As an interior designer working on large projects for senior housing facilities for the past 20 years, I have been in a constant battle with manufacturers to produce products that meld the three most important criteria specifically needed for senior housing: aesthetics, code compliance, and durability.

To date, products meeting all three criteria have been virtually nonexistent. In the past five years, however, I have begun to see amazing changes in the availability of such materials and technologies that are universally beneficial to the physical changes that occur with aging and that still meet the growing list of regulatory compliances required for the elderly.

One must also remember that this population is not checking in at the front desk, dropping their bags, and heading out to the pool. They live there 24 hours a day with every type of infirmity imaginable. These facilities are their homes. Their environments must be not only safe and attractive, but durable as well.

The boomers

I believe that the primary catalyst for this current evolution of healthcare materials is the American baby boomer generation. The approximately 77 million people born after World War II, between 1946 and 1964, have the greatest wealth, education, and influence of any American generation before them. Their perception of aging and how to successfully negotiate its consequences is also unique, as they refuse to be perceived as “old” and are therefore healthier, more active, and the youngest-looking generation to date. This group will not accept the same meager surroundings of healthcare facilities for the elderly that their parents and grandparents were willing to endure during the '60s, '70s, and '80s. No, this generation wants to pass gracefully into the hereafter while living the life of a retired vacationer at a resort where every day is a Saturday to play. Their desires, financial status, and sheer numbers cannot be ignored by the free market that will produce the products targeted specifically for this generation and those to follow.


The following is an illustration of a scenario that commonly plays out between a parent and an adult child today.

Let's say your father passed away two years ago and your mom is still living in the home you grew up in. She recently fell and broke her hip, has had surgery, and now needs to spend some time in a nursing facility while recuperating with physical therapy. Both of you had always hoped her retirement years would be spent at home, but in the event she had to be placed in a nursing home (the term commonly used for an independent living, assisted living, board and care, sub-acute or skilled nursing facility [SNF]), it would be at the highest level that her savings would allow. If equated to a hotel chain, this most likely does not include the local motel. This is where aesthetics become an important factor not only to the resident and family member, but to the business of the facility owner/operator as well.

In the United States, facilities reimbursed by government funds don't get paid unless a bed is occupied, much like schools. When the discharge planner at the acute care hospital hands you a list of licensed, local facilities that will accept her government benefits, what will be your deciding factors? Obviously, the competency of the care she is to receive comes first, but how are you to assess that? You can't be a fly on the wall for a 24-hour period to see if she's getting her medicine or assistance to the lavatory in the middle of the night. You are already feeling the guilt of having to move her into a nursing home in the first place.

Unlike any other hospitality venue, the first impression of a nursing facility is not only driven by visual aesthetics, but additionally, by the smell. The assumption is if the facility looks of a five-star quality, the care must be the same. If the available options for her placement include the facilities shown in Image 1-common for a standard, 99-bed SNF in the United States in which very little has been done to improve it aesthetically; Image 2-equal to a moderate level hotel; or Image 3-equivalent to a first-class, five-star hotel-and there is no difference in what she will pay, which one would you choose for her? Aesthetics are the key to forming that ever-important first impression, but what if the materials used to make it so appealing aren't durable or safe? What if that breathtaking first impression in the lobby is ruined by the smell of urine emanating from the giant stain in the carpet that can't be removed due to the incorrect specification of standard commercial carpet instead of one for a healthcare facility?

Regulatory code compliance

I usually begin my lectures with the following question: Can anyone give me an example of a facility more difficult to design for function than a locked Alzheimer's unit in the state of California? The reason the answer is “no” is because of regulatory code and safety compliances that are imposed by government agencies, which dictate their codes and regulations whenever monies are being dispersed through social programs to healthcare providers. In the U.S., this applies to facilities that benefit from such programs as Medicare, Medicaid, and Social Security Insurance.

My work has been focused primarily on the west coast of the United States, specifically in California, which is known for its earthquakes that cause destruction, fires, and floods without warning. This fact, as well as legal liability, has inspired some of the strictest building and safety codes in the world for all types of healthcare facilities in California. As a certified interior designer, I am required by the state to meet all building, life and safety, and department of health codes for fire, earthquakes, barrier-free (handicapped) accessibility and egress, infection control, and privacy-just to name a few. This severely limits the materials and manufacturers that I can use in my designs.

For example, all drapery fabrics must meet the fire code and be washable to 160 degrees for infection control. All cubicle curtains must additionally meet the privacy requirement of no more than 18 inches off of the finished floor. A dining table must be able to withstand 200 pounds of pressure on its edge if a resident uses it to push himself to his feet. Although the inspectors will cite the facility for drapes being noncompliant, the cubicle curtains shrinking in the wash or the table tipping over onto Mr. Smith as he uses it to stand up, it is the designer/specifier who is ultimately responsible for the consequences of noncompliant specifications.


I recently received a very nice compliment from a long-time client of mine who said that one of the things he appreciated most about our work was the fact that if the facility take
s care of the materials we provide in a renovation, it looks as good 10 years later as it did the day it was completed. This is primarily due to the appropriate specifications of durable materials for a senior housing facility. If you've ever designed a hotel project, you know how important durability is in an establishment that is used by the public 24 hours a day. Add to that a full occupancy of 300 or more elderly people who have wheelchairs, motorized chairs, walkers, and canes that constantly bump and scrape the handrails and lower corridor walls, and you can imagine the wear and tear inflicted.

Obviously, residents' physical ailments contribute as well. Problems with hearing, vision, mobility, incontinence, and lack of strength are all enormous factors that impact the specifications of interior materials. The most common stains and odors caused by urine, blood, Betadine, and foods such as coffee and red Jell-O must be removable with standard commercial cleaners. Back in the 1980s, the only upholstery options to meet this need were to use plain vinyl or cover fabric in clear plastic. Today, we have new moisture-barrier fabrics that are impermeable and easily cleaned.

The challenge

Healthcare designers are essentially challenged by every specification made. The residents and their families want to squelch their guilt and anxiety by feeling like they are entering the Four Seasons when they walk into a 50-year-old nursing facility-a facility where the state dictates we only are allowed to use materials that meet its safety code requirements and where our clients want to be guaranteed by the manufacturers that the urine stain will wash off of the sofa fabric when cleaned by the housekeeping staff.

An excellent example of this dilemma is the standard chair used in the main dining room of a facility for the elderly. The code requires that it include arms that can support a minimum of 200 pounds while standing or sitting. It should also be ergonomically friendly with a higher seat than the usual 16 inches and have an upholstered back. The foam within the seat and back must meet the fire requirement of California Technical Bulletin 117. To deal with incontinence, a common problem in these facilities, the chair should be able to withstand constant cleaning through the use of new, phenomenal, moisture-barrier fabrics. To ensure that mom will not plop into the chair and then topple over backwards, the chair should have stretcher bars between the legs for stability. Casters should only be used on the front legs, not the back, so that if she does plop, the chair will not propel backwards without her in it.

Wheelchairs and walkers that roll in close to these chairs at a table can do terrible damage to wood frames. We, therefore, now can find chairs that are made out of steel frames with wood-looking PVC covers that are not only durable, but look great too. Last but not least, California Technical Bulletin 133 dictates that the entire chair has to be tested for fire code compliance at an Underwriters Laboratories Inc.-rated laboratory to receive certification for use in a California healthcare environment. Now, multiply that by every other specified piece within the project, and you can see why products designed with all three criteria included are extremely useful to healthcare design teams throughout the globe.


These days our lives as healthcare designers are finally being made easier through the engineering of better materials, a move that was instigated by the onset of the baby boomer generation. We now have wood-looking furniture made out of PVC plastic that is virtually indestructible, moisture-barrier fabrics that also include built-in antimicrobial properties, vinyl strip flooring that seals between strips to disallow urine to creep between the planks, and carpeting that now can be extruded out of 100% solution-dyed nylon and allows bleach or Betadine to be poured directly on it without any discoloration. Although these products represent only the beginning of what is needed, it is now possible to design an environment that looks like a five-star hotel, withstands the abuse of a high school gymnasium, and is as safe as a newborn's nursery.

Cheryl A. Sanders ASID, CID, is president of Interior Images of Yorba Linda, California, specializing in senior housing design. For more information, visit Healthcare Design 2010 November;10(11):12-16