Best Post-Acute Design of 2020: Vertical Small-House Model with Assisted Living Flexibility

With a history that traces back to 1922, CC Young is one of the most venerable senior housing and care providers in Dallas. But with skilled nursing buildings dating to 1969 and 1974, the continuing care retirement community (CCRC) badly needed some upgrades at the dawn of the 21st century.

“We had to make a radical, fundamental change to be relevant going forward,” President and CEO Russell Crews told Senior Housing News.

That commitment ultimately led to construction of The Vista, a 10-story building with assisted living, memory support, skilled nursing, adult day and other services and amenities. 

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The Vista features innovations such as a next-generation therapy suite and small house-style layouts on certain floors, enabling flexibility and enhancing infection control capabilities — unexpectedly put to the test during the Covid-19 pandemic.

The cutting-edge building has been embraced by the market and recognized as raising the bar for the industry, taking top honors for best post-acute design in the 2020 Senior Housing Architecture & Design Awards.

The concept

Like leaders at many CCRCs, Crews and the CC Young board faced some difficult decisions regarding skilled nursing as they began to think about future plans for the campus. With constant reimbursement and staffing pressures, some providers were opting to eliminate skilled nursing beds or drastically reduce them.

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But the board at CC Young remained committed to skilled nursing, seeing it as part of the organization’s legacy. The decision meant one thing to Crews: He had to make CC Young the premier skilled nursing provider in the area.

“You had to be a market leader or get out,” he told SHN.

With a new strategic plan formulated by 2014, Crews began working with Dallas-based architecture firm D2, which has since become part of HKS. One of the first challenges to confront was simply deciding where on the campus to build, architect Grant Warner said.

Located about 8 miles northeast of downtown Dallas, CC Young occupies prime real estate on the edge of Flag Pole Hill Park and White Rock Lake. But, the CCRC is also hemmed in by the park, light rail and major thoroughfares.

“They don’t have a lot of space,” Warner said.

Crews proposed a location on the north side of the campus, which would involve building on a steep slope but would bring advantages by placing the new tower adjacent to an existing assisted living building.

As for the design of the new building, Crews and Warner set out to solve several dilemmas.

“I started thinking about, how do we design a building that gives us flexibility, because I wouldn’t know what the demand for any given care level might be going forward,” Crews said. “I knew that we needed to design a building that would let us adjust.”

He took a year to research design options, including by touring the country to visit other facilities, with a particular focus on their rehab and therapy spaces.

“As we went into their therapy areas, their gyms were so small that the residents and therapists were on top of each other, charting was a nightmare, and if they had any aquatic therapy, it was a small treadmill that was submerged in a small room,” he said. “I was trying to step back and think, can’t we do better than this?”

The ultimate design concept made use of the site’s slope to create below-grade parking and a “drive under” colonnade on the ground level, providing more space for loading and unloading vehicles than a typical porte cochere entrance.

The building’s first level includes a residential adult day center, offices, and the main entrance. Level two includes several amenities, including a hybrid rehabilitation garden and public garden facing the rest of the campus; a cafe open to residents, staff and visitors; an art gallery; a chapel; and a multipurpose room. This level is also where the therapy suite is located.

The design of the therapy suite includes several innovations meant to improve the resident and staff experience, including:

— A walking loop encircling a training kitchen, car, bathroom and stairs

— Separate, more private spaces for particular therapy modalities such as physical and speech therapy

— And area for family members to have a refreshment while their loved one is receiving therapy

— A separate aquatic therapy area with private changing rooms instead of locker rooms, to preserve privacy

The pool in the aquatic therapy area can be used for recreation as well as rehab, and is specially designed with features such as a resistance walking loop, a deep water well, built-in benches and rest areas, and lifts allowing access from anywhere on the pool deck. It goes from shallow to deep across its short axis, so that people can find a comfortable depth and walk the length of the pool.

The third level of the tower is dedicated to assisted living, and connects to the main amenity level of the neighboring AL building; the project also added dining room space and additional amenity space such as a salon. The units on this level — and on level nine of the building, which is also dedicated to AL — are in the 500- to 1,400-square-foot range, which is larger than the 350- to 500-square-foot AL units typical in Texas, Crews said.

“We wanted you, when you walked in, to think you were in independent living,” he said.

Floors four through eight of The Vista feature household-style environments with capacity for 16 residents each. To meet CC Young’s need for flexibility, these floors are licensed to the highest standards, and are designed to be able to shift from assisted living to memory care to skilled nursing, as needed.

Each household has its own family-style kitchen (backed up with a shared warming pantry); recreational and activity spaces; a looped corridor so those with memory care needs can ambulate; and private apartment units.

The layout flows from public to semi-public to semi-private to private spaces, like a home, Warner said. The homelike feel extends throughout — for instance, nurses stations are subtly integrated into the design of the kitchen.

“There’s someone there to watch who’s coming and going,” Warner said. “It looks like someone just sitting in the kitchen writing a letter, but they’re a nurse at work.”

Depending on a household’s level of care, it can be secured or can be open to the other household on the same level, balancing safety with the option for greater socialization if appropriate.

The construction

Creating a vertical small house design allowed for a less institutional and more flexible environment, but such an approach did not neatly fit into Texas building codes.

And, the project team wanted to push the envelope in the design of the apartment units as well, to make the bed systems movable. Doing so allows residents to rearrange their furniture, and makes the rooms feel more like bedrooms than skilled nursing units.

“We spent time designing and planning and went to the state to approve a mixed building concept; they finally came back and said they liked it,” Crews said. “Then, we had the green light to move forward, and built the building to the skilled nursing construction code, so that we could then make any aspect a lesser level of care.”

Those shifts to higher or lower levels of care are accomplished through minimal adjustments such as activating or deactivating certain systems, and using sliding doors and panels that can be locked into place. CC Young has to notify state authorities if any household shifts to a new level of care.

With Hill & Wilkinson as the general contractor, construction was proceeding smoothly and the main columns had just been put up, when a new market study indicated that the building needed to have more assisted living units. The project team pivoted by redesigning the ninth floor.

Originally, the ninth floor was slated to include two small households, but instead was built as dedicated assisted living. Like on level three, the units are larger than average and include IL-style features like in-unit washer/dryer and balconies.

The ninth floor also includes another dining venue, as well as a sky garden.

Construction was completed in August 2019, with a total project cost of around $85 million.

The completion

Of course, Crews and the project team did not anticipate that a global pandemic would strike during The Vista’s lease-up period. Covid-19 has created challenges, but it also has shown the benefits of the small household model.

Interest in small-house senior living has surged in the last year, due to recognition of possible infection control benefits, such as an easier ability to cohort residents. The Vista provides an example of those benefits in action, with the first positive Covid-19 cases only appearing in the community in November 2020, as the overall positivity rate in the surrounding area spiked to 15% to 20%.

“I think we absolutely saw the benefits of infection control … and I think it’s attributable a lot to our design,” Crews said.

The first residents to live in The Vista also have responded positively. Dining has been a high point, and a vast improvement from CC Young’s previous skilled nursing buildings, which distributed food from one main kitchen. The Vista has a large production kitchen plus additional kitchens on levels eight and nine, with a dumbwaiter system to move food throughout the building. The result is fresher, hotter food for residents.

Equipping each resident unit with a 55-inch television and a 55-inch board that displays the identification information of staff who enter also have been popular and helped from a patient care and staff management perspective, Crews said.

He and Warner praise Faulkner Design Group for the interior design, which creates a striking yet homelike atmosphere, and helps divide spaces and bring in natural motifs to match the surrounding parkland and lake.

Creating a small house model in vertical project is a particular point of pride for Warner, who lives close to CC Young and is looking forward to again visiting as Covid-19 restrictions ease.

“CC Young is a beautiful campus, and my daughters and I would ride over there on our bikes — it’s a very open, welcoming, wonderful campus,” he said.

Further projects are in the works as part of CC Young’s master plan, and The Vista provides a strong foundation to build on, by meeting the high expectations of Crews and the project team. The judges of the SHN Architecture and Design Awards gave the project high marks across the board, for its aesthetic appeal as well as its community integration, and amenities and lifestyle.

It’s a “well designed, well programmed project,” noted Bruce Hurowitz, principal with Merlino Design Partnership and an SHN awards judge.

Crews believes that due to the changing nature of skilled nursing and post-acute care, The Vista’s multiple innovations were a must.

“You can’t just be average,” Crews said.

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