“She told my Mom, ‘You should have that checked out,’” Murray recalls. It was a prudent decision: Murray had a birth defect and needed open heart surgery for pulmonary stenosis.

“I was in the hospital for four months. I went back when I was 16 to meet some of the people who had treated me, and by then some were in a nursing home,” she said. “I felt like there was a lot of need, and things that could be improved.”

The daughter of a farmer/construction company owner and a licensed practical nurse at hospitals near their hometown of Chillicothe, MO, Murray has a younger brother, Chad. After graduating from the University of Missouri, she began her nursing home career with Hillhaven. She arrived at Life Care Centers of America in 1994. 

But after years in Tennessee, Murray and her husband, David, relocated with LCCA to Missouri. They sought to raise their children there: Daughter Aimee, 26, has today completed her doctorate in physical therapy from the University of Missouri, and son Bryson, is 22 and headed to law school.

By 2009, Murray had helped Life Care  Centers achieve various successes and wanted to pursue a “bucket list” item: completing her doctorate.

She also decided to volunteer at Tiger Place in Columbia, MO, a facility known for its work on aging research under the auspices of professor Marilyn Rantz, Ph.D.

“The first day I met Dr. Rantz, she said, ‘You’ve got to do some research with me,” Murray laughs.

Rantz raves about Murray, noting she “is one of my very favorite people to work with.”

“You talk about a leader — this gal knows how to lead,” Rantz says. “She gets the best out of people. There are lots of folks who know long-term care pretty well but they don’t know it nearly as well as Cathy Murray.”

Those sentiments are echoed by LCCA President and CEO Forrest Preston, who lured Murray back last year, first as a consultant and then as chief operating officer.

“Beyond her qualifications, her success is grounded in a passion for the residents and patients we serve and the associates who deliver their care,” he says. 

Murray is now on the road around 80% of the time, visiting various Life Care facilities.

“I can make the biggest impact” that way, she says. “I actually prefer being out there and touching the residents.”

Even in her free time, she loves to travel with her family, which includes visits to her father, who is still farming in Missouri at age 76.  Her mother died in 2006.

“She was a wonderful woman, and my Dad has been one of the ones I’ve admired,” she says of her role models. “Failure is not in his vocabulary.” 

Additionally, “my husband has been a huge support — that’s certainly the only way I could do all this. My children and my Dad also help support me.”

In her free time, the 57-year-old listens to New Age gospel music and reads professional development books such as the “Long-Term Care Leader’s Guide to High Performance.” She’s on a “quest” to build and develop good leaders.

“I really think our administrators and directors of nursing are the key to our facilities,” she says.

It’s a welcome message when it comes from a COO leading with a strong heart.

Resume

1984

Graduates from the University of Missouri with bachelor’s degree in health services management

1986 

Begins as director of operations at Hillhaven Corporation 

1987 

Completes MBA at University of Missouri

1994 

Begins at Life Care Centers of America as a regional vice president

2004

Named chief operating officer at Life Care

2009 

Leaves to pursue doctorate

2015

Awarded Doctor of Education in Learning and Leadership from University of Tennessee. 

2016

Starts as researcher with University of Missouri on project to reduce avoidable hospitalizations

2018

Returns to Life Care Centers as consultant, and then COO

The Gateway Care Home in the city of Bradford, England, spent about three months constructing its own dining car, complete with scenic views and a ticket office. Gateway Express riders are treated to a first-class meal on a table decorated with linen napkins and cherry blossoms.  

Organizer Arthur Gallagher said the idea came after residents made recent trips to the Keighley Worth Valley Railway.

“This is something they really enjoy and look forward to every time we visit, so we decided we wanted to bring the railway here and build our own life-size carriage so they can enjoy trips all-year round,” he told the Telegraph & Argus.

There is a station platform and dining booths are perched next to TV screens with countryside footage that give the appearance of a real train trip. It’s also handicapped-accessible. In the past, some residents could not participate in Keighley Worth Valley Railway trips because of those limitations, said Administrator Nikki Bryar.

 “It’s so important for our residents. They can sit there and reminisce while having a chat and a bite to eat,” Bryar said. “It’s been like a new lease of life for some.”

While she maintains eye contact throughout the process, Jones also keeps an eye on safety in the spa room.

Given an increasingly ambulatory population, the presence of water and the kind of warm and moist environment that invites bacteria to breed, risk is inherent in skilled nursing bathing areas. 

It takes careful strategy, attention to detail and smart use of equipment to deliver a sanitary and satisfying bath while preventing accidents that could leave residents or staff injured.

At Levindale Hebrew Hospital and Nursing Center in Baltimore, Jones’ job is made easier because staff pair up for every single transfer, whether they’re using a Hoyer lift to get someone from bed to a shared bathing area or doing a slide transfer to a shower bed.  

“It’s not really a hard part of the job,” says Jones, who works the evening shift on Levindale’s Golden Hill unit, home to about 50 residents. “I feel wonderful that I can do this for them. We always talk to them, talk them through the shower, which part of the body we’re cleaning, asking them if it’s OK to move on.”

About 80% of falls among seniors happen in bathrooms, according to the National Institute on Aging. In the community, one-third to one-half of those falls are blamed on environmental factors like poor lighting or uneven surfaces.

But even in nursing homes that control for those variables, danger can suddenly appear in places it never has before — or in patients who’ve always seemed ready and willing to take a shower.

Some residents may become agitated due to dementia or other cognitive impairment, and conditions ranging from diabetes to a new hypertension medication could increase fall risk overnight.

“Bathing safety requires good communication between the nurse and her CNAs,” says Jacqui Moran, RN, nurse account manager for education and compliance for Guardian Pharmacy in Southeast Florida.

She recommends shifts begin with a review of any new fall risks, and that the right transfer tools and safety equipment be used even if a resident appears steady.

“Make sure you’re using your gait belt or their walker,” Moran says. “And CNAs need to know that the path is clear. You are that resident’s eyes and ears. Never turn your back. That one moment is when someone can slip and fall.”

Super-vision

For most of nursing home residents, a shower takes place in a shower chair. And the vast majority of those are made of inexpensive medical grade PVC piping with relatively low weight limits and short life spans.

Supervision is essential, as is use of safety features such as lap belts and brakes. It’s also important to understand how shower chairs will work on different surfaces.

In a recent column for
McKnight’s Senior Living, Lisa B. Bixler says chairs pitched too steeply toward a central shower drain could “twist a person’s legs to the point of collapse, even while being used ‘properly.’” 

And if a resident attempts to stand from a lightweight chair while holding a grab bar, the seat could tip as the weight is removed. She recommends strip drains for facilities using those chairs.

Drains should flow freely so excess water doesn’t pool at residents’ or staff members’ feet. Staff members also should be wearing non-skid shoes.

As a secondary technique of preventing water from leaving the shower area, Levindale aides roll resident chairs onto oversized, flat towels, catching any water dripping from a residents’ hair or elsewhere before they head back to their bedroom.

A shower chair also allows nursing aides to extend a resident’s legs or tilt the resident back.

Others may be whisked to the shower room on a shower table, which allows for a side-to-side transfer and disrobing in bed, instead of in the shower room.

“I’m often confused as to why we don’t see more of those,” says Len Sears, director of sales for Lopital by ProCare Medical. “The shower table is the easiest way to shower and to transfer.”

Levindale residents who are most at risk of falling in the shower use shower tables. Jones says these are typically people who have poor core strength and are unable to remain upright in the shower chair even with the use of a safety strap.

No matter what, the resident’s bathing preference should be documented on admission, quarterly and with a change in condition, experts remind. Finding the right method often requires talking to the resident and understanding his or her specific wants and needs. Having two sets of hands available at all times — and a built-in safety call button at the shower side — helps Jones and her staff feel secure. 

In settings that don’t require multiple staff for showering, Moran says aides shouldn’t try to reach out a hand to catch a tumbling resident.

“Often, if someone goes down, you’re inclined to reach out and catch them, but they’ll take you down, too,” she says. “It’s better to get close and ease them down.”

Staff protection

ProCare introduced its Lopital line to the U.S about nine years ago after it proved popular in the Netherlands. The battery-operated chairs can provide tilt, height adjustment and/or seat widths and weight limits designed for bariatric residents.

The height-adjustable chairs, in particular, are ergonomically designed and help reduce caregiver strain. They also can put resident and caregiver eye-to-eye during the entire bathing process.

While Sears says his products are gaining traction in Veterans’ Affairs facilities and in some faith-based communities, he admits that operators may still find the upfront cost of a $6,500 shower chair daunting.

But he expects that over the next few years more facilities will invest in durable equipment because it makes the bathing process easier for residents and caregivers, improves clinical outcomes and cuts down on cross-contamination.

“There is buy-in now to using motorized devices on the appropriate residents who need it,” Sears says, noting the almost wholesale migration to power lifts. “In the past, there was a lot more manual lifting, and it was arduous work.”

Making the process easier on staff may mean they do a better job. For instance, using a shower chair that raises a resident as high as 44 inches will reduce the potential for back strain and encourage a CNA to do a more thorough job on foot care. The same holds true for the frequently uncomfortable task of pericare, which is often performed while the CNA is on his or her knees.

“If you give the caregiver better access, that’s better pericare. And better pericare means better quality of life,” Sears says. “It’s not just a difference. It’s a profound difference.”

Healthcare bathing units featuring whirlpool action are also a good option for skilled nursing facilities. They can deliver a home-like and unique cleaning experience.

“The more submerged the body is, the cleaner the body gets,” explains Lee Penner, founder of Penner Bathing Spas. “They get clean by cavitation, a bubble in the water that explodes or breaks against the body and creates a vacuum that pulls dead skin and dirt away.” 

Disinfection station

Penner says his system works better than a plumbed whirlpool because it doesn’t circulate that dirty water with a motor. Water enters through one line, more water is added through another and water is drained out by another at the end of the bath.

That means fewer twists and turns where bacteria may hide from even the best sanitizers.Penner sells its own sanitizing solution, but any quaternary formula will do as long as it is used according to directions.

Lopital chairs also come with wall-mounted disinfection cabinets, to reduce contamination associated with undiagnosed C. diff or other infections.

“The infection prevention issue is much larger now in the Rules of Participation and because of QAPI,” Sears says. 

“Not only do you have the infection concern, but many of these residents are incontinent and have episodes while the chair is being used.”

Where possible, look for shower equipment made of smooth bent metal, which has fewer nooks and crannies where bacteria or mold could form. Likewise for mesh designs — those types of equipment may require a longer, hands-on cleaning approach to completely sanitize.

Reducing rates of reportable infection is just one way a safe and pleasant bathing program can impact the bottom line.

“Facilities want for people to tell their friends, ‘The staffers here are really great,” says Guardian Pharmacy’s Moran.

Common areas in nursing homes provide the ideal place for socialization, something that is increasingly important in buildings where individuals can easily lapse into self-imposed isolation and withdrawal.

In some respects, the common area in a skilled nursing facility is not much different from the family room at home — a place where everyone gathers to talk or join in communal activities. The forms these rooms take can vary from one large expanse to a collection of spaces, both inside and out.

It fits right in with the trend toward creating more homelike environments.

One of the guiding principles in long-term care design today is to create a residential, non-institutional environment in layout, scale and architectural language, as Robert Wrublowsky, principal of MMP Architects, pointed out in a 2018 update to his “Design Guide for Long-Term Care Homes.”

In fact, Wrublowsky asserts that the institutional-based environment that care architects and planners have been designing for seniors has contributed to agitation and restlessness. 

“It appears that our current priority is to provide the operational efficiency of a hospital,” he laments, citing the tight spaces of nurse stations, central dining rooms, commercial kitchens, central laundry facilities and supply rooms.

The “small house” movement of the past few decades attempts to combine all of the “positives” of communal living and around-the-clock medical care for seniors. 

It has succeeded in various pockets across the world. Scalability created limitations among skilled nursing facility builders since the concept seems to work best with smaller numbers of cohabitating seniors.

Still, the core elements of the Green House movement — open kitchens, family-style dining and communal “hearths” — have left an indelible mark on today’s nursing home designers and architects.

Sweating the details

Most nursing home visitors might look at a typical common area and see nothing but chairs and couches, lamps and side tables. Non-discerning observers might mistake quirky, or even common, elements of common spaces as accidental. Virtually no detail, however, is unplanned.

Designers sweat all of the so-called “small stuff,” the most important of which is that which creates first impressions.

As RAND Corp. discovered a few years ago in a sweeping nursing home study commissioned by the U.S. Department of Health and Human Services, seniors and their families generally felt a prospective nursing home provided quality care if it “looked nice, smelled nice, and had nice amenities,” much like the homes they were leaving behind.

“Creating more home-like environments is key to helping residents feel comfortable in the common areas,” says Stacy Rubenstein, Medline’s public relations manager. 

“Furniture should be similar to what they are used to having in their own homes with fabrics that remind them of home — loveseats, chairs, coffee tables, end tables, lamps, and the like.”

Many facilities struggle with their multiple and often competing personalities as a healthcare space, a hospitality space and a residential space, observes Laura Holzer, segment design manager, healthcare and education for J+J Flooring Group.

Designers today are challenged to create public spaces that not only appeal to residents, but also the family influencers who hold so much sway over which facility to choose, says Andrew Christmann, marketing manager for Hekman Contract.

Both want to get away from the classic nursing home “feel and look. Something that is warm and inviting in the lobby, not unlike what you’d see in a hotel,” Christmann adds. “A nice, welcoming reception area and open environments with some basic lounge seating would seem to be the best fit for both audiences.”

While the physical space is important, what’s happening inside them is even more notable, says Jeanna Swiatkowski, interior design team lead for Direct Supply Aptura.

“What’s really going to get residents out of their rooms are the activities and programming the community provides,” she says. “We design the space based on the types of activities. If residents are into completing puzzles, we’ll design the area to support that.” 

Swiatkowski says the company’s designers seek feedback from the residents themselves when creating or re-imagining common spaces, then follow with furnishings that support those activities. 

“Based on the resident mix and interests, we’ll design the space so they can actually use it, so it’s not just a sitting area,” she says. “The more interesting and exciting the space is, the more the residents will want to come out and engage.”

Still, luring residents from their private spaces to public areas entails selling them on an inviting space that allows them the ability to retreat to enclaves away from the madding crowd. 

Enticing seniors to engage in common areas also involves imbuing confidence they will be safe and able to ambulate freely with or without assistance.

For example, Garnet Sofillas, marketing manager for Ecore International, believes an important consideration that encourages mobility in common areas includes “providing a surface that supports the residents’ sense of comfort and safety without compromising balance. A too-soft floor can have a detrimental effect on balance, which is a challenge with senior residents and inhibits their confidence to ambulate.”

Jodi Fazio, marketing director for Kwalu, advises facilities to provide rest stops en route to common areas.

“Particularly in skilled facilities, the use of benches is very important to get the residents out of their rooms,” Fazio says. “They can sit down and rest on their way out to a common area to participate in activities. Most residents who don’t leave their rooms are worried they will run out of steam before they get to their destination.”

Randy Schellenberg, president of Comfortek, acknowledges common spaces can provide a great way for seniors to engage with one another and their families, but not for the mobility-challenged individuals among them. Much of the problem might center around available hands. People must buttress common-area goals.

“There simply is not enough staff available to meaningfully move and interact with mobility-challenged persons in a common room,” Schellenberg says. “In a world where the mobility limitations of each resident increase daily, I do not think the design of a common space alone will attract greater use.”

Schellenberg believes mobility-challenged seniors would make greater use of common areas “if adequate levels of staff could accommodate them with dignity and respect so they don’t feel awkward in these public spaces.”

No other space within a nursing home undergoes more change than the common area — a must in order to accommodate growing kinds of activities in a fixed place.

“Sectioning off spaces within the larger room helps foster intimacy,” says Swiatkowski. 

Seating arrangements, casegoods or even window treatments also work as effective and easy demarcations of spaces within spaces, she adds.

With so many stakeholders competing for valuable internal real estate, nursing homes rely on designers to create common spaces that can easily be transformed from a calming lounge to party room at a moment’s notice.

Flexible furnishings — chairs and tables and floor coverings that are as neutral as they are multifunctional — assist greatly. They can transform numerous areas.

“Multifunctional spaces can incorporate a wide variety of ideas to benefit communities with limited space. Rooms that are used for crafts can be used to play cards and run bingo,” Fazio says. “By moving furnishings around, the same space can be used as a yoga room with soft mats, aromatherapy and lighting that can be dimmed to create the effect of calm.” 

The ‘biophilic’ touch

Until recently, natural elements like sunlight and landscapes played a very minor role in creating common spaces in long-term care. Today, designers draw heavily from a natural palette to create calming places for people to gather.

“Natural lighting through the entry of such architectural elements as clerestory or large window expanses have been known to positively support the program spaces within a nursing home,” says Melinda Ávila-Torio, senior associate, project manager for THW Design. Anecdotally, residents and staff have told her that such techniques result in less emotional strain and stress.

Jeanna Swiatkowski, interior design team lead for Direct Supply Aptura, uses generous amounts of large windows and natural views when creating common spaces, and when appropriate, uses fixtures that mimic natural light. 

“In the morning, we start with ambient light. At midday, we’ll have brighter light, and then we’ll start dimming it again at the end of the day to coordinate with the circadian rhythm,” she says. “This helps keep residents active and vibrant.”

“Biophilic [life-loving] design” is the term designers employ when describing their use of natural elements and hues, an evidence-based effort that brings a host of positives to nursing home life — including lowered blood pressure.

Laura Holzer, segment design manager, healthcare and education for J+J Flooring Group, says biophilic design influences many of her company’s floorcoverings with “soft, calm blues and greens, clean and clear neutral shades, from warm beige to cooler greys, with small flashes of color.”

“Having durable furniture that looks like wood and evokes nature has been shown to cut down on stress,” adds Jodi Fazio, marketing director for Kwalu. “Natural colors and light are known to positively affect people who have to spend a lot of time indoors.”

So there I sat in a mind-boggling PDPM training recently, with one recurring thought: You long-term care people are incredibly smart. 

It’s astounding, and admittedly sometimes a little annoying. The Patient-Driven Payment Model has clearly revealed your superior intellects, and my own mental deficiencies — a reminder I didn’t want or need.  

Towering over the audience in that hotel ballroom were two huge screens filled with indecipherable spreadsheets and incomprehensible data — to me, anyway. It appeared to make perfect sense to the rest of you. Because you’re smart. 

No wonder people (just me, actually) call it the Patient-Driven Panic Model. My eyes glazed over and blood pressure spiked in the red, and it’s not even part of my job to know all this stuff. 

I shared my PDPM inferiority complex with my ultra-smart CEO, who is part of a five-generation long-term care family, and he responded, “Don’t feel bad. Remember, I’ve been in this business since I was 13.” 

That got me thinking. But after sober reflection, it appears that nothing I’ve been doing since age 13 has prepared me for comprehending the intricacies of PDPM. 

I still listen to rock and roll and watch bad ’70s TV, but all that offers is useless escape. I’m still unsuccessfully trying to figure out relationships, an area of study at least as baffling as PDPM. 

So, no, apparently I didn’t spend a lifetime preparing for this moment. 

Fortunately, I don’t need to figure it all out. If everything had to make complete sense to me before I could write about it, most of my columns would be white space. This is why this space is called, “Things I Think,” not “Things I Understand.” 

Perhaps I just need to accept that it takes better brains than mine — specifically, yours — to comprehend the nuances of PDPM. Maybe I should stop beating myself up about that. I’m smart in other ways, I think.

If you’ve toiled around the skilled nursing field over the last year, you might have noticed there’s this PDPM thing that seems to be grabbing a lot of attention. 

As you flip through this issue of McKnight’s Long-Term Care News, in fact, you’ll notice each of our expert columnists, and our corp of Reader Poll respondents (at right), have weighed in on PDPM.

I merely want to ask if they’ve even named it properly.

This RUG-IV replacement system officially stands for “Patient-Driven Payment Model,” of course, or so they tell us.

My colleague, the inimitable Gary Tetz, however, first noted in January that, to him at least, PDPM stands for the “Patient-Driven Panic Model.”

He might have something there. After all, it wasn’t long after he started using his form of PDPM that Centers for Medicare & Medicaid Services Administrator Seema Verma revealed herself as an avid reader of his   columns. She’s tweeted about or at him multiple times — and always it has been with respect. Coincidence?

Perhaps it’s because she knows Gary was on to something and might start a movement where others come up with insightful theories of what PDPM could really stand for. We may never know, but now that we’re thinking about it …

What if instead of the Patient-Drive Payment Model, we call it the “Panic-Driven Payment Model”? It’s well known, after all, that the Medicare fund is careening toward bankruptcy even as you read this.

Then again, depending upon how preparations progress, providers might start calling it the “Pretty Darn Preposterous Model.”

Or, given the mixed reviews it has received, some surely see it as “Partly Desirable, Partly Menacing.”

We know with certainty that others are worrying and thinking “Please Don’t Pimp Me” or simply, “Please Do Pay Me.”

And one suspects that when providers do get paid, many will be looking at their reimbursement checks and saying the same thing: “Please Deliver Poor Me” or more likely,“Pretty Damn Puny, Man!”

The stoic ones in the crowd may give their version of “tsk, tsk” about the overhaul and call it a “Philosophically Darn Poor Move.”

But come October 1 and beyond, it’s safe to say that providers and federal regulators alike simply will be hoping that nobody will be calling it the “Pretty Dumb Payment Model.”

Spring is in the air. So, too, is provider angst about Medicare’s looming Patient-Driven Payment Model, better known as PDPM.

The Centers for Medicare & Medicaid Services is promoting this updated system for classifying residents and care payments as a change that will ensure two benefits. The first is better care. The second is reduced costs. Anyone who thinks those two goals will receive equal treatment is either naïve or not paying attention.

If past behavior is any indication of future performance, I can boldly predict two things we will absolutely see under PDPM.

The first is that providers will find hidden funding streams in the new rules and exploit them to the absolute limit. For this, the industry owes no apology.

After all, I don’t see the dozens of Fortune 500 companies that are paying no 2018 federal taxes apologizing. This august list is headed by Amazon Inc., which actually received a tax refund, despite generating more than $11 billion in profits. 

As for the companies’ collective response when questioned about the seeming incongruity, it amounted to this: We played by the rules that exist. If you don’t like it, tough.

OK, they only implied the second part. But the first point still stands. And skilled care operators who play by the rules and find windfalls along the way need not even pretend to be sorry.

Which brings us to prediction No. 2: Once the government realizes the industry has located new funding geysers, you can be sure regulators will do everything possible to shut them down — or at least, limit their impact.

And for that response, the government need not apologize. After all, these are taxpayer dollars we are talking about. And CMS has a fiduciary responsibility of its own: namely, to make sure the healthcare-related funds it doles out are not being used in wasteful or sketchy ways.

So if you don’t learn anything else about what PDPM will deliver, know this: The industry will push the limits of funding creativity, and the government will crack down on the resulting windfalls.

Everything else is, well, everything else.

In fact, Vienna administrator Corey Wright calls it “the best salon in town.”

Salon Vienna “is not your typical four-walled room that looks utilitarian,” he says. “We wanted to make a statement. The attention to detail and the finishing touches make it truly a thing of beauty.”

The 1,300-square-foot salon suite is located 20 feet south of the main building and is connected by a covered walkway. It is housed in a space formerly occupied by a solo practitioner physician, part of a 4,000 square-foot medical suite Vienna acquired in 2012. 

The new salon idea began in earnest in February 2018.

“When we bought the property, we had talked about potential use and kept going back to the concept of a new beauty salon,” Wright recalls. “It took quite a while to get approval permits to move forward. Overall, it took nine months to complete.”

Wright credits Vienna owner Ken Heffel with having “a great vision” for the salon. Together, they created the design and oversaw the $300,000 remodeling project.

Soft chandelier lighting, marble-inspired flooring and granite countertops provide a modern aesthetic that accompanies three styling stations, two hair-washing stations and four wall-mounted hair dryers. The dryers and sinks are adjustable, to fit each individual’s height. 

Each station has one standard salon chair, with plenty of room allocated for wheelchairs.

Other furnishings include a full-sized pedicure chair with a massage back and a manicure table. Incorporated into the design is a special vignette area showcasing an antique barber pole and antique barber chair with razor strap and pedestal sink.

With 150 beds for skilled nursing residents and short-term rehab patients, the old salon was small and provided tight quarters for the beauticians. When the medical space became available, Heffel and Wright agreed on the importance of creating a place to make people feel rejuvenated.

“The first thing people want when they are discharged from acute care to a SNF is to take a shower, wash their hair and shave,” Wright says. “We try to get new arrivals into our beauty salon within 24 hours … part of the healing process and journey to recovery is feeling good about yourself and personal hygiene is a big part of that.”

Salon services go beyond personal hygiene to include dental hygiene as well, with a specially trained dental hygienist hired to perform routine cleaning and assessments.

“Oral care in the SNF population has not been a priority and often gets overlooked, so we created a space for it,” Wright says. “We have purchased all the machinery and tools needed for this additional service that is available to our residents and patients on a daily basis.”

1. A disciplined approach to fundamentals can set a strong foundation to rely on months or even years later. 

Sound recordkeeping practices are important. “Clean, organized and consistent” monthly financial statements are essential, bolstered by monthly meetings to address fluctuations. 

“Lenders want to know what positive and negative factors impact cash flow,” says Brett Murphy, vice president of Lancaster Pollard, adding “lenders find comfort knowing management is analyzing expenses.”

As every lender asserts, keeping a constant eye on a facility’s operations is paramount.

This includes enhancing the top line with the right mix of referral sources, ancillary businesses, staffing and expense control — regardless of when capital is needed, adds Laca Wong-Hammond, managing director, mergers and acquisitions, for OREC Securities LLC.

“When a facility can generate this type of information quickly, whether for five years or trailing 12 months, it speaks to a level of professionalism that lenders will take seriously,” adds Bill Wilson, senior vice president of Lancaster Pollard.

Neal Raburn, managing director of senior housing lending at Greystone, also advises borrowers to regularly check their credit status.

2. Stay focused on the “big picture.” Lenders caution to not miss the forest for the trees. Long-term plans can easily fail from poor preparation.

As Wong-Hammond observes, “the best time to execute a transaction is when there’s no pressure for one. Lenders and investors alike focus on current but also historical financials, so keep focused and engaged in the business.”

Never forget that a sound relationship with the bank is something that needs tending in the off-years between transactions.

“Developing a strong, trusting relationship with an independent financier specializing in SNF financing is key,” says Steve Kennedy, senior managing director of Lancaster Pollard. “This enables the owner-operator to receive unbiased and proactive updates regarding unique financing opportunities that may unexpectedly arise.”

Matthew Huber, senior vice president, market manager healthcare at People’s United Bank, believes a well-tended relationship could even result in more favorable, lower-cost financing. 

“A financially viable project is not the only factor to consider,” he says. “The character and integrity of the borrower is paramount above all else.”

3.  The end game is clear: Set the stage for a quick and painless approval.

“The ‘story’ of how a SNF has performed over the past several years is instrumental to the financing process,” says Anthony Luzzi, president of Sims Mortgage Funding. “Administrators are crucial participants in the development of that story, which can have a significant impact on how well — or how poorly — a financing several years out is executed.”

How an owner-operator behaves in a prior loan transaction also can impact their success on the next, as Huber describes.

Communicating about and handling thorny issues or problems could color a bank’s thinking on the SNF’s risk profile. Once any challenges are put behind the borrower from a prior transaction, “the bank will have a good picture of exactly who they lent the money to,” he adds.

Erik Howard, managing director, real estate finance for Capital Funding Group, says choosing the right lender remains ssential.

“Finding a lender that can service the life of the loan and provide a holistic strategy will help you build long-term relationships in the industry and keep your information in one place,” Howard says.

4.  Be mindful of tempting potential pitfalls. Borrowers can easily fall prey to gimmicks and short-term fixes between transactions.

One of them is a “dry run” to test the market without serious intent, according to Huber. “If you waste a bank’s time, they will be cautious about looking at your next deal, and it may cause a trust issue,” he says.

Other mistakes include failing to check if investors have skeletons in their closets and giving the appearance that you’re “bribing your bankers with gifts.”

Luzzi urges all borrowers to stick to the current loan’s script, and avoid “instituting program changes that might take long to implement and skewer the financial and operational performance of the property.”

Huber also cautions against midstream accounting method changes. Providers should wait until after the fiscal year to alter anything, he said.

Mistakes to avoid

—Taking one’s eye off the ball when it comes to basics. Sound financial statements, routine credit checks and sound operational acumen will go far in assuring a constant state of readiness.

—Getting mired in a “transactional” mindset. Sticking to long-term goals and maintaining regular contact with lenders in the years between transactions is sound advice.

—Falling prey to gimmicks and short-term fixes. Stay away from accounting method changes at lending time and avoid loan test runs in the market.