about how to best support people as they age. Senior living organizations are continually innovating how they deliver care. As residents with dementia, including Alzheimer’s, become a larger segment of the population, senior living facilities are rushing to develop special care units and stand-alone facilities to address their needs. 

It is common knowledge that the Baby Boomers are ballooning the ranks of seniors, with an average of 10,000 people turning 65 every day. Less known are the statistics about Alzheimer’s disease and other dementias. An estimated 5.3 million Americans of all ages were estimated to have Alzheimer’s in 2015, including 5.1 million people age 65 and older. According to the Alzheimer’s Association, currently one in nine people age 65 and older (11%) and about one third of people 85 and older (35%) suffer from dementia. Longer life expectancies and the aging of the Boomers will increase these numbers rapidly. By 2025, the number of people 65 and older with Alzheimer’s disease is estimated to reach 7.1 million, a 40% increase from today’s numbers.

The increase in the development of memory care units is not entirely altruistic. These facilities are profitable and maintain high occupancy rates. One senior living administrator observed that nearly all new senior living building starts seem to be assisted living memory care. They are being rapidly developed because the need exists. Assisted living is generally private pay, often offsetting losses that occur in the nursing care units due to lower Medicaid reimbursement and subsequent operating losses.

Senior living facilities generally fall under one of three broad categories. Independent living is the entry level, with residents living in fully equipped apartments with some shared services, such as dining as desired, medication management and housekeeping. When a senior can no longer live fully independently but does not need the high level of care offered in a nursing facility, assisted living becomes more appropriate. Nursing homes offer on-site medical care and a high level of assistance. A range of interesting programs, including fitness, education and entertainment, are generally offered at all levels of senior care. 

New memory care units tend to be found at the assisted living level, although early stages of dementia and Alzheimer’s are becoming more prevalent among independent living residents. Generally attracting people with a wide range of perceptual and physical capabilities, the assisted living level of care offers more services than independent living, yet still within a residential-type setting. According to Ross Wilkoff, chairman of dementia services at Menorah Park Center for Senior Living, “There are two groups of people in assisted living. Some are physically well and not mentally alert; some are mentally alert yet not physically well. These two groups are very different.” Flooring for memory care rides a line between the types typically used in assisted living and those required for a nursing environment, due to the higher level of perceptual issues in residents with dementia. 

New facilities and renovations for memory care are being designed on the Small House model, with “households” of ten to 12 residents grouped together, sharing common living areas. Layouts are residential in feel, following the natural sequence of rooms you would find in a private home. Materials used on both the exterior and interior have a home-like look. 

Typically, there is a central courtyard with a front door opening into each household. Following an entry and public area of some sort, corridors will flow throughout the open plan living spaces. 

These corridors are a key part of the design, as they allow a resident to wander through the rooms and see activities to engage in and opportunities for social interaction. People with dementia can be easily overwhelmed or confused when faced with large groups or spaces, and they are more comfortable with being able to sample activities before joining in. Naturally, the corridors also serve as wayfinding, helping residents easily find their way back to the private apartments.

The open plan has a living area, dining area and possibly activity areas, all flowing into each other. They have permeable boundaries; it is easy to see into one area from the other. Windows and clerestory architectural features offer plenty of natural light, helping residents recognize the time of day and regulate their circadian rhythms. 

The Small House approach, based on the original Green House concept, centers on the “heart and hearth” of the home. One key feature is a neighborhood or “country kitchen,” with handcrafted-looking counters and tile, and a wood-look floor, usually LVT plank. The kitchen will have cues, such as a large bowl of fruit on the counter, to help orient residents to the function of the space.

Clearly, interiors for memory care are being thoughtfully designed to create a supportive environment. And flooring, from both a functional and aesthetic perspective, is a fundamental part of the design.

Flooring choices for any given area in a senior living environment present a balance of properties and trade offs. In some situations, there is a clear case for soft or hard floorcovering. In others, it is a question of preference, and of balancing product attributes. 

Carpet tile is one example. It offers many key solutions, such as ease of maintenance and replaceability, and a range of wonderful looks, yet has the downside of seam permeability. 

Starting from the ground up, the subfloor condition is key. According to Melinda Avila-Torio, associate and managing interior designer at THW, “In many cases our clients can’t afford to seal the concrete, which makes carpet tile not the best choice for areas with frequent incontinence episodes. There have been several projects where the owner specifically asked for carpet tile in certain areas. Collectively, we all discuss and review the pros and cons of the carpet tile solution. It is important to clearly understand where this product will perform the best for the operator.”

Memory care dining rooms, in many cases, will have hard surface flooring as opposed to soft. Yet an operator may want carpet for its acoustic properties and home-like feel. In this case, carpet tile presents a good solution. It is important to keep the dining rooms peaceful and quiet, both for ease of conversation during meals and for nutritional reasons—Alzheimer’s Association studies report that noisy dining spaces have been linked to reduced food intake. 

Resident rooms may use carpet with a moisture barrier or vinyl flooring. While sheet vinyl is very easy to clean and offers the visual warmth of a plank wood floor, LVT plank flooring in a wood visual is also a popular choice. Yet, in HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) surveys, facilities with carpeted resident rooms often receive higher resident satisfaction ratings.

Owners often prefer porcelain tile for private bathrooms and public bathing or spa-like areas. However, many communities may not have the financial ability to purchase this hard surface flooring. Sheet flooring with slip resistant characteristics is a well accepted alternative for bathroom environments. Typically, this is vinyl sheet flooring with an integrated base. Two colors of vinyl may be welded together so that the integral cove base has the appearance of traditional cove base, while helping the resident distinguish the edge of the walls and floor. Altro’s safety flooring, a patented vinyl flooring formed with slip-resistant grains throughout the wearlayer, is also frequently specified for areas that have potential for standing water.

Underlayment systems, such as QuietWalk from MP Global, can help mitigate moisture. Some also have acoustic properties and provide extra underfoot comfort. 

Color requirements for assisted living memory care units are very similar to any senior environment. Typically the carpet is neutral overall, with low-contrast combinations of light, clean shades.

For example, the color palette used in Nashville’s Abe’s Garden, an assisted living community, is soft and light, yet clear enough to register on the aging eye. Flooring colors form a neutral backdrop, allowing the colors of fabric, paintings and other small features to pop. Jennifer McDermott and Joseph Hassel, associate principal and principal at Perkins Eastman, respectively, approach color for memory care in a variety of different ways—keeping in mind changes in visual perception of the residents, using color to create energy and excitement, and at the same time taking into account how the color palette relates to outdoor views. 

Although it is commonly known that perception changes with aging, memory care residents tend to have a more extreme degree of perceptual change. The most difficult colors to see are blue, turquoise and green. Avila-Torio always has her design team look at materials and colors through yellow-tinted glasses when selecting both color and pattern of floorcoverings. “Patterns can be interpreted as something else, increasing an unsafe feeling for the senior resident,” says Avila-Torio. “When looking through the yellow film or squinting, one can see how color appears and how the elderly may perceive the pattern. In most cases, soft organic patterns or linear striations may not create a lot of movement.” 

High contrast in a pattern and strong borders are generally avoided, so that a resident does not fear tripping or falling into a “hole.” At the same time, some degree of color contrast between flooring and cove base or baseboards can help a resident with dementia discern the edges of a room and feel more comfortable. 

In order to make sure the best flooring is chosen, designers need to determine that they have a large enough sample so they can try out material in the actual space with staff and residents. The size should be at least a 6’x6’ piece. The optimum would be to install the flooring in a 10’x10’ room. Many flooring manufacturers will work with the design team, sending these samples to the site so that that the staff and residents can see them firsthand and be able to move around on preliminary floor selections.

Abe’s Garden is an assisted living community solely offering memory care; it is new construction in a free-standing building. Home to 60 residents, Abe’s Garden is part of Park Manor, a complex that offers both independent and assisted living senior housing. McDermott and Hassel in Perkins Eastman’s Chicago office headed up interior design on this project, working in collaboration with local architect Manuel Zeitlin. 

Abe’s Garden is made up of three households or neighborhoods. Each of the neighborhoods is arranged around a central courtyard. And each household has a different theme and related color palette, although the flooring is consistent throughout. The themes are lifelong learning, nature and gardening, and music and movement.

The house’s front door opens directly from the central courtyard. Immediately after going through the door, a visitor walks through a vestibule installed with Ecore’s Eco Plains flooring, tiles of recycled post-consumer PET fusion bonded to a post-consumer recycled rubber base. This product was selected because of its inherent slip-resistance and acoustic comfort, as well as the ability to change out tiles as needed. 

Just after entry, a large community room known as the Club offers programs, a café/snack bar area and adult day services. The Club is a focal point for visitors and family, with key design features constructed of interesting materials, such as a wall of reclaimed barrel wood and a decorative glass room divider. Flooring in the Club mirrors the rustic barrel texture, with Interface’s Walk the Plank carpet tiles from the Urban Retreat collection. The tiles have antimicrobial in the backing and adhesive. Carpet tile was also selected for this public space because it can be easily—and discreetly—replaced with new tile if soiled. 

Abe’s has an open layout, with natural light throughout. There are very few long, linear areas. Instead, spaces are broken up into zones. These non-rectangular spaces, fluid and open-ended, presented a challenge for flooring layout. To address this challenge, designers stayed with two key flooring products throughout the space. 

From the core area of heavy traffic, the space flows into a corridor. “Due to the organic layout in the plan, we selected a carpet tile that was non-directional and allowed for a more random pattern, so that the flooring flowed throughout,” explains McDermott. Tandus’ Arboretum, a carpet tile with a subtle, leafy pattern in a low contrast palette, is installed throughout all corridors and living room areas. 

The carpet tile transitions seamlessly to an LVT wood-look plank flooring using a low profile Johnsonite rubber transition strip. The LVT flooring, Floorworks Plank from Mats Inc. in Pine Wood color, is used in all dining and kitchen areas. 

Each of the three households has a different theme. The focal point for activities in the Life-Long Learning household is an art studio with sealed concrete flooring. The sealed concrete was selected for ease of cleaning as well as affordability. 

A second household is based thematically on how music can inspire movement and fitness. The music neighborhood’s activity space continues the same wood-look vinyl plank as the adjacent dining area, allowing for a seamless transition between the spaces.

Activities in the nature and garden themed neighborhood offer a very different environment from the two other households. Looking out at a clear view of the courtyard garden, residents grow herbs, tomatoes and vegetables in pots in a gardening activity room known as the Conservatory. Amtico Abstract-Fusion LVT from Mannington supports this environment with graphic herringbone stripe planks in contrasting yet neutral colors. 

Designers at Perkins Eastman explained the reasoning for their color choices: “When designing for seniors and the aging eye, it is important that we have clear, saturated color. The rust color in the music and movement house was selected to evoke energy. The nature house uses an accent color of green connecting it to the outdoors and symbolizing new beginnings. Lastly, the art and engagement house uses yellow as an accent to promote happiness and optimism.” 

In addition to the main activity space within each household, there are also adaptable areas for activities, such as exercise classes, discussion groups and family visits. These impromptu activity areas are spaced at intervals through the winding, open corridors.

Carpet in the individual apartments are installed with Shaw’s Prosper EcoWorx Performance Broadloom, selected for its solution-dyed fiber, moisture barrier backing and multi-level loop construction that works well with rolling mobility devices. Altro’s Suprema flooring, a slip-resistant sheet vinyl with a flash cove base, is installed in the private bathrooms. 

Abe’s Garden is connected to the existing Park Manor building with a welcome center and reception area featuring Root by Ceramiche Caesar, a wood-look porcelain tile selected to handle the lobby’s heavy traffic. This flooring continues into connected spaces of the existing senior living complex.

Abe’s Garden is an incubator for evidence-based research, as well as a supportive home for memory-care residents. Although units are in the upper middle price range, findings from the ongoing research will translate to a wider range of price points. Hopefully, learning from these studies will generate ideas for developing communities at different economic levels.

Abe’s Garden was developed in close collaboration with a few key partners. The Vanderbilt Center for Quality Aging is one such partner. Essentially a laboratory for various concepts, Abe’s Garden is being monitored by Vanderbilt in real time, in order to learn about the influence of programming and the built environment on dementia and Alzheimer’s residents. Hearthstone Institute, a group currently operating five assisted living dementia communities in the Northeast, is a second partner, offering Abe’s Garden the opportunity to study memory care best practices. 

Perkins Eastman will return to Abe’s Garden for post-occupancy evaluations at one year, five years and ten years in order to assess the functionality of design solutions and evaluate the durability of materials.

Helen’s Place is the new memory care unit at Menorah Park, a non-profit continuing care retirement community (CCRC) in the Cleveland, Ohio suburbs. Perkins Eastman designed the interior of Helen’s Place, headed up by associate Jennifer Schuster-Sansonetti. From independent living to nursing care, Menorah Park facilities are interesting due to their lack of flash and their laser focus on care.

Four or five years ago, it became apparent to Menorah Park administrators that the senior living market was selecting memory care. This was based on both the composition of residents living in its CCRC campus and the growing wait list of residents. 

Helen’s Place was created on the second floor of Stone Gardens assisted living. Designed on the Green House model, the new special care unit was a renovation of the third floor, incorporating 15 to 20 units. Guiding principles include many of the Green House features, along with a thoughtful Montessori approach. Montessori is a teaching method originally designed to help young children, featuring experiential learning and collaborative play. Menorah Park learned about this approach from collaborator Dr. Cameron Camp, a psychologist who is known for successfully adapting Montessori methods for use with people suffering from dementia.

In addition to perceptual changes, people with dementia may become overloaded by decisions, so Helen’s Place staff offers carefully limited choices—of menu, activities and self-government, such as resident-run welcome and conflict resolution committees. When describing the social construct, Menorah Park’s Wilkoff adds, “We want to institutionalize choice.” 

Residents each have a private apartment at Helen’s Place, unlike many assisted living memory care facilities that offer only single rooms. The residential style apartments are carpeted with Bolyu’s Rush Hour, a solution-dyed nylon textural loop broadloom carpet. Soft floorcovering was chosen for its warm and friendly residential feel. 

Shaw Floors’ Hancock, a residential resilient sheet with the look of variegated ceramic tile, is installed in all of the apartment bathrooms and kitchenettes. Although Wilkoff would have preferred using ceramic tile, the sheet vinyl was chosen for reasons of cost, maintenance and sanitation. Currently, the campus has ceramic tile in kitchens, public bathrooms and laundry rooms, and much time is spent re-grouting and replacing tiles.

Public spaces and resident corridors are installed with Mannington’s Torre, a performance-backed broadloom from the Il Palio collection with an impermeable moisture barrier. Torre has a simple geometric design with a traditional hospitality look that is in keeping with this renovation of an older building.

Helen’s Place has a country kitchen, featuring Shaw Contract’s Uncommon Ground wood-look luxury vinyl plank on the floor. Flooring in the larger dining room has recently been changed to a quarter-turned carpet tile that combines both linear and organic elements in a softly textural look. 

Senior care facilities tend to have a strict maintenance regimen. Helen’s Place has one dedicated maintenance person for its 10,000 to 15,000 square foot space. For example, staff uses steam extraction to spot clean soiled areas of the dining room flooring once or twice a day.

The Cohen-Rosen House in Rockville, Maryland is new construction for 18 to 20 residents. It is part of the Charles E. Smith community, a non-profit CCRC serving the greater Washington, D.C. area. The project was designed by THW Interiors, with a design team of Stephanie Clements, director of interior design; Bethany Luhrs, interior designer; and Melinda Avila-Torio.

Also based on a Small House concept, the Cohen-Rosen House is entered through a front door from a central courtyard directly into the great room. The great room is carpeted in Masland Contract’s custom CYP broadloom carpet with cut/loop construction and moisture barrier backing. The multicolor pattern has a traditional hospitality look, yet is colored with a soft, low-contrast residential-type palette. 

To bring down the scale of the high-ceilinged great room, designers created semi-transparent boundaries and flexible spaces. An aquarium and see-through bookshelves separate the resident common areas of the great room from the dining room and neighborhood kitchen. As explained by the design team, these so-called “semi-transparent” boundaries not only enable individuals to get glimpses of the resident spaces beyond, but they also help them focus on the immediate space they are occupying. Residents understand the function of the space with the various visual cues, increasing their individual sense of choice and comfort. These simple and immediate messages reinforce the comfort level that the built environment aimed to achieve. 

The floor plan is designed in a large “U” with nine rooms at the end of each leg. The great room is in the center; the dining room and kitchen, as well as a link to the other building, are off to the right. Nursing support is on the left. 

In corridors, THW has specified another custom Masland CYP broadloom with moisture barrier backing in conjunction with a millwork-profile cove base from Johnsonite. The designers note that the corridor carpet was selected for both aesthetic and performance reasons. Its construction was higher in density than the tufted products they reviewed. The carpet’s flowing pattern has a more contemporary feel than in the lobby, with an art nouveau design of hand drawn leaves.

Contour Plank from Tandus Centiva, a 6”x36” LVT plank, was specified for resident rooms. In the Cohen-Rosen House, households are made up of single rooms rather than the multi-room apartments seen at Helen’s Place. In integrated assisted living, where residents of varying cognition levels are mixed, a memory care resident may have an apartment with a galley kitchen but no heating elements. This same wood-look vinyl plank runs through the adjoining dining and neighborhood kitchen areas.

Avila-Torio observed that any vinyl flooring should have a durable wearlayer and that design firms need to educate for-profit facilities that a 20 mil to30 mil wearlayer is optimal. The goal of a thicker wearlayer is to withstand the wear of rolling equipment and assistive devices moving along the circulation paths day in and day out. 

Resident bathrooms are installed with Pavimenti Stone, a 12” square porcelain tile from Ceramic Technics in a dark color to provide contrast between the floor, wall and fixtures. Communal bathrooms and spa areas also use a ceramic tile from this source, in an 18” square format.

Sustainability is a key consideration when specifying materials. However, LEED certification is not a must-have for senior living operators. It can be very costly to achieve and is often seen in this segment as more of a marketing tool than a true measure of the sustainability of a project. 

Designers and operators understand that the physical environment, especially for healthcare, is paramount to a successful delivery of care. They also have learned that manufacturers have raised the bar on product sustainability, making an outside certification such as LEED nearly irrelevant in this type of market. Though communities may not be able to participate in pursuing LEED certification, design teams are committed to selecting products that offer a high quality of indoor air, ease of mobility and optimized maintenance regimes.

Copyright 2016 Floor Focus

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