Assisted Living Facilities are run by companies who are out for profit.  They aggressively market the facilities because the bottom line is to produce profits, not to provide care.  There is zero compassion, only greed.

Patricia McGinnis is the executive director of California Advocates for Nursing Home Reform. She told FRONTLINE that the for-profit model in assisted living has left seniors vulnerable to neglect, abuse, and in some cases, death. If profit continues to take precedence over quality care and supervision, “then I don’t know that we have much hope for better care,” said McGinnis. This is the edited transcript of an interview conducted on Dec. 3, 2012.

Assisted living was initially viewed as a way for people who needed help to get into a facility and get that help without having to go into a nursing home. Why do you think that was attractive to seniors?

I never met anybody who said, “Oh gee, I’m 93 years old, I can’t wait to go into a nursing home!”

Nursing homes have, and probably rightfully so given the problems, a very bad reputation. People are terrified of ending up in a nursing home totally dependent for the rest of their lives.

… That kind of reluctance to go into a nursing home really started the cry for an alternative to nursing home care. …

… How has the population that’s going into assisted living facilities changed over the years?

I can only speak for California, although I’ve looked at other states. But in California I would say that the same people who are in what’s called assisted living today are the people who were in nursing homes 10 years ago.

You have people who are permitted to be in what we licensed as residential care facilities for the elderly in California. They can have stage I, stage II decubitus.

Ulcers, pressure sores?

Ulcers, that’s right. They can have healing wounds. They can be bedridden.  I remember 15 years ago when we had a women who was bedridden for seven days, and the Community Care Licensing was trying to evict her out of this residential care facility because she was bedridden for seven days.

Today there wouldn’t even be an issue about that. …

And why is that a concern?

It’s a concern because our regulatory system is so very weak. We haven’t changed our regulations in California for years in terms of the number of staff and the type of staff and the training and the kind of medical care.

Now we pretend that residential care facilities for the elderly are not medical facilities. They’re nonmedical, and yet the people who are in these facilities today have acute medical needs. So we tend not to address those.

Instead what we’ve done in California is kind of just stretched the regulations to accommodate this higher level of care that are needed by people.

So as this population in assisted living has changed, their needs have grown more intense. They’re more frail. They’re more ill. Have the regulations kept up that?

Absolutely not.  We haven’t changed the staffing regulations for years in California, except in terms of, for example, if you are a staff person who is going to help self-administer medications, then you need a little bit more training in that.

But in terms of staff-to-resident ratios, in terms of the number of staff, in terms of the requirement of training staff, nothing has really changed in all these years.

And that causes a big problem because we have, as I said, people in residential care today who have very high medical needs and very high social needs. And this is not to say that all the facilities aren’t prepared to deal with them, but I’d say the overwhelming majority certainly aren’t prepared to deal with that.

Does that worry you?

More than worries me. It makes us very busy in our organization because [it] used to be most of the complaints that we would get about long-term care had to do with the nursing homes. I would say 50, 60 percent of the complaints that we get today have to do with residential care for the elderly. …

What does that say to you?

It says there’s a lot of problems and there’s really not much regulatory oversight. …

And in that vortex of regulation, who steps in? Who works to advocate for seniors?

We’ve got the Long-Term Care Ombudsman Program. Each county has a sub-state program. Then their mandate under the Older Americans Act is to investigate and resolve complaints made by or on behalf of residents.

In California the ombudsman also has the ambit of assisted living, so you can call the ombudsman program. But assisted living facilities are overseen by the Department of Social Services Community Care Licensing. So you can call up a Community Care Licensing office and you can register a complaint. You can write to them and you can register a complaint.

And we tell consumers to do that. We want them to do that because at least that complaint would be on file. We also have provided them with a warning: Don’t expect a whole lot.

And who actually does get results, in your opinion, for consumers when they have a problem in an assisted living facility, when something has gone terribly wrong?

If it’s a minor complaint, then sometimes the ombudsman can resolve it.  And if it’s serious complaint, it’s very unlikely that Community Care Licensing will resolve it. I would say that today one of the few remedies that consumers have with regard to assisted living are lawsuits, and that’s what we see.

And that’s unfortunate because the industry is always complaining, oh, there’s too many lawsuits and they are frivolous, etc. But we actually looked into the kinds of elder abuse lawsuits that are filed against these facilities, and they are all very serious, absolutely very serious lawsuits.  They’re certainly not frivolous at all. I’m shocked that there aren’t more to tell you the truth.

You’re surprised there are not more lawsuits?

Absolutely. Because when you see what happens in nursing homes and in assisted living every single day, we call it a “river of grief,” because that’s what it is for people.

When you have a regulatory system that’s not doing its job, when you have people who are filing complaints and you might as well file those complaints down a black hole, that’s what’s going to happen. It’s just a horrible system right now.

More and more assisted living facilities are providing dementia care, Alzheimer’s care, and they’re billing that as a specialty that they’re providing. And if you look at the numbers, we know that more people with Alzheimer’s and other dementias are ending up in these facilities.  What do you think of that?

I think it’s fine. Any alternative to nursing homes is just fine, particularly the status of the nursing homes we’ve got today.

But if you are going to be advertising that kind of care, and if you are going to pretend to provide that kind of care, then you’d better make sure that you provide it. And that’s been the biggest problem, is that sometimes they really don’t provide the level of care that people are paying for.

Mind you, this is private pay. The assisted living facilities in California are not reimbursed by any federal moneys, by Medicare or anybody. People are paying privately as much as $7,000 a month for this level of care, and oftentimes they’re not getting the care promised by that facility.

In California and many other states we see similar language about how assisted living facilities must staff their building. And typically we see language says something like the facility must have “sufficient staff to meet the needs of the residents,” something like that. What do you think about that kind of language?

I think it’s ludicrous, because then it’s very arbitrary and capricious as to what level of staffing a facility is supposed to have.

We have the same regulatory requirements in California with the exception of night supervision. Then you have to have a little bit more. If you have more than 16 beds in that facility, you actually have to have the staff awake, if you have 16 to 100 beds. Apparently they don’t have to be awake if you have 16 or fewer beds, so our staffing system as a whole is ludicrous to tell you the truth.

Assisted living is not regulated [with] any kind of consistency at the national level. From state to state to state, as you see when you read the comparative regulatory systems, they are completely different. They call the facilities different names. They have different levels of care. …

How did we get to this point where we have regulations that vary wildly from state to state, we have different definitions from state to state, we have different types of facilities? There’s no uniformity whatsoever.

We got to this place because we don’t have any national long-term care system. We have no hook for federal oversight. If these facilities were like nursing homes being reimbursed under the Medicare system or some kind of long-term care insurance program, then actually the federal government would have a hook to also regulate them and to create some kind of consistency. …

Compare the basics of this mishmash of regulations for assisted living to what we have for nursing homes, because it seems pretty different.

It is different in that 88 percent at least of the nursing homes in the country are certified for Medicare and/or Medicaid.

In California, for example, 64 percent of the people who are in nursing homes have all or part of the cost of their care paid for by the Medi-Cal program. So therefore what you’ve got is you’ve got a hook under the federal government. You have to follow the federal government rules and regulations regarding oversight of nursing homes.

We don’t have that for residential care, and that’s one of the biggest reasons.  If we had some kind of a reimbursement system for residential care, that would make all the difference in the world …

If the federal government was paying?

The Class Act, for example, would have made a big difference. That’s now gone. That was part of the Affordable Care Act. I thought that was one of the most important programs to come along in my history anyway with long-term care, and now that’s not something that’s going to be going forward.

But we need some kind of a national long-term care system that enables people to get some reimbursement to pay for assisted living. Right now what will happen is that somebody will go into assisted living, they get the care and supports that they need but they’re paying privately. They’re dipping into their savings.

When those savings are gone, and I venture to say every single day of my life I get an e-mail or somebody in our offices gets an e-mail, “What am I going to do? My mother is in assisted living. It costs $5,000 a month. Her savings are running out. Where’s she going to go?”

The only place that we have for somebody like that to go, even if they don’t need it, is nursing homes, because then Medi-Cal will pick up the cost.

And when you talk about staffing in federally regulated nursing homes versus staffing in most state-regulated or state-licensed assisted living facilities, what’s the distinction?

In terms of staffing there’s not much. Because again, even if you’re under the federal law, even under the facilities where Medicare and Medicaid certified, the staffing level’s kind of left up to the state. In California we require 3.2 nursing hours per patient per day. There’s a minimum standards, and certainly not adequate to provide decent care.

But it’s at least a number, a formula.

But at least it’s a number, absolutely. And in some states when you look at the assisted living regulations, some of them have staff-to-patient ratios.  Some of them require a higher level of staff.

But you’re correct in that most of it says you have to provide sufficient staff to meet the needs of the residents. What does that mean? We do at least have some standards under federal law regarding staffing that are completely lacking in most of the states, including California, for assisted living.

And do those standards kind of create a baseline for what you have to provide as a nursing home?

Absolutely. We have at least certain standards in terms of what kind of care you have to provide, what kind of training you have to have. Even the training for nursing homes, even albeit very limited, it’s like 150 hours of training for nurses aides. At least they have to be certified. They have to have 160 hours: 60 hours of classroom training, 100 hours of in-service training.

For an assisted living facility in California, 10 hours in the first four weeks. Ten hours. And then four hours of continuing education every year thereafter. That’s absurd.

So I’m looking at other states. We are looking at other states in terms of the training requirements. Washington State, for example, just passed a law that they’re going to require 75 hours of training over the first 150 days, and they’re going to create long-term care workers.

And that’s the other thing. We don’t really create paths for people who work in these facilities. They’re some of the lowest paid staff or employment that we’ve got in the state and probably in the country. I’m always touched by how much we pay childcare workers and nursing home and residential or assisted living workers.

… I’m a high school graduate.  I have no medial training. I have no training in psychology or social work or geriatrics. But I could take a 40-hour class from the state of California, take a test, and I’d be licensed to run an assisted living facility. Is that right?

That’s correct. In fact, you can have your GED. You don’t even have to graduate and walk across the stage.

And do you think that’s enough?

I don’t think it’s enough, not given the complications of the people who are in these facilities today. I would think that you’d need a lot more than that. …

You mentioned nighttime staffing requirements in California. As I understand it, if I’m running a facility with 101 to 200 residents in California, I only need to have one staff member awake and on duty overnight, is that right?

These are again minimum requirements, so yeah, you have to have at least one staff person awake and on duty. But that doesn’t mean you don’t have to have other staff, because you have to have adequate staff to care for the needs of 150 residents, for example.

I would think that the facility that only had one staff person awake and on duty would be considered to be understaffed and not able to take care of the residents. …

We’ve looked [at] personnel reports for Emeritus facilities in California and seen facilities with say 80 people, and there are two people assigned to the overnight shift. That’s it.  We’ve looked at facilities where the memory care unit in the Emeritus facility had nobody assigned to it on an overnight basis.  What do you think when you hear those kind of stories?

I’m not surprised at all because we hear those kinds of stories all the time. I think that it’s a travesty. First of all, how much money these facilities are getting paid per resident, and that’s coming out of the resident’s pocket or their family’s pocket — I think it’s a travesty.

And it just makes me wonder, where is the oversight once again? Why would they do this? I realize corporations are people, however behind these are actual, real people, and how do they sleep at night? How do they do that knowing what’s going on in these facilities?

But I think it’s also a national problem of ageism and looking at people as numbers. And older people when they’re institutionalized, they become a number rather than a real person. And until we get person-centered care, until we start looking at people as human beings, how is this going to change? …

If I wanted to find an assisted living facility for my mother in the state of California, what sort of tools are available to me to find a place that’s good and has a good track record and is doing well on its inspections?

There’s no tools. … The Department of Social Service is under Community Care Licensing, which is the oversight regulatory system. They created a website. But if you go on that website the only thing that you’re going to find out is the name of the facility, the administrator of that facility, the licensee of that facility, and the number of beds.

You will know nothing about the enforcement. You won’t know whether or not they’re even under investigation. You don’t know whether or not their license is pending. It will tell you absolutely nothing.

If you want to find out about a particular facility, you’re going to have to go to one of their seven or eight district offices. And again, you’re a senior. …

You’d have to ask for the public files on every single facility that you might be interested in. And of course it brings you back to, how would you know what you’re interested in in the first place?

And tell me what’s in this public files, because you helped create the law to make this available. …

I can tell you what’s supposed to be in them versus what’s actually in them, because sometimes their files are incomplete. What’s supposed to be in them of course is their action plan.

Plan of operation.

Plan of operations for the facility is supposed to be in there. The names of the owners, the licensee information, all of the deficiencies, all the surveys, and the plan of corrections in the deficiencies are supposed to be in there. …

Even if you see that public file, though, it’s very complicated information.  …

In this arena of assisted living there are for-profit placement agencies that are out there that help steer people towards different facilities, isn’t that right?

There are tons of them.  And the for-profit facilities actually get a kickback from the facility to direct them there. So we’re not talking about necessarily directing somebody to the best facility. …

… Where does this leave the consumer?

It leaves the consumer in a real dilemma of trying to sort through: What am I going to do?  I see in my city that there are 52 residential care, assisted living facilities. How do I choose one of those facilities?

Now we’ve created how to evaluate these facilities, the kinds of things you might want to look at when you’re choosing a facility. … And I never recommend that anybody would want to pick a facility just looking at online data any more than you would a new car, for somebody that you care about, one of the most important and difficult decisions in your life placing somebody.

But at least you want to be able to get that information to make an informed consumer decision, and we don’t have that available for consumers. …

I can go on Yelp and get all kinds of information about restaurants, about car lots, about any kind of business, and yet we have this paucity of information for consumers about what can be a life or death choice. What does that say to you?

It says to me that the state of California doesn’t really care whether consumers have choices. They care whether or not they have choices in terms of restaurants. They are very interested in making sure that we have the stars systems for that [like] we have for cars and other kinds of things.

But in terms of for our elders, making a choice for the last days of their lives, what may be their last home, tells me that they don’t care.

Why has there been such resistance in your opinion from the state to actually creating what many other states have, which is a searchable web interface that lets consumers know what’s going on in these facilities?

There’s two things. The number [one] is money. They say it’s going to cost a lot of money because whatever system they have apparently is so antiquated and so out-of-date that they just can’t update it easily.

But I will tell you, we’re a non-profit organization. We had the first consumer information system in the country for nursing homes, and that was 20 years ago when we had a budget of about $20,000 a year. It doesn’t cost that much if you’re not trying to put all the bells and whistles on it.

But number two is that I think that they’d be embarrassed. I think that they are going to be very embarrassed when they start putting that information out to consumers of the fact that they really don’t regulate facilities in the manner that they are supposed to.

In California, assisted living facilities get inspected how often?

Well, 20 percent a year, but basically once every five years. At least once every five years.  So you can be pretty sure that you’re going to be able to roam free for at least four years out of five.

And how well is that working in your opinion?

It’s not working at all. …

In California, the inspectors are expected to go out to a facility within 10 days of getting a complaint. Some of these complaints are very serious. There are allegations of abuse; there are allegations of neglect; there are allegations that someone’s been harmed. What do you think about having a 10-day window before somebody actually needs to go into the facility and check out the allegation?

We think that it should be similar to what it is for nursing homes. If there is a complaint where someone is in imminent danger of death or serious bodily harm, they have to go out within 24 hours, and that’s for nursing homes. …

So assisted living blew up in the 1990s.  It grew very rapidly.  Do you think that companies were attracted to this sector of senior care because it had less regulation than nursing homes?

I’m sure, and particularly the for-profit companies. When you look at the system, you don’t have to worry about federal government, you don’t have to worry about rules and regulations like you have to with a nursing home, for example, and you can charge whatever the market can bear.

If there are people who are willing to pay $5,000, $6,000, $7,000 a month for care, you can charge that. And there is no limitation on fee increases. That’s the other thing.  That’s pretty rampant in most of the states.

When we speak to people in the industry, they’re opposed to federal regulation by and large, and they say things like it would limit flexibility, it would limit choice. Why do you think they’re opposed to regulation?

If you are running a business, you’re opposed to regulation; it would make things a little bit more difficult for you. You actually have to follow protocols and laws. I understand that. I certainly understand that if I were running a business I wouldn’t want regulations either.

However, if you want consumer confidence and if you want somebody to actually believe in the product that you have — in this case it’s very similar to health care — one would think that you’d be supportive of that.

If you want federal money, which they also like to have, then they are going to have to come with federal regulations as well.

We hear this from the industry:  Hey, we don’t want federal regulation because it would limit consumer choice, and people in different places want different things. Do you think a consumer in Idaho really wants something different than a consumer in Florida, or something different from a consumer in Minnesota?

No, I think consumers want pretty much the same thing.  If your mother has dementia, for example, and you have to place your mother in an assisted living facility, you want to know that when you leave there at night, because your mother has to stay there, that if your mother rings the call bell, somebody’s going to come, and they are going to care for her and care for her in such a way that they are going to treat her as a human with dignity and with respect, and that you don’t have to worry about that when you leave.

That’s what people want. They want the care and supervision. They want the kinds of things that these facilities say they’re going to provide to you. You pay them the money and your mother gets the care that she needs.  I think that’s universal. Everybody wants that.

One thing we hear from people familiar with the nursing home industry is because it’s generally federally regulated, there’s a lot of paperwork that needs to be done that goes along with Medicare and Medicaid requirements.  And they say if assisted living had that kind of regulation, we’d be drowning in paperwork. What do you think of that?

… I agree there’s a lot of paperwork.  On the other hand, there is hell of a lot of money involved. We’re talking billions of dollars provided of taxpayer money going to the nursing home industry every single year, an awful lot of money. And so in order to get that kind of money they have to document.

The other thing is it protects them as well. You don’t document, that’s why facilities ended up losing lawsuits, because they don’t have the documentation. …

You’ve sketched out a scenario where we have seniors who have increasing needs, who are increasingly frail, going into assisted living and people working in those facilities who don’t have a lot of training.  What’s the peril there?

The peril is that they don’t know how to deal with people. They don’t recognize the kinds of signs when people are in distress. Sometimes you will see some of these problems that come up. They don’t know how to do CPR even though they are supposed to have training in that. …

They don’t know how to deal with emergencies. They don’t know how to deal with people with different kinds of frail conditions, and there’s an awful lot of peril in that.  Allowing people to wander around without providing the supervision — we have many falls in assisted living, so many falls, which again leads to people being hospitalized.

What we don’t think about is the high cost of poor care. When people are sent to acute care hospitals out of assisted living, then Medicare kicks in. The Medicare bills are so very high because so many people are being sent back and forth between assisted living and nursing homes to hospitals and then back again and then back again because they are not getting the care and supervision they need. And Medicare is picking up the bills on acute care hospital.

… In California, a nursing home that provides care that leads to somebody’s death, makes a mistake that leads to someone’s death, can be fined up to $100,000?

That’s correct.

… If an assisted living facility makes a mistake that leads to someone’s death, what kind of fine are they looking at?

The same fine that they would get with a serious deficiency, they would get up to $50 a day, or maybe $150 a day. But frankly, we don’t know for the most part what kind of fines are being leveled against these facilities, because unless you do a Public Records Act request for 7,300 facilities, we wouldn’t know.

When we’ve looked at the Emeritus Corporation and we found cases where state regulators linked the death of residents to poor care, the fines were typically $150. What do you think of that?

I think, obviously, it’s certainly not much of an incentive or disincentive to stop providing poor care. And that’s the purpose of the civil monetary penalties system for assisted living and for nursing homes. …

When you look at the for-profit chains in particular, I always say you’re not going to get them.  If you want to get them where it hurts, it’s not going to be in their hearts because they are for-profit chains. They are answerable to their investors and they care about return on investment.

You’re going to get them where it hurts, and that’s going to be in their wallets. And the only way you’re going to do this is through a citation system that actually works, and it provides a disincentive that is equal to the violation and may stop the violation.

So what does a $150 fine for killing someone say to a company that had $1.3 billion in operating revenue in the year 2011?

Exactly my point. They’re going to look at that and say it’s just a fly on the wall. It’s nothing.  It doesn’t mean anything. …

What does it say about how much we value the lives of seniors if the state is handing out $150 fines for essentially facilities that have failed and allowed seniors to die?

It says that we don’t value the lives of seniors. We don’t value the lives of seniors and disabled when we allow facilities to provide that kind of poor care, when we allow facilities to harm people, to neglect people, and to kill people. We don’t value their lives. And at the state level, that is exactly what we’re saying.

We’ve been looking very closely at the Emeritus Corporation, which bills itself as the largest assisted living operator in the U.S. They have more than 50 facilities here in California. In California, in a five-year time span, from 2007 to 2011, the company had about 600 violations. Almost 100 of those were medication errors. As someone who knows this world, how serious would you consider that?

It’s one of the most serious violations and that’s because medication errors can kill people.  It can permanently damage people. …

And what should we think about a company that’s accumulated nearly 600 violations in a five-year time period?

I think that’s a great deal given the reluctance on the part of Community Care Licensing to issue violations in the first place. Sounds like an awful lot.

Would you be concerned about that company and about their facilities?

I would be.  But I have nothing to compare it to, which is one of the problems, and that’s exactly why most likely CCL is too embarrassed to put any other information online. …

I’d be very concerned about going with a major for-profit care organization in the first place just because of what the priorities would be for one of those kinds of companies.

… In addition to nearly 100 medication errors, we found 31 instances where the company was cited for lack of staff training, 37 instances where the company was cited for insufficient staff, numerous cases where the company was cited for failing to do criminal background checks on caregivers. What should we make of that?

It’s very, very poor operational standards. First of all, criminal background checks are extremely important, because we’ve seen far too many incidences where people were not only injured but in some cases killed by caregivers who did not have a criminal background check.

Number two … that’s an awful lot of medication errors. But when you talked about the lack of training, staff training, then it makes sense. Because first of all, assisted living facilities are not supposed to be dispensing medication, number one. The purpose of assisted living is for people who can self-medicate.

Now if you have a staff person who is helping people take medication, they are supposed to have an additional 16 hours of training. So all of that kind of goes together and it makes more sense.

If you are going to be dispensing medications to people who live in assisted living, then you’d better be a qualified medical professional, an LVN [Licensed Vocational Nurse] or an RN [Registered Nurse]. So it all kind of sounds like there is a really poor operational standards.

Additionally, we found 14 cases where the state cited the company for failing to prevent people from eloping, five cases where the states cited the company for physical or verbal abuse by staff, 10 cases where the state cited the company for failing to prevent falls. What kind of concerns do those numbers raise for you?

All those concerns that we’ve talked about. We always worry about whether somebody has enough supervision for wanderers. If you are going to hold yourself out to be able to accept people with dementias, then you’d better make sure that you have enough staff to provide the supervision.

One interesting thing about California … we do not require a wander alert system of any sort in these facilities, even when they are dementia care facilities. … That’s a cause of concern. Anytime anybody is eloping from a facility is the possibility of a death, and we’ve seen that many times in California.

If you looked at the number of elopements in California, people wandering away from facilities, it’s generally out of assisted living. So all of these things are cause for concern, all of them. …

We got the internal tracking documents for one Emeritus facility in Auburn, California.  The facility had about 80 people living in it at any given time.  We found that it was experiencing more than 100 falls per year, according to their own documents, in a two-year span. So each year there were more than a hundred falls. What do you think of that?

… I think that’s extraordinary. This is exactly the [reason] why consumers need to know this information. If I have a relative who is likely to fall and I place him in that facility, is he going to be safe? Absolutely not. Because that number of incidents of falls is extraordinarily high.

It speaks to the lack of supervision, … and if you can’t provide the adequate supervision, you shouldn’t be running one of these facilities. …

… In your view, how do we improve the quality of care for seniors in assisted living in this country?  What do we need to do?

I think we need to do a number of things. I think we do need a national long-term care system so that people can get assistance in paying for assisted living, and we need federal oversight as well as state oversight of these facilities, and we need a consumer protection agency, which we don’t have.

When I started my organization 30 years ago, the Community Care Licensing really acted as that, community consumer protection agency. It’s not anymore. It’s a provider protection agency at this point. They’re much more interested in providing information and assistance to the providers than they are in protecting consumers.

And we need to make those kinds of agencies relevant again so that consumers have a place to go where they can complain. And we also need to take the profit out of assisted living. As long as that’s the motive — and providing quality care and supervision is not the motive — then I don’t know that we have much hope for better care.

But finally we need consumer demand. When consumers get fed up enough at the lousy care that their relatives are getting, or that they’re getting, and they start making their voices heard, that’s going to make a difference because the policymakers listen to their constituents. And they need to contact the people who create policy in their states and who create policy at the federal level.

… When you speak to people in this industry they’ll say, hey, if we weren’t doing a good job, we wouldn’t have all these people in our facilities. The fact that we’re doing a good job is reflected in our occupancy rates; it is reflected in the fact that people are moving into our buildings.  What do you say to that?

I can say on one level, there are some very, very good facilities, and you understand why consumers are moving into them. On the other hand, frankly, it’s only people who can really afford that level of care.

There’s an awful lot of people who simply can’t afford it and their money runs out.  There’s no sympathy on the part of the facilities. They will kick you out once your money runs out.

So there’s no alternatives. What do we have? Where are people supposed to go? That’s a sure way to increase your occupancy rate when you have no other alternatives except for a nursing home. If people have a choice, they’re not going to go to a nursing home.  They’re going to go to assisted living. It’s as simple as that.