Cottage Senior Living
The leadership of Cottage Senior Living (CSL) assembled at a strategic
planning retreat away from their headquarters in Huntsville, Alabama to prepare a
plan to move the business “to the next level.” For the president of the company,
Cliff White, the goal of reaching the next level involved growth that focused on
identifying locations for acquisition and development. In addition to White,
attending the retreat were: Sandy Brackin Vice President of Operations, Cheryl
Westlake, Director of Operations; Alan Hangartner, Vice President of Marketing
and Sales; Greg Dykes, Regional Managing Director – South; Selena Jackson,
Regional Managing Director – North; and Holly Mitchell, Senior Accountant.
To begin the retreat, White articulated Cottage Senior Living’s vision as the
“development of housing and service offerings that attract empty nesters who
choose to live an active, vi
ant, and engaged lifestyle.” He further explained,
“Our product is differentiated from the traditional markets for independent living
(IL), assisted living (AL), memory care (MC), and skilled nursing facility (SNF)
y focusing on non-subsidized, private-pay customers in tertiary markets.”
White continued, “Moving toward the goals of the retreat, our task today is
to answer three questions: 1) How to grow? 2) Where to grow? and 3) Do we have
the organizational capacity to grow? Answering the ‘how to grow’ question
involves assessing additions to existing capacity, offering services we presently do
not, and expanding our same product into other geographic markets (horizontal
integration). The ‘where to grow’ question involves the consideration of new cities
and perhaps new states. And both questions, how to grow and where to grow,
equire us to examine our organizational capacity to grow.”
The Cottage Story
Cottage Senior Living, also known as “the Cottages,” was headquartered in
Huntsville, Alabama. The founders of Cottage Senior Living, Peg Thompson and
Wade White, met in Doylestown, Pennsylvania in 1980 while consulting as turn-
around specialists focused on continuing care retirement communities (CCRCs)
and more specifically, the Pine Run Community, a for-profit CCRC. The Pine Run
Community opened in 1976, and was one of the first retirement communities to be
developed and the only one at that time with a full service, 200-bed regional health
center devoted to senior care.1 Thompson and White ma
ied and spent the
emainder of the 1980s creating the assisted living service model, something that
did not exist prior to 1980. Thompson and White sought distressed retirement
communities, especially religiously-affiliated CCRCs and spent the mid-1980s
1
through the mid-1990s making deals. Their first venture was a management
contract to operate the “Regency” Community in Huntsville, Alabama. The
Regency Community became the company’s headquarters. During the 1990s,
Cottage Senior Living developed CCRCs in Florence, Alabama; Russellville,
Alabama; Corinth, Mississippi; Lawrenceburg, Tennessee; Mountain Brook,
Alabama; and acquired CCRCs in Hoover, Alabama; Decatur, Alabama; Hartselle,
Alabama; and Huntsville, Alabama (see Exhibit 1 for Cottage Senior Living’s
market area).
Exhibit 1. Cottage Senior Living Service Area
Cliff White, Wade and Peg’s eldest child, returned to the family business in
2009 after completing an MBA at the American University in Washington, DC.
Beginning in 2011, White served as president of Cottage Senior Living, LLC.
Among Cliff White’s accomplishments was the development of The Commons, a
54-unit active adult community in Huntsville, Alabama where he implemented
several information technology (IT) projects to improve operational efficiency and
management reporting. White focused much attention on innovating assisted
living. He was a member of the U
an Land Institute Senior Housing Council and
the American Seniors Housing Association and was a Certified Public Accountant.
The Industry
The long-term care industry was composed of health-service, social service,
and residential service organizations that provided rehabilitative, restorative, and
ongoing skilled nursing care to disabled and elderly patients who required
assistance with daily living.2 The assisted living industry was comprised of a
variety of senior care services; generally divided into two major subcategories: (1)
2
continuing care retirement communities and (2) homes for the elderly. The
primary difference between the two subcategories was the presence of nursing
care. Continuing care retirement communities provided on-site nursing facilities
whereas homes for the elderly did not. Future growth of the industry would be
spu
ed by 77 million Baby Boomers and the increasing life expectancy of the
elderly population. Approximately 1 million Americans lived in senior care
facilities and the number was expected to double by 2030.
Competition in the assisted living industry was intense. The four largest
providers in the industry (Brookdale Senior Living, Sunrise Senior Living,
Emeritus Corporation, and Atria Senior Living Group) controlled only about 13
percent of the market share. The remaining 87 percent was comprised of a variety
of not-for-profit and for-profit enterprises. The largest source of revenue for
providers came from private payers representing almost two-thirds of total
evenue. Medicaid provided about 10.5 percent, Medicare about 6.2 percent, and
private insurance about 3 percent. The remaining 14 percent came from a variety
of sources including other government programs and assigned Social Security.
Great variety occu
ed in the demographic make-up of retirement communities.
Approximately 69 percent of residents were female and 31 percent were male. The
typical resident of a senior living community was an 85-year-old female.
Individuals over the age of 85 made up the largest percentage of residents in senior
living facilities.3 More specifically, the industry was comprised of a variety of
facilities differentiated by the intensity of care provided as summarized in Exhibit
2.
Exhibit 2. Senior Living Communities in Order of Increasing Intensity of Care2
Type of
Community
Age
Range or
Average
Age of
Residents
Regulation Transportation Activities Services
Senior
Apartments
55 plus Not regulated Occasional
Daily, but
not
equired
A la carte
Independent
Living
82
average
Not regulated Scheduled
Daily, but
not
equired
Housekeeping
(included*), nursing
call system3,4
Assisted
Living
Facilities
85 plus
and need
driven
Regulated by
state
government
Scheduled and
equired by
egulation
Scheduled 6
times per
day;
(schedule
equired by
egulation)
Housekeeping
(included); nursing
call system; food
service (3 times/day,
scheduled);
medication assistance
– all required by
egulation
Memory
Care – a
85 plus
and need
Regulated by
state
Scheduled and
equired by
Scheduled 6
times per
Housekeeping
(included), nursing
3
Specialty
Care Assisted
Living
Facility
(SCALF)
driven government regulation day;
(schedule
equired by
egulation)
call system, food
service (3 times/day,
scheduled), nurse
administered
medication, monthly
RN assessments- all
equired by regulation
Skilled
Nursing
Facility
(SNF)
Adolescent
and older
Regulated by
state and
federal
governments
Scheduled and
equired by
egulation
Scheduled, 6
times per
day;
(schedule
equired by
egulation)
Housekeeping
(included); nurse
calling system; food
service (3 times/day,
scheduled); nurse
administered
medication; monthly
RN assessments – all
equired by regulation
*Included means incorporated into the residential fee-for-service structure
Independent living settings were adult communities that usually imposed
age restrictions, offered social activities, provided security, offered access to
transportation services, but did not provide medical services. Although no
uniformly accepted definition of assisted living facilities (ALFs) existed, ALFs
were considered “multi-family properties with personalized support services for
seniors.”4 A relatively new development in the long-term care industry was the
Continuing Care Residential Community or CCRC. CCRCs attracted private-pay
esidents5 “of high socioeconomic status, who were independent upon entering the
CCRC.”6 CCRCs offered a variety of services providing a progression of care
from independent living to nursing facilities in a single campus setting focusing on
wellness activities and amenities.7,8,9 The progression of services offered by
CCRCs acknowledged the inevitable decline of independent older adults during
the last few years of life, making CCRCs the “final station” of an older adult’s
life.10 A skilled nursing facility (SNF) was defined by the Social Security Act as
an institution (or a distinct part of an institution) that was primarily engaged in
providing skilled nursing care and related services for residents who required
medical or nursing care, or rehab services for the rehabilitation of injured,
disabled, or sick persons, and was not primarily for the care and treatment of
mental diseases; and had in effect, a transfer agreement with one or more
hospitals. Nursing facilities offered the most intense level of long term care and
were for individuals requiring around the clock care.11 Memory care facilities
catered to the needs of individuals with Alzheimer’s disease or a related disorder
(ADRD)12 and was an emerging development within CCRCs.13 Memory care and
skilled nursing facilities were categorized as Specialty Care Assisted Living
Facilities or SCALFs.
From an industry perspective, Medicaid was the primary payer of long term
care services inasmuch as more than 60 percent of the patients in nursing homes
4
were Medicaid recipients and that Medicaid patients comprised almost 20 percent
of residents in assisted living facilities.14 The Cottages did not market to or admit
Medicaid recipients.
The CSL Regulatory Environment
The Cottages operated three types of facilities – Assisted Living, Memory
Care, and Active Adult as “group” facilities or “congregate” facilities. The word
congregate used as an adjective to describe long-term-care facilities is a synonym
of the word group and thus appeared to refer to the same thing;15 however, state
egulations distinguish between the terms as they applied to health care facilities.
Because the Cottages operated facilities in three states, agencies in each state
egulated the facilities; however, the majority of the Cottages’ facilities were
located in Alabama and as a result the company was profoundly affected by
egulations of the Alabama Department of Public Health (ADPH). ADPH
egulations differentiated between group assisted living and congregate assisted
living facilities. Group assisted living facilities were authorized to care for three to
sixteen adults. Congregate assisted living facilities were authorized to care for 17
or more adults. Regulations addressed staffing requirements and the qualification
of key members of the staff. The key regulatory parameters, shown in Exhibit 3,
indicate that in general, ALFs had fewer staffing requirements than SCALFs and
oth ALFs and SCALFs had similar building requirements.
5
Exhibit 3. Key Regulation Parameters within the Cottages Footprint15
ALF SCALF
Staffing
General requirement: sufficient staff on duty
to provide the care needs of all residents
twenty-four hours per day, seven-days per
week.
General requirement: sufficient staff on duty to
provide the care needs of all residents twenty-four
hours per day, seven-days per week.
Staff requirement: based on resident
population and time of day; no set, specific
equirement.
Staff requirement: based on resident population and
time of day:
Staff
Residents by Time Period
7am-3pm 3pm-11pm 11pm-7am
XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX128
XXXXXXXXXX144
XXXXXXXXXX-160
XXXXXXXXXX-176
+1 per XXXXXXXXXX
Specific professional licensed staff:
Administrator
Dietician – could be full-time, part-time, or
consultant
Specific professional licensed staff:
Administrator
Medical Director – licensed physician
Registered Professional Nurse
Coordinator – an administrator who was an RN
Dietician – could be full-time, part-time, or consultant
Building Requirements
Dining separate from kitchen Dining separate from kitchen
Separate rooms for administrative and office
purposes
Separate rooms for administrative and office purposes
Centrally located staff station with call for
assistance and fire alarm communication
system
Centrally located staff station with call for assistance
and fire alarm communication system
Grab bars conforming to cu
ent building
code
Grab bars conforming to cu
ent building code
Commercial exhaust food system Commercial exhaust food system
Institutional grade range with double oven Institutional grade range with double oven
Bedrooms individually and consecutively
numbered
Institutional grade refrigerator
Hand washing lavatory in kitchen with soap
dispenser, supply of soap, disposable towels,
and hot and cold running water running
through a mixing valve or combination faucet
Hand washing lavatory in kitchen with soap dispenser,
supply of soap, disposable towels, and hot and cold
unning water running through a mixing valve or
combination faucet
Commercial grade dishwashing equipment
with a booster water heater
Three-compartment sink with a booster heater or
chemical sanitizing system
Laundry rooms shall not open directly into
esident rooms or food service areas
Doors of resident bathrooms swing into the bedroom
6
ALF SCALF
Utility rooms on