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HomeMy WebLinkAbout09.03.2021 R. Schlank CommentsROSEMARY A. SCHLANK 9 Bayberry Lane Rye Brook, NY 10573 (914) 939-9273 RSchlank@ix.netcom.com September 3, 2021 Mayor Rosenberg and Honorable Members of the Village Board of Trustees Village of Rye Brook Offices 938 King Street Rye Brook, NY 10573 Dear Mayor Rosenberg and Trustees, Re: Comments on Site Plan Application for 900 King Street: Issues with the Design of the Assisted Living and Memory Care Center This letter focuses on the design of the assisted living and memory care facility. In a facility of this type, a review of architectural design needs to go beyond the usual features of rooflines and grand entrances. It needs to consider the effect of the built environment on the health, safety, and well-being of the occupants. For long-term care facilities like the one proposed for 900 King Street, there are design standards developed by specialists in gerontological environments. These standards are based on extensive research into what works for occupants with certain profiles, such as individuals who need to be placed in memory care units. Six research-based issues Research on the applicable architectural design standards and consultation with a well-respected industry expert indicate that the proposed design would not result in the kind of care or quality of life that would be suitable for Rye Brook residents. Changes should be made to the proposed design for six main reasons. 1. The site plan reflects an outdated institutional model. Extensive studies have shown this approach results in adverse health-and-safety effects. 2. The site plan departs from modern architectural design standards in many areas, and this will result in a material loss of benefits to future occupants. 3. If approved as is, there is a significant risk that the plans will be more suitable for supportive housing than the typical memory care resident. 4. The approach is inconsistent with the intent of the comprehensive plan. 5. The approach is inconsistent with the direction of legislative reforms Rosemary Schlank 900 King Street, page 2 6. Even seemingly minor modifications to incorporate modern design standards would result in significant improvements and help dispel perceptions of “putting profits over people.” The attachments to this letter provide more detailed explanations of each of the reasons. For your convenience, they also provide background information on the health and safety concerns related to institutional-type facilities, the applicable architectural design standards, and the direction of legislative reform initiatives. The standards listed on the attachments represent a partial list and are not meant to be all-inclusive. Links are provided to more complete sources. A matter of good governance and social responsibility The owner of 900 King Street is copied on this letter because the issues with the site plan involve sensitive tradeoffs between profitability and social responsibility, including the social responsibility of his company as well as that of the Village. One of the key reasons why the site plan should not be approved is because the proposed design of the assisted living and memory care center is the very essence of what legislators all over the country are trying to reform in the aftermath of a deadly pandemic that focused the nation’s attention on the devastating effects of facilities where too many seniors are housed together in close confines in outdated institutional facilities that do not follow modern design standards. The citizens of Rye Brook deserve first-rate care facilities, and the owner of 900 King Street deserves to make a reasonable profit from the sale or use of this property, even if he has ignored and trampled on the rights of fellow stakeholders in the same PUD. We can forgive that. But the bottom line is this site plan doesn’t work. So please look into your hearts and souls as well as your budget worksheets. And do the right thing for Rye Brook. Please vote “No” to the site plan application and draft resolution as currently proposed. Yours truly, Rosemary Schlank c: Peter Duncan, Owner of 900 King Street Dan Barnett, President, Board of Directors, Arbors Homeowners Association Rosemary Schlank 900 King Street, page 3 Chris Bradbury, Administrator, Village of Rye Brook, NY Members of the VRB Planning Board Members of the VRB Architectural Review Board Attachments: A. Explanations of the reasons why the design should be revised B. Modern Architectural Design Standards and Recommendations  Selected Design Considerations for Long-Term Care Facilities published by Perkins Eastman and the Alzheimer’s Federation of America  Additional Evidence-Based Architectural Design Standards for Long-Term Care Homes, Robert Wrublowsky, MMP Architects C. Comparison of 900 King Street Plans with Facilities that Use a Small-House Residential Model  White Oak Cottages at Fox Hill Village  Hebrew SeniorLife, Gilda and Alfred A. Slifka Memory Care Assisted Living Residences  900 King Street D. Independent review, Robert Wrublowsky Rosemary Schlank Attachment A, Page 1 Attachment A Explanations of the reasons why the design should be revised Reason No. 1 The site plan reflects an outdated institutional model. Extensive studies have shown this approach results in adverse health-and-safety effects. The design of the facility follows the “institutional model” which is well-known for causing adverse health and safety effects. The root causes of the harmful effects are the mass and density of the facilities. In effect, these features provide staffing and operational efficiencies at the expense of safety, quality of care, quality of life, and human dignity. Critics have faulted this design for “putting profits over people.” This approach raises a number of sensitive concerns about the social responsibility of the owner and the Village. The issues fall into the categories of safety concerns and other health-related concerns. Safety concerns The recent pandemic provided ample evidence of the adverse effects of the design institutional-style facilities on the safety of the occupants of these facilities. A recent study by Perkins-Eastman on the impact of the pandemic found that “…providers had to pivot to focus solely on fulfilling the core promise of keeping residents safe. (Note 1) The reason for the pivot is because the designs of some facilities were not effective in preventing the spread of infectious diseases. This trend was also discussed in my letter of March 11, 2021 to the Planning Board. Here are a few excerpts from that letter:  Well-publicized statistics show that altogether approximately 40% of COVID-related deaths took place in nursing homes and congregate care facilities where seniors were living together in close confines.  The infection and mortality rates were especially high in assisted living facilities. A Congressional investigation into the experiences of the nation’s eleven largest assisted living facilities showed that the residents of these facilities tested positive for COVID at a rate of over five times the national average, and 30% of the residents who contracted COVID in an assisted living facility died from it.  The statistics are even more alarming for residents of memory care facilities. Studies supported by the NIH National Institute on Aging show that people with dementia were twice as likely to get Covid-19 and four times more likely to die from it. Rosemary Schlank Attachment A, Page 2 Other health-related concerns There is also ample evidence that the institutional model causes other adverse effects on the health and well-being of the occupants. The perceptions that the providers were putting profits over people has led to extensive research studies that probed the effects of the designs of those facilities on quality of care, qualify of life and human dignity. Here are some examples of the findings:  Studies done prior to the pandemic confirmed that the institutional model was, in effect, setting up patients for failure because it contributed to their agitation, restlessness, and declines in both physical and cognitive health.  Life in a traditional institutional-style adult care facility was typically likened to a factory in which large numbers of residents are treated in an assembly-line manner due to the cramped quarters and tight spaces that are designed to provide the operational efficiency of a hospital.  A key complaint was that it was more efficient for staff to allow a wheel-chair bound resident to become incontinent than to create an environment in which the resident could self-toilet. It was dehumanizing. The concerns about the effects of the institutional model on the health and safety of the occupants of long-term care facilities led to the establishment of more modern architectural design standards for long-term care facilities using a systematic evidence-based approach. (Note 2.) Note 1. 2021 Edition, “The State of Senior Living: An Opportunity for Change,” Perkins Eastman. https://www.perkinseastman.com/white-papers/ Note 2. Robert Wrublowsky, Design Guide for Long-Term Care Homes, 2018 Edition, MMP Architects, 2017.) Available for download from Facility Guidelines Institute, https://www.fgiguidelines.org/wp- content/uploads/2018/03/MMP_DesignGuideLongTermCareHomes_2018.01.pdf Rosemary Schlank Attachment A, Page 3 Reason No. 2 The site plan departs from modern architectural design standards in many areas, and this will result in a material loss of benefits to future occupants. For new construction, developers are can overcome the health-and-safety issues and the profits-over-people perception by following modern architectural design standards. These standards limit the adverse effects of too much mass and density. When used in this context, “mass” refers to the exterior dimensions and shapes of the buildings (i.e., the scale of the building). “Density” is reflected in the internal layout or floor plan. It refers to the number of occupants per building or household. The density is highest when the layouts try to cram as many residents as possible into a facility by omitting features with a residential character, such as kitchens, dining rooms, and easy access to the outdoors. Below is a brief overview of today’s design standards and benefits, followed by an analysis of the some of the areas in which the plans for 900 King Street depart from the standards. Overview of modern architectural design standards and benefits Today’s design standards are known as “evidence-based” standards because they were developed by specialists in gerontological environments based on extensive research. Studies have consistently shown that use of modern design standards results in significant health and safety benefits, especially the standards for building layout, population size, residential character, and access to outdoors. Here are the highlights:  Smaller scale facilities with open floor plans. A core guiding principle is that adult care facilities should be less institutional and more like smaller-scale residences. Modern design principles emphasize that long-term care facilities should be organized into households with no more than 14 residents in a household and they should use an open floor plan that includes living space, a dining area and an open kitchen. Additionally, the floor plan should provide for private bedrooms with a full bathroom and a readily accessible, secure outdoor space for use at any time but dedicated to the household. (In effect, the residents of each household have their own back yard.) Rosemary Schlank Attachment A, Page 4  Benefits for memory-care facilities. The strong relationship between the design of the built environment and outcomes of people with dementia was confirmed in a landmark study on the “Impact of the Design of the Built Environment on People with Dementia” that was conducted by the Centre for Health Design in 2014. The study showed that the use of a lower density is especially critical for memory care facilities where institutional conditions may cause increased wandering, anxiety, agitation, and depression; and staff may rely too heavily on physical restraints and/or psychotropic drugs to control these reactions.  Benefits for other long-term care facilities. As documented in the 2014 study and in the 2018 architectural design guide, the health benefits of modern design standards are measured by outcomes that range from better mobility and higher cognition scores to reductions in stress, anxiety, depression, blood pressure and muscle tension, as well as a lower incidence of declines in daily living activities (DLAs). The benefits are also reflected in better orientation success and improved social awareness and communications skills.  Benefits for all senior housing facilities. The use of modern design standards has also been effective in controlling the spread of infectious diseases in nursing homes during the pandemic, and leading architects are suggesting this finding has implications for other senior housing facilities as well. As Perkins-Eastman explains: “Recent research by the Green House Project ... demonstrated that the spread of disease was significantly lower in smaller group settings. . . This preference for smaller group living settings may impact other levels of care, such as assisted living and even independent living. The ability to break down a building into small-scale pods, each with its own amenity spaces and access to the outside, is likely a trend that is here to stay.” (Perkins-Eastman, 2021 Edition, “The State of Senior Living: An Opportunity for Change.”) Comparison of 900 King Street Plans with Modern Architectural Standards After the COVID pandemic added better control of infectious diseases to the list of the benefits from smaller-scale facilities, many developers went back to the drawing board in an effort to replace institutional facilities with residential models that use a “small-house” design. But the developer of 900 King Street did not do that, and the design used in the site plan for 900 King Street falls short of today’s standards in a number of areas, including the following: Rosemary Schlank Attachment A, Page 5  Building layout. The proposed facility is not broken down into small-scale self-sufficient pods or clusters known as households. It has a capacity of 94 residents including 25 in the memory care unit, which far exceeds the standard for the maximum number of residents per household (i.e., 14). Additionally, the design does not follow the standards for minimizing the use of hallways and avoiding dead-end corridors. Instead, the floor plans include dead ends and “double loaded” corridors. “Double loaded” means there are resident rooms on both sides of a hallway that is used for passage by other occupants. This approach maximizes profitability because it is designed to fit as many occupants on each floor as possible, but it undermines the quality-of-life goal of providing maximum freedom to mobility-impaired occupants, such as those who use walkers or wheelchairs and who would find it difficult to enter and use the hallways without assistance.  Population size. Other major shortcomings include the overall size of the population of occupants and the use of facilities located in another building. The proposed facility does not follow the standard of providing a resident- accessed kitchen, dining room, and living room for each household of 14 or fewer residents in a size or scale that is appropriate for smaller populations. Instead the occupants would need to use a single centralized kitchen located in another building, as well as amenities that are expected to be open to the entire community of 231 residences (126 independent living units, 85 assisted living and memory care units, and 20 townhouses) in a project that is expected to add a population of 386 people to the site (this is described as a conservative estimate in the site plan application).  Lack of residential character. The exterior of the proposed facility does not follow the standards for residential character despite the fact that it has windows and some minor articulations because overall it could be described as the type of solid, monolithic façade that is considered inappropriate for long-term adult care facilities. The plans further depart from the standards because the facility does not use residential details, such a front entrance for each household and the ability to walk through rooms with unique visual impacts rather than down hallways that are frustrating for memory-impaired and mobility-impaired residents. Additionally, the outside kitchen departs from the standards because it does not offer sensory cues to encourage residents to eat, (e.g., sightlines into the kitchen to the ability to smell food being prepared). Rosemary Schlank Attachment A, Page 6  Lack of suitable access to outdoors. The proposed facility does not provide free access to outdoor areas in a scale that is appropriate for smaller households. Nor does it provide that access from a central activity room where residents can visually see and freely access a safe outdoor patio area. Nor does it appear to provide decks on upper stories so that each household has its own outdoor environment. Instead, an occupant of the memory-care facility would need to go up and down four stories to get to a 5,000 square foot area that is shared with up to 93 other residents. It is unlikely that the typical memory care occupant would be able to do that and then find his or her way back to the 4th floor without assistance.  Lack of small group spaces for occupants and visitors. The floorplan does not appear to provide sufficient small private or semi-private group gathering spaces with visual and acoustic privacy so residents can spend time with visitors outside of their bedrooms. These spaces are especially helpful for memory care residents who get easily overwhelmed by crowds and noise - a common symptom of Alzheimer’s disease - and one that would likely be exacerbated by the proposed location of the facility, (i.e., in close proximity to the Village’s fire house and police headquarters where the sound of sirens can be quite audible). There may be additional departures from the standards. The above observations do not constitute an in-depth comprehensive review, and the list is not meant to be all-inclusive. Additional details of the design standards and benefits are provided on Attachment B which provides selected recommendations from Perkins Eastman and the Alzheimer’s Federation of America, as well as additional selected standards from the design guide published by Facilities Guidelines Institute. Emily Chmielewski, Excellence in Design: Optimal Living Space for People with Alzheimer’s Disease and Related Dementias, 2014, Perkins Eastman and Alzheimer’s Federation of America. The entire publication is available at: https://www.perkinseastman.com/white-papers/excellence-in-design-optimal-living-space- for-people-with-alzheimers-disease-and-related-dementias/ and https://alzfdn.org/wp-content/uploads/2017/11/Excellence-in-Design-white-paper- June-2014.pdf Robert Wrublowsky, Design Guide for Long-Term Care Homes, 2018 Edition, MMP Architects, 2017.) Available for download from Facility Guidelines Institute, https://www.fgiguidelines.org/wp- content/uploads/2018/03/MMP_DesignGuideLongTermCareHomes_2018.01.pdf Rosemary Schlank Attachment A, Page 7 Reason No. 3 If approved as is, there is a significant risk that the plans will be more suitable for supportive housing than the typical memory care resident. Architectural reviews of long-term care facilities need to take into account the intended occupants. Since the site plans reflect the use of the institutional model, the future occupants of the building will not realize the health and safety benefits that are made possible by modern architectural design standards. But this needs to be put in perspective by considering the condition of the intended occupant, especially in memory care facilities. Consultation with an industry expert indicates the facility proposed for 900 King Street will not likely be suitable for typical memory care occupants. But it could be suitable for “supportive housing” because the occupants of supportive housing are more likely to accept the loss of health and safety benefits as an economic necessity, since these would be formerly homeless individuals who might otherwise not have access to any care at all. The potential usage as supportive housing raises questions about the compatibility with ownership and management by a for-profit enterprise. Below is a brief overview that helps to explain the nature of a typical memory care resident and the reasons why the facility appears to be more suitable for supportive housing. It also contains some observations about the related uncertainties for for-profit ownership and management:  Reasons why the facility appears to be more suitable for supportive housing. The project description leaves some uncertainty about the types of individuals for whom the facility is intended because memory care is typically considered a special form of skilled nursing, and the site plan application indicates that skilled nursing services will not be provided. To help resolve the uncertainty, Robert Wrublowsky, author of the book on architectural design standards for long-term facilities, was asked for an independent review and recommendation. Mr. Wrublowsky’s comments are provided on Attachment D. Mr. Wrublowsky explained that placements in memory care facilities generally depend on how an individual scores on the RAI-MDS outcome scale. If a future occupant’s score is similar to the memory care profile shown on Attachment D, then the proposed facility would, as Mr. Wrublowsky Rosemary Schlank Attachment A, Page 8 phrased it, not be very successful as a memory care environment. Instead, the facility might be used as supportive housing. . . More information about the Minimum Data Set (MDS) Resident Assessment Instrument (RAI) is available from The Centers for Medicare & Medicaid Services at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/MDS30RAIManual .  Uncertainties about compatibility with for-profit ownership and management. Supportive housing could be seen as the opposite of putting profits over people. It puts people over profits because it is defined as affordable housing with onsite services to help formerly homeless, disabled tenants live in dignity in the community. These occupants do not pay full price for their housing and services. As a result, any usage for supportive housing would cut into the owner’s profit, and renegotiation of the PILOT agreement (payment in lieu of taxes) might be appropriate if for-profit ownership of supportive housing is permitted under law. If it is not permitted, then a new legal entity might need to be created. But this is all speculative because of the uncertainties involved More information about the use of supportive housing in New York is available from the Supportive Housing Network of New York. The Network’s website explains that the residences used in supportive housing in New York are generally owned and operated by nonprofit organizations and are accountable to their city, state, and federal funders. Supportive Housing Network of New York (https://shnny.org/supportive- housing/what-is-supportive-housing/) Rosemary Schlank Attachment A, Page 9 Reason No. 4 The approach is inconsistent with the intent of the comprehensive plan. The site plans are inconsistent with the comprehensive plan in these respects:  Size and scale of buildings. As currently proposed, the plans for the assisted living and independent living facilities include 3- and 4-story buildings – an approach that was mentioned for consideration in the comprehensive plan but was not supported by the community in a pre-plan survey. The authors of the plan would have expected the Village would conduct research before approving this concept. And extensive research shows that a smaller scale, more residential model is far better from a health and safety perspective.  Uncertainties about types of care provided. The intent of the comprehensive plan was to provide a care facility within the Village so Rye Brook residents could stay in Rye Brook, rather than move to another municipality when they get to the point in life where they need long-term care. The proposed facility is inconsistent with this intent because: (1) the facility is not designed to provide skilled nursing services other than memory care, and (2) the quality of life inherent in the site plans does not appear suitable for Rye Brook residents, very few of whom are homeless and in need of supportive housing. Rye Brook residents will still need to move to another municipality to find more modern and more suitable care when they need it.  Questionable benefits of rentals and pay-for-service facilities. Rye Brook may have senior citizens who have become empty-nesters and who feel the desire to downsize. But generally, this is done well before they reach the age of 62, and it is often done by buying a smaller home. It is unclear what benefit a Rye Brook senior would gain from selling his house and moving to the kind of rental or fee-for-service facility proposed for 900 King Street, except perhaps to get transportation for grocery shopping and doctors’ visits. And legislators are actively working on plans to provide other assistance with these items.  Uncertainties about other benefits. The site plans are also inconsistent with the expected outcomes cited in the 2021 zoning amendment for 900 King Street. This resolution represents the project will promote sustainable development; encourage a stable and enduring economic base; provide for safety health and education; serve as an example of smart-growth develop- ment; and enhance the quality of life of Village residents, business, interest groups, and future generations. This may have been the intent of the comprehensive plan. But a comparison of the site plan with modern design standards casts considerable doubt on the accuracy of those statements. Rosemary Schlank Attachment A, Page 10 Reason No. 5 The approach is inconsistent with the direction of legislative reforms Similar to the intent of the comprehensive plan, the legislative reforms that were initiated after the pandemic are also designed to promote smart growth and enhance quality of life. Some reforms include funding for home- and community- based services that will allow seniors to stay in their homes and out of long-term care facilities. Others open up new sources of funding and financial assistance for smaller-scale facilities that follow modern architectural design standards. Still other reforms would address the profits-over-people issues head on by limiting new construction or expansion by for-profit enterprises. All of these initiatives will lower the market for (and economic viability of) the facility at 900 King Street. Here are some examples of recent legislative actions:  In May 2021, the U.S. Dept. of Health and Human Services’ Administration for Community Living released $1.4 billion in funding from the “American Rescue Plan for Older Americans Act.” This funding provides help to individuals as an alternative to long-term care facilities. It includes $460 million for Home and Community Based Services (HCBS). These services provide help with household chores, transportation to essential services (such as grocery stores and doctors), and case management. The funding also includes $145 million to help family caregivers provide in-home support and $44 million to help address fall prevention, managing a chronic disease, and programs to detect and reduce depression among seniors. ( https://www.whitehouse.gov/briefing-room/statements- releases/2021/05/03/fact-sheet-biden-harris-administration-delivers-funds- to-support-the-health-of-older-americans/ )  In August 2021, six US Senators introduced the “Nursing Home Improvement and Accountability Act of 2021.” This bill responds to criticisms of institutional-type nursing homes. It would provide $1.3 billion for a small- house nursing facility demonstration program, along with additional funding for smaller-scale facilities that have between 5 and 14 residents, provide private rooms, offer accessible outdoor space for residents, and have “standing resident and family councils.” If approved, the program would start in July 2023, and it would establish a model that could be used by assisted living and memory care facilities as well. Rosemary Schlank Attachment A, Page 11 (https://www.finance.senate.gov/imo/media/doc/Nursing%20Home%20Impr ovement%20and%20Accountability%20Act_Sec-by-Sec_Final.pdf )  At the state level, the scope of potential reforms is very broad. The Senate and the Assembly have passed bills that will create a “Reimaging long-term care task force” to do a comprehensive study of the state of long-term care services and explore ways the state can better meet the needs of New Yorkers while prioritizing safety, affordability, and enhanced quality of life for those in need of such care. The scope of task force’s mission includes both in home-based and facility-based settings, and it addresses the full range of adult-care services including community-based services, independent living, assisted living and skilled-nursing facility care. (A3922A/S598B)  Other state reforms address the perception that there may be a conflict between for-profit ownership of long-term care facilities and the health and safety of the occupants. The state has focused on restrictions that would apply only to for-profit entities, a category that includes the owner of 900 King Street. In March 2021, the NY state Assembly passed a bill that would prohibit construction for establishment or expansion of bed capacity of a nursing home owned or operated, in whole or part, by a for-profit entity. This bill sets precedent for similar legislation that may restrict construction of assisted living facilities by for-profit entities. (A5842/S5269) Rosemary Schlank Attachment A, Page 12 Reason No. 6 Even seemingly minor modifications to incorporate modern design standards would result in significant improvements and help dispel the perception of putting “profits over people.” The final reason for rejecting the site plan application is that this might encourage the applicant to revise the plans to conform to modern architectural design standards. This would likely result in long-lasting benefits that go beyond the health and safety benefits while resulting in only minor short-term project delays. Here are some of the potential benefits of switching to a small-house model:  It would help stop the spread of infectious diseases and avoid school and business disruptions that might otherwise result from a surge in COVID variants or another future pandemic.  It would help to address concerns about building height and fit in better with the character of the community,  It would position the owner and the Village to take advantage of funding and financial assistance provided by legislative reforms,  It would address some of the risks and uncertainties associated with the project. These risks include the risks associated with being locked into a multi-year PILOT agreement (payment in lieu of taxes) that will be difficult to unwind at a time when evolving legislative initiatives could make other funding and financial assistance more attractive; the risks of potential limits on for-profit ownership; and the risks that any use for supportive housing will cut into profits and undermine the economic viability of the project. Addressing these risks upfront will provide a more sustainable revenue base for both the owner and the village.  It would provide better safeguards for the other land-owners in the PUD against the hardships faced by our neighbors in Doral Greens when the hotel and conference center in that PUD went out of business. Arguably the biggest complexity involved in achieving these benefits is that some compromise in overall population size would need to be made to meet the dwelling- unit-per-acre density reflected in the site-specific zoning statute. Examples of designs that follow the small-house model are provided on Attachment C. The building footprint of SeniorLife is similar to the site plans and might serve as a helpful example of how the 900 King Street plans might be revised. Rosemary Schlank Attachment B, Page 1 Attachment B Selected Design Considerations for Memory Care Facilities The following principles and recommendations were adapted from Excellence in Design: Optimal Living Space for People with Alzheimer’s Disease and Related Dementias, authored By Emily Chmielewski and published in 2014 by Perkins Eastman and Alzheimer’s Federation of America. (https://www.perkinseastman.com/white-papers/excellence-in-design-optimal-living-space-for- people-with-alzheimers-disease-and-related-dementias/ ) The introductory section of the publication explains that the design principles were adapted in part from the successful design of the Woodside Place in Oakmont, PA. The Woodside Place project began with the formation of a multidisciplinary team, including specialists in dementia, geriatrics and architecture. The team saw the need for a better kind of therapeutic environment to address the increasing number of people with mid-stage Alzheimer’s disease who were being placed in nursing homes — despite their otherwise good physical health — because limited other options were available to them. After conducting research including site visits and many interviews with academics, gerontologists, service providers, and people in regulatory positions, the team conceived of a non-institutional, resident-focused model…The resulting residence opened in 1991. Woodside Place became one of the first of its kind in the long-term care industry where design goals directly connected the physical environment to the philosophy of care. Guiding Principles The basic principles include the following:  Personal relationships are supported by households of 10 to 14 residents with shared living areas  Residential kitchens are a key part of enhancing home-like experiences  Residents should have direct access to secure outdoor spaces  Private hallways help distinguish private bedroom areas from common living spaces  Single-occupancy rooms offer residents privacy, independence, control and dignity Specific Recommendations Specific recommendations for designing facilities for people with Alzheimer’s and other dementias include the following: 1. Create small-sized groups of people, forming clusters or “households” of 10 to 14 residents. In addition to bedrooms, households should provide a shared, resident- accessed kitchen, dining area, and living room, plus secure outdoor space. Additional areas for residents within the household may include (but are not limited to) a spa/bathing room, small den and/or activity space. 2. Within the household, provide small group spaces with some visual and acoustic privacy. These spaces can be used by residents who get easily overwhelmed by crowds and noise, a common symptom of Alzheimer’s disease that can result in behavioral issues and distractions. For instance, large, noisy dining spaces have been linked with an individual’s reduced food intake. Rosemary Schlank Attachment B, Page 2 3. 4. Avoid multi-purpose rooms. Though the general concept of flexibility is important so the building can evolve over time, multi-purpose spaces are not recommended since a person with Alzheimer’s disease may not adapt to the room’s changes in use and expected social patterns. Instead, provide small group spaces that are distinctive, like in a home. There should be designated zones for pastimes such as casual conversation, dining, cooking, and watching television. 5. Exterior massing should be articulated (with distinct elements and walls that jog to create different planes, rather than a solid, monolithic façade) and at a scale that relates to a person (i.e., “human-scale”), with residential detailing and materials appropriate to the building’s locale. 6. Interior layout and hierarchies of space and circulation should reflect conventional residential layouts. For instance, in modern Western cultures, this layout usually consists of a public-to-private transition of entry foyer to living room to dining room and kitchen, with bedrooms in the most private zone. The kitchen/dining/living area is the “heart” of the home, with the hearth a central place of activity. 7. Minimize the use of hallways. Western-style homes rarely use corridors. Rooms are arranged enfilade, which means walking through rooms rather than hallways to get to a place (e.g., walking through the living room to enter the dining room). Small hallways are usually only offered as a way to access private areas, such as bedrooms or back-of-house spaces. By replicating typical home layouts, the building design can help residents feel comfortable, safe, less frustrated, and reduce challenging behaviors. 8. Have food in the household’s kitchen available at all times. … The environment should offer sensory cues to encourage residents to eat, from sightlines into the kitchen to smelling food being prepared. Provide small private or semi-private group gathering spaces so residents can spend time with visitors outside of their bedrooms. 9. Providing unrestricted access to secure outdoor spaces — even for residents with development issues — is vital since it can reduce agitation and frustration, relieve stress, and improve physical fitness (from walking to exposure to sunlight that regulates mood, circadian rhythms, etc.). By giving residents a secure place to go outside, it can even help reduce elopement attempts since residents do not feel as cooped up. 10. While safety and security are always a concern and must be taken into consideration, the outdoor space should be designed so that staff and families are comfortable with the residents’ unaccompanied access to the outdoors, when appropriate. 11. Locate outdoor spaces in serene settings (e.g., not on a busy street) since “older people with dementia generally enjoy going out, but anxiety, disorientation or confusion can occur in complex, crowded or heavily-trafficked places or when startled by sudden loud noises.” 12. Just as it is important for facilities to include areas that support resident activity and engagement, it is also necessary to provide quiet, peaceful spaces. Provide each resident with a private bedroom where the person can be alone and keep personal Rosemary Schlank Attachment B, Page 3 belongings, helping the resident to feel secure and express a degree of territoriality. Locate private bedrooms in a residential zone, away from noise. 13. Do not terminate circulation paths in dead ends. Looping paths and end-of-hall destinations, (e.g., sitting area, activity room) can help redirect or engage a resident. The principles listed in this Attachment are not meant to be all-inclusive. Additional details are available in the below-referenced publication of Perkins Eastman and Alzheimer’s Foundation of America. Emily Chmielewski, Excellence in Design: Optimal Living Space for People with Alzheimer’s Disease and Related Dementias, 2014, Perkins Eastman and Alzheimer’s Federation of America. The entire publication is available at: https://www.perkinseastman.com/white-papers/excellence-in-design-optimal-living-space- for-people-with-alzheimers-disease-and-related-dementias/ and https://alzfdn.org/wp-content/uploads/2017/11/Excellence-in-Design-white-paper- June-2014.pdf Rosemary Schlank Attachment B, Page 4 Evidence-Based Architectural Design Standards for Long-Term Care Homes The following standards were adapted from the 2018 Edition of the Design Guide for Long- Term Care Homes, which was authored by Robert Wrublowsky, MMP Architects and published in 2017. The standards were culled from extensive evidence-based research. The entire 162-page publication is available for download from the Facility Guidelines Institute, https://www.fgiguidelines.org/wp-content/uploads/2018/03/MMP_DesignGuideLongTermCareHomes_2018.01.pdf The introductory section of the guide explains: The institutional-based environment of care (EOC) that we have been designing for our elders has contributed to their agitation and restlessness... To date, the priority has been heavily weighted on operational efficiencies and processes of care. . . We need to refocus our priorities on understanding the relationship between the people who occupy these facilities, the care processes and needs AND the built environment—how all these elements interrelate, not how they work in isolation. . . . This document will provide the designer with the guidelines, supported by research, to design better environments in which our elders can live out their later years with purpose and fulfillment. Guiding Principle One of the guiding principles is to design a residential (non-institutional) environment in layout and scale. Specific Areas of Site Plan Design Brief highlights of the guidance on specific areas of site plan design, including building layout, population size, residential character, and access to outdoors are as follows. A. Building layout Decisions on the building’s spatial layout are among the first steps when designing care environments. . . . Studies have shown conclusively that designing smaller scale clusters has produced a more positive quality of life for residents . . . Partial list of design standards for building layout  Organize the Facility into Households that are as small as staffing and servicing efficiencies will permit. Provide no more than 14 residents to a household. The traditional model is 10-12.  Include familiar spatial organization similar to that found in a typical house/home.  Design the spaces to allow residents to move freely within the household and from one room to another without having to use a corridor.  Eliminate corridors whenever possible.  Do not create dead end corridors. Rosemary Schlank Attachment B, Page 5 Partial list of benefits  Residents in small-scale living environments had a better cognitive and functional status, than residents of traditional institutional style PCHs [personal care homes].  Small scale home-like environments evoke positive outcomes such as higher emotional well-being, pleasure, and social interaction among residents and with the care staff, and with less anxiety, agitation, and depression.  Decreased use of psychotropic medications. B. Population size Previous traditional PCH models were based on staffing and medical efficiencies . . . However, the vast majority of all studies on population size promote smaller groupings as a healthier environment for residents . . . The design standards for population size include the following:  Households should provide a shared, resident-accessed kitchen,... dining area, and living room, plus secure outdoor space appropriate in scale for smaller populations.  Within the household, provide small group spaces with some visual and acoustic privacy.  Avoid multi-purpose rooms for residents associated with the household or neighborhood. Partial list of benefits  . . . behavioral changes in residents with cognitive impairment, including decreased wandering, pacing, and aggression and increased engagement.  Residents or families of the small houses reported better quality of life on 7 of the 11 subscales (privacy, dignity, meaningful activities, relationship, autonomy, food enjoyment, and individuality) . . .  Small house residents also reported greater satisfaction, emotional well-being, functioning, and mobility. In addition, they had lower prevalence of bed rest, fewer residents with little or no activity, less depression, and a lower incidence of decline in ADL’s. [activities of daily living] C. Residential character A setting that has an institutional look and feel is not a “home.” The residential quality of the building is very important, inside and out. The design standards related to residential character include the following:  Design spaces so that smaller groups function autonomously. Households with smaller population sizes reduce over stimulation. Rosemary Schlank Attachment B, Page 6  Design dining areas that provide the optimal dining experience. Provide a larger table for larger groups of higher functioning individuals to sit together family-style while providing smaller tables for those in need of assistance.  Provide a distinct entrance to each household complete with all the elements consistent of a home entrance. Front porch, mailbox, door bell, exterior materials, and so on. The household entrance IS the front door to each person’s residence no different than the front door in your own home. Benefits  Non-institutional environments characterized as having homelike or “enhanced” ambiance (personalized rooms, domestic furnishings, natural elements, etc) are associated with improved intellectual and emotional well-being, enhanced social interaction, reduced agitation, reduced trespassing and exit seeking, greater preference and pleasure, and improved functionality. D. Access to outdoors Many long term care homes do not provide easy access to outdoor natural environments due to safety concerns, or physical design limitations. Access to nature provides access to daylight, but also exposes people to the natural elements as well as engagement to nature. All residents within a long term care environment are entitled to the opportunity to move about freely in a safe and secure outdoor environment. It is considered unethical to restrict residents’ access to outdoors if they wanted to go outside. The design standards related to access to the outdoors include the following:  Provide easy access to an outdoor space. The best location to provide access is from the central activity areas where residents can visually see and freely access a safe outdoor patio area.  Provide decks on upper stories so that each household has their own outdoor environment.  Consider including enclosed courtyards within the building footprint.  Ensure all outdoor areas remain wheel chair and walker accessible.  Secure outdoor spaces with perimeter fencing at least six feet high, and camouflage the fencing with landscape design features such as trees or shrubs so it does not attract residents’ attention or feel prison-like.  Provide sufficient resting spots (benches) along longer walkways, or handrails to assist those with mobility issues. Partial list of benefits  Well-being benefits including reduced stress, anxiety, blood pressure and muscle tension.  Bright light exposure and sunlight therapy. Maintain circadian rhythms.  Produces higher cognition scores. Rosemary Schlank Attachment B, Page 7  Reduction in high dose anti-psychotics and other medications.  Opportunity to exercise or participate in daily living outdoor activities, such as gardening. Comparison of Personal Care Homes – Institutional Model vs Small House Model Institutional Model Small House Model Size 20-40 elders for operational group 10-14 elders per household Philosophy Medical model emphasizing provision of clinical services to patients (nourish, protect, shelter). Quality of Life model emphasizing purpose, community, family extension and fulfillment. Outdoor Space Most often challenging to get to and access is most often prevented due to locked doors. Outdoor secure fenced, shaded, easily located space remains accessible to all household residents. Living Areas Lounges and dining rooms usually at the end of long corridors often designed to accommodate larger social densities greater than 12 elders (often 20-40). Central hearth with an adjacent open kitchen and dining area, short distance to bedrooms that follow a similar spatial relationship to one’s own home, Kitchen Central kitchen disconnected from elders. Food carts, uniformed servers, trays, cafeteria style dishes. Kitchen located in center of household and plays important role in daily lives of elders through meal prep and activities or socialization. The design standards listed in this Attachment are not meant to be all-inclusive. Additional details are available in the below-referenced publication. Robert Wrublowsky, Design Guide for Long-Term Care Homes, 2018 Edition, MMP Architects, 2017.) Available for download from Facility Guidelines Institute, https://www.fgiguidelines.org/wp- content/uploads/2018/03/MMP_DesignGuideLongTermCareHomes_2018.01.pdf Rosemary Schlank Attachment C, page 1 Attachment C: Comparison of 900 King Street Plans with Small-House Model Example of Memory Care Facility that uses the Modern Small-House Model WHITE OAK COTTAGES AT FOX HILL VILLAGE Photo from https://www.whiteoakcottages.com/architecture/cottagearchitecture/ Description from Architectural Design Standards for Long-Term Care Homes Located on the Fox Hill campus in Westwood, Massachusetts, the White Oak Cottages are designed as a small house model long term care residence supporting memory care. The design is warm, technologically smart, and supportive of a small house staffing model and philosophy of care. Each cottage has a living room, dining room, kitchen, den, enclosed garden, and 12 private bedrooms and bathrooms. Its layout offers Residents a combination of privacy and the opportunity for engagement. Elements within each cottage support Residents with memory loss, allowing them to achieve maximum functioning and independence. The scale of the project makes it a strong candidate for rural settings where land area may not be as much of an issue. The cottage can easily be designed so that it can be mirrored to create an enclosed courtyard to form a neighborhood of 24 residents. This model most closely resembles a family home, and the small scale eliminates long hallways and elevators, making it easier for Residents to move throughout the cottage. The interior layout and décor have been specifically designed to support the needs of those with memory loss through the use of color and contrast, circular pathways, and bright lighting. The homes offer inviting community spaces, more intimate areas for small gatherings, and the privacy of one’s own bedroom. The daily rhythms of the cottage are also those of a home. Residents wake up and go to sleep when they want to. Someone arriving at the home may smell dinner cooking in the oven, see laundry being folded, or meals being planned with Resident participation. Architectural features that support functioning abilities of residents with cognitive disorders include the easy wayfinding due to the absence of corridors. Dutch doors have been utilized which provides a visual ability to check in on a resident while reducing intrusion of private space. The cottage is flooded with ample natural light providing correct color spectrum and intensity (80-100 foot-candles, 5600K°). Enclosed and accessible Rosemary Schlank Attachment C, page 2 outdoor space allows residents to enjoy nature and go outside freely. There is no audible paging system. All paging systems utilize texting messages only. The fabrics, artwork, and color schemes account for the visual and spatial deficits of those with dementia, and provide gentle cueing. The interior and garden areas have circular traffic patterns to allow Residents to wander without the need for staff redirection. Reprinted with permission, Case study, 2018 Edition of the Design Guide for Long-Term Care Homes, Robert Wrublowsky, MMP Architects, 2017. Floor Plan Source: Cottage layout from https://www.whiteoakcottages.com/wp- content/uploads/2012/06/whiteoak_cottagelayout1.gif White Oak Cottages was designed by EGA Architects, a firm that specializes in senior living environments. EGA is based in Newburyport, Mass. EGA’s architects have designed a variety of assisted living and memory care facilities including some in nearby CT and NY locations. https://ega.net/firmprofile/ Rosemary Schlank Attachment C, page 3 Comparison of 900 King Street Plans with Small-House Model Example of Memory Care Facility that uses the Modern Small-House Model Hebrew SeniorLife, Gilda and Alfred A. Slifka Memory Care Assisted Living Residences The Hebrew SeniorLife, Gilda and Alfred A Slifka Memory Care and Assisted Living Residences are located at NewBridge on the Charles, Dedham, Mass. The following description is from Excellence in Design: Optimal Living Space for People With Alzheimer’s Disease and Related Dementias, Emily Chmielewski, 2014, Perkins Eastman and Alzheimer’s Federation of America. Opened in 2007, this assisted living building for people with Alzheimer’s disease is part of a 162- acre intergenerational residential care campus for 750 aging adults. The Alzheimer’s-specific households are attached to an assisted living building that has a strong connection in both physical distance and design to the campus’ community center. This proximity allows the community’s frailer residents to access the retirement communities’ plentiful amenities and maintain a strong sense of belonging The assisted living building for people with Alzheimer’s disease is 27,367 square feet in size, with a cost per square foot of $250 (in 2007 dollars). There are 40 bedrooms, divided into four households of 10 residents each. Each of the two floors contains two neighborhoods consisting of two households apiece. The two households on each floor share a family-style kitchen and a large gathering and activity room. Residents enjoy small-scale dining connected to a family kitchen, great room, living room, screened porch, and covered terrace for outdoor connections. The building was designed around the concept of creating an optimal living environment that is grounded in the belief that an individual’s life, although not defined by his or her functional ability, will be enhanced by an environment that supports his or her needs. The environment supports choice, diversity and individuality Source: Excellence in Design: Optimal Living Space for People with Alzheimer’s Disease and Related Dementias, which was authored By Emily Chmielewski and published in 2014 by Perkins Eastman and Alzheimer’s Federation of America. The entire publication is available at https://www.perkinseastman.com/white-papers/excellence-in-design-optimal-living-space- for-people-with-alzheimers-disease-and-related-dementias/ and https://alzfdn.org/wp-content/uploads/2017/11/Excellence-in-Design-white-paper-June- 2014.pdf Rosemary Schlank Attachment C, page 4 Floor Plan Note that a back hallway and sitting area on the right hand side connects the two households and encourages the professional caregivers to travel through and monitor the households. The Hebrew SeniorLife, Gilda and Alfred A Slifka Memory Care and Assisted Living residences were designed by Perkins Eastman, a firm that specializes in senior living environments. https://www.perkinseastman.com Rosemary Schlank Attachment C, page 5 Comparison of 900 King Street Plans with Small-House Model Assisted Living and Memory Care Facility that uses the Institutional Model PROPOSED FACILITY FOR 900 KING STREET (Building F/G) Source: Perkins Eastman Architectural Plans, 7-2-2021 Description The Project includes an 85-unit, 94-bed, three- and four-story AL building attached to the northeast portion of the IL building. Assisted Living provides care for individuals who need help with one or more tasks of daily living, but who do not require skilled nursing care. The AL units will not have a kitchen and therefore do not meet the definition of a “dwelling unit” as set forth in §250-2 of the Village’s Zoning Code. Twenty-five AL units would be reserved for “memory care,” which provides services to those with some form of dementia. All memory care units would be on the fourth floor and the remaining 57 AL units would be located on the first, second, and third floors. The AL building would share back-of-house space with the IL building, including mechanical equipment, housekeeping, kitchen, and receiving facilities. To the east of the AL building would be a secure “wandering garden” in which AL residents could safely and securely access the outdoors. Source: Paragraph 2.2, pages 3 and 4 of the Revised Project Description, Site Plan Application, 900 King Street, 7-2-2021 A Memory Garden (the East Garden, approximately 5,155 sf) would be located east of the AL facility for use by the facility’s residents. This secure, outdoor area would be landscaped and programmed to allow AL residents to safely enjoy the outdoors. Source: Paragraph 5, page 8 of the Revised Project Description Site Plan Application, 900 King Street, 7-2-2021 The Project would conservatively be anticipated to add a population of 386 people to the Project Site. Source: Paragraph 5, page 9 of the Revised Project Description Site Plan Application, 900 King Street, 7-2-2021 Rosemary Schlank Attachment C, page 6 Proposed layouts from site plan application 1st Floor Plan Source: Perkins Eastman Architectural Plans, 7-2-2021 Rosemary Schlank Attachment C, page 7 2nd Floor Plan Source: Perkins Eastman Architectural Plans, 7-2-2021 Rosemary Schlank Attachment C, page 8 3rd Floor Plan Source: Perkins Eastman Architectural Plans, 7-2-2021 Rosemary Schlank Attachment C, page 9 4th Floor Plan – Memory Care Facility Note that the memory care occupants, who are among the most vulnerable residents, would be located on the 4th floor. They would need to go through long hallways and up and down 4 stories to get to and from the shared kitchen and the outdoor area which they would share with an extended household or neighborhood of up to 93 other residents. . Source: Perkins Eastman Architectural Plans, 7-2-2021 Rosemary Schlank Attachment D, page 1 Attachment D Independent Review and Recommendation By Robert Wrublowsky From: Robert Wrublowsky Sent: Sunday, August 29, 2021 9:43 AM To: Rosemary Schlank Subject: Re: FW: Request for permission to quote from guide A few quick thoughts. (Feel free to share my email with those who might also care about this environment.) Memory care residents typically present with moderate to high MAPLe Scores. This tells us that 24/7 supervision is required and that support for QoL through design is very important. Early-onset Alzheimer's (83% of the residents presenting with a form of dementia) is subject to agitation. (typically nonviolent). Placing what appears to be 27 residents on the same household (floor) on the fourth floor will not end well for residents easily agitated or confused and provides realistically very limited access to outdoor gardens. (There was no mention of the garden design, but it also should be very well thought out to include therapeutic, horticultural, and sensory elements in the design.) This plan may be more acceptable to Supportive Housing individuals where cognitive abilities are more intact. Placing a Care environment on the fourth floor is not a great design solution providing a lack of direct access to the outdoors. (unless there is a large patio/balcony design which there is not.) Your questions to the Architect and or operator would be to confirm that the functional status of the residents is in fact similar to what I have shown here (attached) in the RAI- MDS outcome scale. (The operator will be familiar with that). If this is the case then this environment would not be very successful as a MC environment. Some other quick observations. 1. Hallways too long and require designed pauses. No more than 3 sets of doors before there is a purposeful node. 2. Would like to see how the bathroom is configured to support incontinence. 3. The resident room doors should be offset to effectively reduce the width. Right now the 36" doors coplanar to the hallway are difficult to negotiate in a wheelchair. (if the doors are 36" or smaller) 4. It appears this plan requires MC residents to come downstairs to a central dining hall? That doesn't work. (for supportive it does) 5. Maintaining kitchen function in the daily experience is very much supported in all the research to being one of the most important aspects of the environment. The Rosemary Schlank Attachment D, page 2 Cadence of socialization occurs around the kitchen. There should be a residential kitchen serving a memory care population. I would suggest that you also run this design through the E.A.S.E scale to see how it would perform. The University of Kansas is currently validity testing this new scale to assess how successful environments will perform for those inflicted with cognitive challenges) (E.A.S.E Environmental Audit Scoring Evaluation). I am involved in this project and can set that up for you if you like. But I can tell you the design wouldn't meet the minimum requirements as a care environment for Memory Care. My recommendation for this design is NOT to brand it as a memory care environment but rather a supportive housing style that would house a more independent person than what a MC individual presents with.