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Home > Design Guidance > Building Types > Health Care Facilities > Nursing Home






by Robert F. Carr NIKA Technologies, Inc. for VA Office of Construction & Facility Management (CFM) Revised by the WBDG Health Care Subcommittee Last updated: 12-30-2010

Nursing ho mes serve patients requiring preventive, therapeutic, and rehabilitative nursing care services fo r no n-acute, lo ng-term co nditio ns. Specialized clinical and diagno stic services are o btained o utside the nursing ho me. Mo st residents are frail and aged, but no t bedridden, altho ugh o ften using canes, walkers, o r wheelchairs. Stays are relatively lo ng, the majo rity fo r life. Nursing ho mes also care fo r a smaller percentage o f co nvalescent patients o f all ages. These patients are in lo ng-term reco very fro m acute illnesses, but no lo nger require ho spitalizatio n.



Nursing Home



Achieving Sustainable Site Design through Low Impact Development Practices Aesthetic Challenges

Within This Page Overview Building Attributes Related Issues Emerging Issues Relevant Codes and Standards

Aesthetic Opportunities Air Barrier Systems in Buildings Air Decontamination VIEW ALL RELAT ED (4 3)


Nursing ho mes, o r sectio ns o f them, are o ften classified into intermediate and skilled nursing units, definitio ns related to Medicare/Medicaid standards. Intermediate-care facilities have just eno ugh nursing to qualify fo r Medicaid; skilled nursing facilities meet the mo re demanding medical standards to qualify fo r Medicare as well as Medicaid suppo rt. The co gnitively impaired are frequently ho used separately in Alzheimer Related Dementia (ASD) units. See Alzheimer's Fo undatio n o f America Excellence in Care Pro gram Nursing ho mes present special design challenges in that fo r mo st residents the nursing ho me is no t just a facility, but indeed their ho me. The reality is that in mo st cases the residents will live there fo r the rest o f their lives and, mo reo ver, rarely leave the premises at all. The nursing ho me beco mes their entire wo rld in a sense. The challenge is to design a nursing ho me that is sensitive and respo nsive to lo ng-term human needs and well-being, bo th physical and emo tio nal. BACK TO TO P




BUILDING AT T RIBUT ES A nursing ho me o perates primarily in a patientcare mo de rather than a medical mo de. Co nsequently, its mo re impo rtant attributes are tho se fo cusing o n the general well-being o f its residents rather than high-tech co nsideratio ns. The principal attributes o f a well designed nursing ho me are:

Homelike and Therapeut ic Environment Inherent in any institutio nal stay is the impact o f enviro nment o n reco very, and the lo ng-term stays typical o f nursing ho me residents greatly increase Floor Plan of Missouri Veterans Home—St. this impact. The architect and interio r designer James, Missouri must have a tho ro ugh understanding o f the Architect: Kennedy Association Inc. nursing ho me's missio n and its patient pro file. It View enlarged plan is especially impo rtant that the design address aging and its acco mpanying physical and mental disabilities, including lo ss o f visual acuity. To achieve the appro priate nursing ho me enviro nment every effo rt sho uld be made to : Give spaces a ho melike, rather than institutio nal, size and scale with natural light and views o f the o utdo o rs Create a warm reassuring enviro nment by using a variety o f familiar, no n-reflective finishes and cheerful, varied co lo rs and textures, keeping in mind that so me co lo rs are inappro priate and can diso rient o r agitate impaired residents Pro vide each resident a variety o f spatial experiences, including access to a garden and the o utdo o rs in general Pro mo te traditio nal residential qualities o f privacy, cho ice, co ntro l, and perso nalizatio n o f o ne's immediate surro undings Alleviate po ssible diso rientatio n o f residents by pro viding differences between "residential neighbo rho o ds" o f the nursing ho me, and by use o f clo cks, calendars, and o ther "reminders" Enco urage resident auto no my by making their spaces easy to find, identify, and use Pro vide higher lighting levels than typical fo r residential o ccupancies

Ef f iciency and Cost - Ef f ect iveness The nursing ho me design sho uld: Pro mo te staff efficiency by minimizing distance o f necessary travel between frequently used spaces Allo w easy visual supervisio n o f patients by minimal staff

Make efficient use o f space by lo cating suppo rt spaces so they may be shared by adjacent functio nal areas, and by making prudent use o f multi- purpo se spaces

Cleanliness and Sanit at ion An o do r-free enviro nment is a very high prio rity in nursing ho mes, since many residents are o ccasio nally inco ntinent, and the pervasive o do rs can give an impressio n o f uncleanliness and po o r o peratio n to family and visito rs. In additio n to o peratio nal practices and careful cho ice o f furniture, facility design can help o do r co ntro l by: Adequate and highly visible to ilet ro o ms in key lo catio ns near spaces where residents Western New York State Veterans Home co ngregate Batavia, NY, Kideny Architects The use o f appro priate, durable finishes fo r each space used by residents Pro per detailing o f such features as do o rframes, casewo rk, and finish transitio ns to avo id dirt-catching and hard-to -clean crevices and jo ints Adequate and appro priately lo cated ho usekeeping spaces Effective ventilatio n, which may need to exceed no minal design levels Inco rpo rating O&M practices that stress indo o r enviro nmental quality ( IEQ)

At t ent ion t o Way- f inding A co nsistent and well tho ught o ut system o f way-finding helps to maintain the residents' dignity and avo id their diso rientatio n. It sho uld: Use multiple cues fro m building elements, co lo rs, texture, pattern, and artwo rk, as well as signage, to help residents understand where they are, what their destinatio n is, and ho w to get there and back. Identify frequently used destinatio n spaces by architectural features and landmarks which can be seen fro m a distance, as well as symbo ls, signage, art, and elements such as fish tanks, birdcages, o r greenery Avo id pro minent lo catio ns and high visibility o f do o rs to spaces which patients sho uld no t enter Use simple lettering and clear co ntrasts in signage (See VA Signage Manual ) Clearly identify o nly tho se ro o ms that residents frequent

Accessibilit y Many residents may be ambulato ry to varying degrees, but will require the assistance o f canes, crutches, walkers, o r wheelchairs. To acco mmo date these residents, all spaces used by them, bo th inside and o ut, sho uld: Co mply with the requirements o f the Americans with Disabilities ( ADA) and, if federally

funded o r o wned, with the Unifo rm Federal Accessibility Standards (UFAS) Be designed so that all spaces, furnishings, and equipment, including sto rage units and o perable windo ws, are easily usable by residents in wheelchairs Be equipped with grab bars in all appro priate lo catio ns Be free o f tripping hazards Be lo cated o n o ne flo o r if feasible, preferably at grade. If residents' bedro o ms must be lo cated o n mo re than o ne flo o r, then dining space must be appo rtio ned amo ng tho se flo o rs, no t centralized

Securit y and Saf et y Design to address security and safety co ncerns o f nursing ho mes includes: Use o f no n-reflective and no n-slip flo o rs to avo id falls Co ntro l o f access to hazardo us spaces Co ntro l o f exits to avo id residents leaving and beco ming lo st o r injured Pro visio n o f secure spaces to safeguard facility supplies and perso nal pro perty o f residents and staff

Aest het ics Aesthetics is clo sely related to creating a therapeutic ho melike enviro nment. It is also a majo r facto r in a nursing ho me's public image and is thus an impo rtant marketing to o l fo r bo th residents' families and staff. Aesthetic co nsideratio ns include: Increased use o f natural light, natural materials, and textures Use o f artwo rk Attentio n to pro po rtio ns, co lo r, scale, and detail Bright, o pen, genero usly scaled public and co ngregate spaces Ho melike and intimate scale in resident ro o ms and o ffices Appro priate residential exterio r appearance, no t ho spital-like Exterio r co mpatibility with surro undings

Sust ainabilit y Nursing Ho me facilities are public buildings that may have a significant impact o n the enviro nment and eco no my o f the surro unding co mmunity. As facilities built fo r "caring", it is appro priate that this caring appro ach extend to the larger wo rld as well, and that they be built and o perated "sustainably". Sectio n 1.2 o f VA's HVAC Design Manual is a go o d example o f health care facility energy co nservatio n standards that meet EPAct 20 0 5 (PDF 1.3 MB, 550 p g s ) and Executive Order 13423 requirements. The Energy Independence and Security Act o f 20 0 7 (EISA) (PDF 740 KB, 310 p g s ) pro vides additio nal requirements fo r energy co nservatio n. Also see LEED's (Leadership in Energy and Enviro nmental Design) USGBC LEED fo r Healthcare . BACK TO TO P

RELAT ED ISSUES The HIPAA (Health Insurance Po rtability and Accessibility Act o f 19 9 6 ) regulatio ns address security and privacy o f "pro tected health info rmatio n" (PHI). These regulatio ns put emphasis o n aco ustic and visual privacy, and may affect lo catio n and layo ut o f wo rkstatio ns that handle medical reco rds and o ther patient info rmatio n, paper and electro nic, as well as patient acco mmo datio ns." BACK TO TO P

EMERGING ISSUES There is a gro wing reco gnitio n o f the need fo r dementia day care. This can o ften be effectively pro vided within o r adjo ining an inpatient nursing facility. There is a need fo r better no n-medical residential facilities fo r the frail but independent elderly. Managed care pro grams fo r the aged are being develo ped to prevent, o r at least po stpo ne, institutio nalizatio n. BACK TO TO P

RELEVANT CODES AND STANDARDS Like o ther buildings, nursing ho mes must fo llo w the lo cal and/o r state general building co des. Ho wever, federal facilities o n federal land generally need no t co mply with state and lo cal co des, but fo llo w federal regulatio ns. To be licensed by the state, design must co mply with the individual state licensing regulatio ns. Many states ado pt the AIA Guidelines for Design and Construction of Hospitals and Health Care Facilities, listed belo w as a reso urce, and thus that vo lume o ften has regulato ry status. State and lo cal building co des are based o n the mo del Internatio nal Building Co de (IBC). Federal agencies are usually in co mpliance with the IBC except NFPA 10 1 (Life Safety Co de), NFPA 70 (Natio nal Electric Co de), and Architectural Barriers Act Accessibility Guidelines (ABAAG) o r Unifo rm Federal Accessibility Standards (UFAS) takes precedence." To care fo r residents who are reimbursed under

To care fo r residents who are reimbursed under Medicare o r Medicaid, facilities must also meet federal standards, and to be accredited, they must meet standards o f the Jo int Co mmissio n o n the Accreditatio n o f Healthcare Organizatio ns (JCAHO). Generally, the federal go vernment and JCAHO refer to the Natio nal Fire Pro tectio n Asso ciatio n (NFPA) mo del fire co des, including Standards fo r Health Care Facilities (NFPA 9 9 ) and the Life Safety Co de (NFPA 10 1). The American with Disabilities Act ( ADA) applies to all Library, Missouri Veterans Home, St. public facilities and greatly the building design with its James, MO, Kennedy Assoc., Inc. general and specific accessibility requirements. The Architectural Barriers Act Accessibility Guidelines (ABAAG) o r the Unifo rm Federal Accessibility Standards (UFAS) apply to federal and federally funded facilities. The technical requirements do no t differ greatly fro m the ADA requirements. See WBDG Accessible. Federal agencies that build and o perate, o r fund, nursing ho mes have develo ped detailed standards fo r the pro gramming, design, and co nstructio n o f their facilities. Many o f these standards are applicable to the design o f no n-go vernmental facilities as well. Amo ng them are: Department o f Veterans Affairs (VA), Office o f Co nstructio n & Facilities Management Technical Info rmatio n Library co ntains many guides and standards, including: Design Manuals o f technical requirements, equipment lists, master specificatio ns, ro o m finishes, space planning criteria, and standard details. BACK TO TO P

MAJOR RESOURCES WBDG Federal Mandate Executive Order 13423 Technical Guidance Products and Systems Building Envelo pe Design Guide

Websit es See WBDG Health Care Facilities fo r generic health care facilities websites

Publicat ions Contemporary Environments for People with Dementia by Co hen and Day. Baltimo re, MD:

Jo hns Ho pkins Press, 19 9 3. Design Details for Health: Making the Most of Design's Healing Potential, 2nd Edition by Cynthia A. Leibro ck and Debra Harris. New Yo rk: Jo hn Wiley & So ns, Inc., 20 11.—Inno vative design so lutio ns in key areas such as lighting, aco ustics, co lo r, and finishes Design for Dementia by Margaret Calkins. Owings Mills, MD: Natio nal Health Publishing, 19 8 8 . Design of Long-Term Care Facilities by Aranyi and Go ldman. New Yo rk: Van No strand Reinho ld, 19 8 0 . Design That Cares: Planning Health Facilities for Patients and Visitors, 2nd Edition by Janet Carpman, Myro n Grant, and Debo rah Simmo ns. New Yo rk: Jo hn Wiley & So ns, Inc., 20 0 1. Designing for Alzheimer's Disease: Strategies for Creating Better Care Environments Elizabeth Brawley. New Yo rk: Jo hn Wiley & So ns, Inc., 19 9 7.


Designing the Open Nursing Home by J.A. Ko ncelik. Stro udsburg, Pa.: Do wden, Hutchinso n, and Ro ss, 19 76 . Hospital Related Facilities for the Elderly by Alicen Hall. Lubbo ck, Tex.: Texas A&M University, 19 9 7. Nursing Home Design by Benjamin Schwarz. New Yo rk: Garland Publishing, 19 9 6 . Nursing Home Renovation Designed for Reform by Lo rraine Hiatt. Bo sto n: Butterwo rth Architecture, 19 9 1. See WBDG Health Care Facilities fo r generic health care facilities publicatio ns BACK TO TO P

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