Purpose
I hosted this breakfast workshop to hear from assisted living owners about the problems they face day to day. Four businesses from Columbia, Pasadena and Baltimore attended, along with a trainer for the 80-hour manager course. Most of these homes opened within the last year.
What I Learned
1. Getting the first resident
Like any business, getting your customers is the hardest part. Most of the owners I spoke to were new to the industry and struggled with getting residents. I got to understand that one of the ways these homes get started is through placement agencies available within the industry. These agencies help match families looking for care.
However, in some cases, they charge the home up to 100% of the resident’s first month of rent for each move-in, and oftentimes with no guarantee of placement (Senior Housing News, 2017). A new owner talked about paying fees to about eight agencies and getting no placements or traction from them. For those with one or two residents, the approach that seems to work starts with word of mouth.
Another owner described why newer homes might get passed over: “What I think the agencies, whoever they have connection with for a long time ago, they keep sending it to them, and not the newer ones.”
Another channel involves hospitals sending referrals, but in most cases this isn’t feasible because these referrals are sent to many homes at once.
Across every industry, the fastest business to respond is able to reach the customer first. This is speed to lead, and it exists here too (Lincware).
2. Staffing
In April 2025, Maryland passed a rule that requires awake overnight staff on Alzheimer’s units, as stipulated by COMAR 10.07.14.14. A home cannot replace that staff member with cameras. Due to this, assisted living managers have talked about agencies holding back residents from any home without overnight staff: “Some agencies don’t send you anyone if you don’t have awake overnight.”
These owners estimate that a new hire takes at least two months to learn every resident’s condition and when to call the owner. In addition, the state allows 10 days before a new hire must show the delegating nurse that they are competent. Every home must also have a delegating nurse under contract, and for new owners, finding one is often a hurdle.
Maryland’s registered nurse shortage is projected to reach 13,800 full-time positions by 2035 (Maryland Hospital Association, 2024).
3. Putting the cart before the horse
Across businesses, it’s common to build for the long term before doing what’s needed first, which is getting clients. Assisted living is no different. A first-year owner described getting the house, furnishing it, setting it up, and carrying running costs without a single resident: “First month, two months, like nothing. I was like, what is wrong with my house? … I would spend a lot of money buying the biggest size TVs, and good kind of furniture.”
Another owner described carrying the mortgage for months before the first resident arrived: “I’ve been open since March … we just got our first one. … I’m putting mortgages for so long, so much renovations.”
4. Losing residents to hospital stays
When a resident goes to the hospital and then to rehab, the family can stop paying for the room, and the home loses the resident. It is important to note that while some hospital stays can’t be avoided, owners are incentivized to catch a change in a resident’s condition early. As one owner put it: “preventing hospitalization is another big thing. We can retain the clients what we have, so we don’t have to keep looking for new people.”
To catch those changes early, owners described having their staff report anything unusual right away, rather than assuming it’s nothing.
Keeping residents out of the hospital also brings in new ones. When families see a resident hasn’t been to the hospital in a long time, they tell others: “And that’s how marketing works, word of mouth.”
In other words, even though these homes are businesses, they are incentivized to take good care of their residents, because they lose money when they don’t.
5. Paperwork and surveys
Citations and surveys are one of the biggest “gotchas” in the senior care industry. The Maryland Department of Health can inspect an assisted living home unannounced at any time, whether to follow up on a complaint or for an annual survey. Owners described the uncertainty of never knowing when the state will show up.
Enrolling in the Medicaid waiver also stalls on paperwork, and one owner had started the waiver training three times.
Takeaway
1. Bring your unique value
The very first thing owners mentioned was finding your unique value and bringing it into your facility. A former physical therapist in the room offered physical therapy in-house, which gave his home an upper hand and helped it grow faster. Another owner, a former chef, described being able to offer more variety in meals. In any business, building on strengths from your past experience can help you get that first customer faster.
2. Community first
Bringing established homes and new ones into the same room can be very useful. At this workshop, some owners were already established, while others were still starting out. By the end of the morning, owners were offering to share placement agency contacts, names of delegating nurses, and training materials with each other. Some established homes also send residents they can’t serve to smaller ones. As one owner, who had recently hosted an open house for other homes, put it: “I want a network for us, so we can help one another. I don’t need to keep it all to myself.”
3. Discount the first resident
For a new home, the first resident matters more than the first month’s rent. Several owners in the room described offering their first resident a lower price, so that families touring the home could see it was open and running: “Getting first is hard, you have to give 50%, whatever you’re gonna do, just get one. Just to show them that you are starting.”
4. Set a price floor that covers your costs
At the same time, owners were careful not to go too low. The Pasadena owner described pricing the first beds to cover the mortgage, and then charging the regular price for anyone who comes in after. With staff, insurance, utilities and food to pay for, a price floor keeps the home running while it fills up.
