The recent COVID-19 crisis has prompted a convergence of interest in the current state of skilled nursing facilities and their preparedness vis à vis outbreaks. Operators are hard pressed to radically improve infection prevention and control (IPAC) and response strategies.

However, decisions made too quickly to manage fear and placate public outcry can run the risk of reverting skilled nursing facilities into cost-effective hospitals. But these communities are homes, hospitals are not. So how do we optimize performance without compromising the integrity of the residential experience?

1. Re-envision community
Modest layout enhancements can vastly improve IPAC and outbreak response in skilled nursing facilities as well as day-to-day operations without altering the residential character of a home. For example, larger amenity rooms will help support physical distancing and, when fitted with videoconferencing capabilities, allow healthy residents to safely participate in activities such as concerts, religious services, or art classes that would typically be offered during an outbreak. Wider, looping corridors and more open, interconnected spaces will not only limit pinch-points and crowding but improve overall circulation. Sitting bays, low sills, and judiciously placed windows throughout the facility will help reduce the psychological impacts of isolation by allowing residents to be visually connected to the outside world. And, generous terraces allow residents safe and secure access to the outdoors, even during lockdowns.

2. Reinvest in the resilience of the resident bedroom
Residents spend a considerable amount of time in their bedrooms—almost exclusively during an outbreak. Several simple investments in bedrooms can vastly improve health and well-being across the home. Filter-equipped fan units, fitted to a standard window frame, can be deployed as an emergency response during an outbreak. These units can create “nearly” negative pressure bedrooms by managing the flow of air and exhausting contaminated air to the outside. This ensures that airborne particles from an infected resident cannot escape the room and directs the flow of air away from caregivers and support staff. True negative pressure bedrooms and positive pressure air locks in key corridors can better manage contaminated air and decrease transmission rates. A negative pressure bedroom will help contain pathogens to the affected room, while the positive pressure air locks, strategically placed in the corridor system, can help isolate larger portions of a building from one another. Additionally, emerging technologies like wearables, voice-command systems, motion detectors, weight sensors, and videoconferencing devices can limit in-person visits without limiting residents’ contact with others.

3. Rethink our readiness to respond
Going forward, new skilled nursing facilities must look and feel in every way like warm, welcoming places to live but also have in their arsenal the flexibility for simple, temporary retrofits that support rapid response to future events. Entrance canopies designed to support temporary canvas panels can become makeshift testing stations. Drop-off zones can be configured to accommodate heated tents for individuals maintaining physical distance while waiting to be screened during inclement weather, while lobby spaces should be sufficiently sized to support additional storage capabilities for personal protective equipment gear, screening desks, and portable partitions. Additional doors, including a secondary entrance used only during outbreaks can create two separate circulation flows. Boardrooms may have increased information communication technology capacity to support web-conferencing between communities and authorities. Finally, nurses’ stations can be designed to accept temporary glass partitions to protect staff during interactions with others.

Moving forward
During this pandemic, outbreaks in skilled nursing facilities have and continue to account for an undue share of deaths. As a result, renewed attention is being paid to the deficient state of much of residential elder care, in particular its capacity to respond swiftly and effectively to the spread of deadly contagions. Despite the urgency to act, design interventions that improve IPAC and outbreak response cannot be made at expense of the residential experience. A home that performs in the best of times and the worst of times is not only possible, but an imperative, and strategies must be considered accordingly.

Santiago Kunzle is a director and principal at Montgomery Sisam Architects (Toronto). He can be reached at