Senior housing occupancy passed 90% in 2026 while new construction fell about two-thirds from 2021, so operators now compete on running their buildings well rather than on filling them. Sixteen leaders on our list are rebuilding the work through health care payment deals, redesigned frontline jobs, and their own data and AI. They're doing it as residents arrive sicker, and Medicare pays nothing toward rent or daily care.
The short version
It is housing plus daily help, paid mostly by families. About 1 million people live in 31,400 communities at a median $6,200 a month. Medicare pays nothing toward it, and states, not Washington, regulate it. More
Demand is outrunning supply. Senior housing occupancy passed 90% in 2026 as the oldest boomers turn 80 and new construction is at its lowest since 2012. Operators now compete on running full buildings well rather than on filling empty ones. More
Labor is the biggest cost and the hardest problem. Pay is more than half of operating budgets, a third of staff leave each year, and residents arrive sicker than they used to. More
Five changes mark the innovators: getting paid for keeping residents healthy, redesigning the frontline job, sensors and AI, a product the middle class can afford, and owning home health and hospice. More
Sixteen senior care leaders on our list are already making these changes, and ten more outside it are moving the same way. Each profile ends with a question to ask. More
Referral services stand between many families and communities. A Place for Mom and its rivals are free to families and charge the community up to a month's rent and care for each move-in. Large operators are building their own marketing to depend on them less. More
Calling it a nursing home or a facility marks an outsider, and so does assuming Medicare pays. Operators want to talk about the care model and the staff before technology. More
How the business works
Families pay most of the bill for assisted living
About 1.0 million Americans live in roughly 31,400 assisted living communities with about 1.3 million licensed beds, according to the 2025 federal survey of long-term care providers. CDC More than half of residents are 85 or older, 62% need help with three or more daily activities such as bathing and dressing, and 44% have a dementia diagnosis. CDC
Assisted living sits in the middle of a ladder of care. The table shows where it fits, because people outside the sector most often confuse it with a nursing home.
Setting
What residents get
Who regulates
Who pays
Home care
Aides who help at home with bathing, meals, and errands
States, lightly
Families, some Medicaid, and long-term care insurance
Independent living
An apartment with meals, activities, and transport, no hands-on care
Mostly unlicensed as care
Families
Assisted living
An apartment plus help with daily activities and medications, staff on site around the clock
Each state; there is no federal standard
Families for rent and care; Medicaid pays for care (never rent) for about 17% of residents
Memory care
Secured assisted living for people with dementia, usually a wing of an assisted living building
States, often with extra dementia rules
Families
Nursing home (skilled nursing)
24-hour licensed nursing, rehab after a hospital stay, long-stay care
Federal government (the Centers for Medicare and Medicaid Services) plus states
Medicare for short stays, Medicaid for long stays
Life plan community (continuing care retirement community, or CCRC)
One campus with independent living, assisted living, and nursing, often with an entry fee
States
Families, through entry fees and monthly fees
Medicaid share from the 2025 CDC survey (16.9% of residents). Medicare pays nothing toward assisted living rent or personal care.
The median price was $6,200 a month in 2025, or $74,400 a year, up 5% on 2024. A semi-private nursing home room cost $315 a day, about $115,000 a year. CareScout
Investors often own the buildings that operators run
In much of the industry, an investor owns the building and an operating company runs it under a management contract. The biggest owners are two public real estate investment trusts (REITs), Welltower and Ventas. Since a 2007 law, REITs can keep a share of operating profit rather than collecting fixed rent, so they now pick, judge, and replace operators. Ventas works with 44 operators, up from 23 in 2023. SHN
A founder who runs 50 communities may own only some of the buildings, and that founder's real assets are the operating company, its people, and its methods. Several leaders on our list own most of their real estate (Juniper owns all but six of its 28 communities); others run buildings for capital partners.
Founders still run much of a fragmented market
Only two operators are public companies: Brookdale and Sonida. Everyone else, from the largest (Discovery Senior Living, now ranked first by the American Seniors Housing Association, or ASHA) to hundreds of regional family firms, is private. ASHA 50 About 41% of communities are single-site independents, and 80% are for-profit. CDC Brookdale's roughly 47,000 units are under 4% of the country's 1.3 million licensed beds.
States, not Washington, set the rules: licensing, staffing, training, and inspections all differ by state, and some states call the setting by other names such as residential care or personal care homes. Nursing homes, by contrast, must meet federal rules. Federal attention has grown since 2024, when the Senate Aging Committee questioned the three largest operators about staffing and residents who wandered off unsupervised. Senate Aging Committee
The economics in 2026
Assisted living fills up as the oldest boomers turn 80
90.4%of senior housing units occupied, Q3 2026source
$6,200median monthly price of assisted living, 2025source
56%of operating budgets goes to pay and benefitssource
Occupancy passed 90% in 2026 SHN while construction starts fell about two-thirds from 2021, so operators can charge more. Senior Housing News describes the industry conversation as moving "from occupancy recovery to margin growth." SHN
So what: Ask a leader what they're doing with the room that full buildings give them: changing the work, or only the price.
Occupancy across senior housing reached 90.4% in the third quarter of 2026, the highest in at least a decade, with assisted living at 89.1%. SHN, NIC MAP data The oldest baby boomers turn 80 this year, and the population over 80 is projected to grow by about a third by 2030. Construction starts have fallen about 67% since 2021, to around 10,000 units a year. NIC MAPNIC MAP, the industry's main data service, estimates the country needs about 576,000 more units by 2030.
Occupancy fell below 79% in 2021 and is now above 90%
So what: In 2021 operators were fighting to fill their buildings. Today most of them are nearly full, which lets them raise prices. Their attention has moved to staffing and margins. Leaders who rebuilt the work during the downturn now have room to grow, and what they plan to do with that room is a good opening question.
All senior housingAssisted living
Share of units occupied each quarter in the 31 largest US metro markets, as first published by NIC MAP. Hover for each quarter; click or tap for details and the source.Show as a table
About 3.8 million more Americans are projected to be over 80 by 2030, while new construction has roughly halved since 2017
So what: The over-80 population is set to grow by about a quarter in five years while new supply shrinks, so the shortage could get worse before new buildings catch up. The shortage also helps explain the surge in deals for existing communities, and it favors operators who already run their buildings well.
Americans aged 80 and over
New senior housing units started each year (thousands)
Population: Census estimates to 2025 and Census projections (dashed) after. Construction: NIC year-end figures as first published, mostly for the 31 largest metro markets; 2025 is NIC MAP's rounded figure; years marked n/a weren't published. NIC MAP's national count, a wider measure, fell about 67% from more than 30,000 units in 2021.Show as a table
Full buildings have given operators pricing power, and capital is flowing back in: senior housing sales topped 230 deals a quarter in the first half of 2026. LevinPro LTC
Three pressures sit underneath the good numbers:
Labor is still the biggest cost. Pay is more than half the budget, a third of staff leave each year, and the share of providers often using temp agencies rose from 16.8% to 24.8% in the latest Ziegler survey. Jesse Jantzen, CEO of Lifespace Communities: "Workforce shortages aren't the core issue anymore - capability is." SHN
Residents arrive later and sicker. In a 2026 survey of more than 500 senior living professionals, 81% reported rising acuity (how much care a resident needs) and only 12% said staffing was consistently sufficient. SHN In effect, assisted living is taking on work nursing homes used to do, without nursing home staffing or Medicare payment.
Most of the coming customers can't afford it. With a $74,400 median annual price and rents rising 5% a year, operators are growing mainly among wealthier families. Medicaid covers some at the bottom. The middle is the unserved market. Federal Medicaid cuts in the 2025 budget law put the state waiver programs that fund assisted living care at risk. Justice in Aging
What is changing
Operators rebuild care work in five ways
The biggest shift is who pays for residents' health. A few operators have stopped leaving residents' health care dollars to outside insurers and started taking on that risk themselves. Five leaders on our list have moved this way. Three own or co-own a Medicare Advantage plan or take full financial risk for its members, and they make money when residents stay out of the hospital and lose it when they don't. The other two run their own home health and hospice, or have joined a care network that operators own together.
From 2023 to 2026, the operators changing their businesses most are doing one or more of five things. The first two have the strongest evidence and the most money behind them.
1. Getting paid for keeping residents healthy
Senior Housing News now calls assisted living "the new skilled nursing" because residents arrive with needs that once meant a nursing home. Their health insurance dollars go to Medicare Advantage plans while the operator provides the daily care. Some operators now co-own a Medicare Advantage plan for their residents (an institutional special needs plan, or I-SNP) or join alliances that put doctors on site and share the savings from fewer hospital trips. Larry Gumina, CEO of Ohio Living, in 2020: "Simply put, we're providing the care at the bedside, so we should be compensated accordingly." SHN
The Serviam network, which operators set up to do this together, reported 41 operators and more than 90,000 residents in 2024. SHN Most operators still take part through partners rather than taking the risk themselves.
Operators that partner rather than own are now asking for a share of the savings. Writing for NIC, the National Investment Center for Seniors Housing and Care, leaders of National Church Residences, a senior housing operator, say outside medical groups working in senior housing have kept most of the financial upside. They tell operators to insist on direct participation and to judge partners by length of stay, occupancy, staff turnover, and family satisfaction. NIC
On our list: Lynne Katzmann, Joel Theisen, Phil Fogg Jr., Andy Eby, Philip Gisi. Also: Ohio Living, Otterbein SeniorLife, Presbyterian Homes and Services, Erickson.
2. Redesigning the frontline job instead of buying temp labor
Wages are still the top reason staff leave. SHN The operators getting ahead are changing the job itself: Capri Communities in Wisconsin moved staff to a four-day, 32-hour week at 40 hours' pay in January 2023; SHN Morning Pointe gave care teams control of their own schedules; Aegis built its own staffing agency; others run internal universities and career ladders from aide to nurse.
On our list: Franklin Farrow, Dwayne Clark, Jim Coughlin, Dan Madsen, Patricia Will. Also: Capri Communities, Lifespace Communities, Front Porch.
3. Sensors and AI that watch for falls and clear the paperwork
Camera and radar systems now detect falls without a pull cord, and in 2026 a few operators built AI agents that check charts, flag residents in decline, and reconcile medication records. SHN Fall detection is common in memory care at larger operators. AI on documentation is early, and most published results come from the vendors or operators themselves.
On our list: Jesse Marinko, Isaac Scott, Joe Jedlowski, Tim Fields. Also: Galerie Living. Vendors: SafelyYou, Inspiren, August Health, Sage.
4. A product the middle class can afford
Operators trying to reach $3,000 to $4,000 a month unbundle services, use one cross-trained worker for care and housekeeping, swap included dining for pay-as-you-go bistros, or use Medicaid waivers and affordable-housing finance. SHN Many operators talk about a middle-market product, but few have built one at scale.
On our list: Jim Coughlin (an affordable model in Washington DC). Also: United Church Homes, Presbyterian Homes and Services, 2Life Communities, Innovation Senior Living.
5. Owning the services that follow the resident
Instead of letting outside home health, hospice, and pharmacy companies into their buildings, some operators now own them. The Dover Companies, which runs Cedarhurst Senior Living, launched its own home health and hospice company in March 2024. Hospice News
On our list: Phil Fogg Jr., Philip Gisi, Joel Theisen, Joe Jedlowski. Also: The Dover Companies, Ohio Living.
Two smaller movements have fewer operators behind them so far. Small-house models put 8 to 16 residents in a home with its own kitchen and a steady team; Otterbein SeniorLife in Ohio is one of the largest providers. Otterbein Dementia villages on the Dutch Hogeweyk model are only now reaching the US: Agrace in Wisconsin announced a $40 million village of eight homes in February 2026. Agrace
The innovators
Sixteen leaders on our list are rebuilding how their firms deliver care
Sixteen senior care leaders are among The Originals. Each runs a firm they control, and each has made a dated, costly change to how the work is done. We have grouped them by the change they made. Names link to their card on the list, and each profile ends with one question that invites them to talk about the work. The highest scorers are Greg Roderick (7.9), Lynne Katzmann (7.8), Jesse Marinko (7.2), and Dwayne Clark and Tim Fields (7.1 each).
19 of these 21 dated moves came in 2020 or later
So what: Most of these leaders changed how their firms work during or after the pandemic, when staffing broke and occupancy fell. The changes are recent enough that results are still coming in, so asking what has worked and what hasn't is a natural way to open a conversation.
Getting paid for keeping residents healthyRedesigning the frontline jobRunning on their own data and AI
Each dot is one costly change to how the work is done. Click a dot for a short summary and a link to the story.Show as a table
Founder and CEO, Juniper Communities · Bloomfield, New Jersey; 28 communities in five states, owns all but six; founded 1988
Lynne turned a senior living operator into a co-owner of a Medicare Advantage plan. She started the Perennial Consortium in 2019, and in 2021 Juniper led the formation of the Perennial Advantage plan with other operators. The member operators are now paid for keeping residents well rather than only for rent and care levels. Juniper also runs its own home health and physician practice and is building its own software, Juniper Connect.
“They are strongly mission-driven and committed, as the rest of our members are, to an operator-owned plan that can set the standard for benefits and reimbursement between payers and senior living providers,” source
Ask aboutWhat an operator-owned plan has taught her about which residents cost the most, and what that has changed in how her buildings run.
Founder and CEO, Lifespark · St. Louis Park, Minnesota; about 50 communities plus home health, a geriatric medical practice, and hospice; founded 2004
Joel turned a home-based care company into a senior living operator paid for outcomes. Lifespark took full financial risk for Medicare Advantage members, built its own medical practice and hospice, and bought a 40-community assisted living operator in 2021 as a learning lab for that model. In January 2026 it put every service line under one model it calls Complete Senior Living and set a plan to nearly double its footprint by 2027.
“I believe we all need to think carefully about how to monetize and bring together all the assets around a person into one vehicle,” source
Ask aboutWhat broke first when assisted living buildings were run as part of a health risk model, and what he would tell an operator starting now.
Founder, President, and CEO, Marquis Companies · Milwaukie, Oregon; family-run skilled nursing, assisted living, home health, and home care, 22 campuses in three states; founded 1989
Phil turned a nursing home operator into a population health company. Over a decade Marquis added employed physicians and nurse practitioners, its own long-term care pharmacy, and its own Medicare Advantage special needs plan (AgeRight Advantage), so the firm takes risk on its residents' care instead of selling beds and services one by one.
“We're managing that population and anything that enables us to do that and achieve the triple-aim goal of creating efficiencies, better customer experience and satisfaction, and better quality outcomes, we're going to probably try to own it ourselves and do it ourselves.” source
Ask aboutWhich of the things Marquis chose to own outright paid off, and which he would hand back to a partner.
CEO, Bickford Senior Living · Olathe, Kansas; family-owned, about 60 assisted living and memory care communities in nine Midwest states
Andy is moving his family's assisted living chain from fee-for-service housing to a value-based senior health model. He co-founded Serviam Care Network and made Bickford its test bed for the HigherPath care model across 60 communities in 2022 and 2023. Bickford later joined an alliance with Curana Health, a company that puts doctors inside senior living buildings.
Ask aboutWhat the HigherPath model changed for a frontline caregiver on an ordinary shift, and how a family company decided to bet on it.
Founder, Owner, and CEO, Edgewood Healthcare · Grand Forks, North Dakota; about 63 communities in seven states; founded 1992
Philip is turning an assisted living chain from housing with meals and activities into a care platform. Edgewood built its own home health, therapy, and hospice division (CaringEdge, from 2017), put clinical services inside its buildings, attached a medical office to a community with a local health system, and launched a care coordination network in January 2020.
“Most assisted living facilities across the country provide meals and activities and things like that. What we've done is we've started implementing health care services right in the building.” source
Ask aboutHow care inside the building changed hospital trips and move-outs, and what it did to the kind of staff he hires.
CEO and Co-founder, Morning Pointe Senior Living · Chattanooga, Tennessee; family-owned, 40+ assisted living and memory care communities in five Southeastern states; co-founded 1996
Franklin moved control of the schedule from the director of nursing to the frontline care team. Teams now run their own scheduling, call-offs, and paid time off, and they earn above-market bonuses for filling their hours. After staffing problems the company also built new training programs and an in-house university.
Ask aboutWhat happened to call-offs and agency use once care teams owned the schedule, and what managers had to give up.
Founder and CEO (executive chairman from Q2 2027), Aegis Living · Bellevue, Washington; 37 assisted living and memory care communities in three states; founded 1997
Dwayne rebuilt the labor model around companies Aegis owns: an in-house staffing agency, Kalon Care, run as a separate company, which Aegis says had cut outside agency spending by 80% by 2023, and a development consulting affiliate in 2022. He hires general managers from hotels and retail rather than from rival operators; about half come from hospitality. He hands the CEO role to his president in the second quarter of 2027 and stays on as executive chairman.
“The [staffing] philosophy that we've used for years and years and years is going out the window,” source
Ask aboutWhat he wants to lock in about how Aegis works before the 2027 handover, and what running his own staffing agency taught him.
CEO and Co-founder, The Northbridge Companies · Burlington, Massachusetts; assisted living and memory care in Massachusetts, Maine, and New Hampshire, plus an affordable model in Washington DC; co-founded 2004
Jim re-engineered how care hours are staffed and measured: a proprietary tool that tracks caregiver hours to cut burnout, and a training ladder that Northbridge says has produced 135 promotions into licensed roles. Northbridge also built a Medicaid-waiver affordable assisted living community in Washington DC and is taking the model to new markets.
“it's been surprising to see how simple it is to remove roadblocks by contributing $500 for books and paying a fee for CNA training.” source
Ask aboutWhether the affordable DC model can work without public money, and what the caregiver-hours data showed that surprised him.
Chairman and CEO, Leisure Care · Seattle, Washington; privately held, about 4,100 US employees; he bought the company in 2003
Dan runs senior living as a hospitality business. In 2008 he pulled travel and other services into owned companies, and since the pandemic he has rebuilt programming around residents leaving the building and cut agency staff from almost a third of the workforce to near zero through in-house training, he says.
“I think we can get in the habit of managing what we have as leaders versus leading change and looking into the future.” source
Ask aboutHow he took agency labor to near zero, and what the next generation of residents is asking for that the industry isn't ready for.
Founder and CEO, Belmont Village Senior Living · Houston, Texas; privately held, about 30 communities, about 4,100 US employees; founded 1997
Patricia moved inside the building some care that used to mean a trip out of it. Her own nurses run urgent-care telemedicine with geriatric emergency physicians, rolled out to about half the communities after a pilot she ran, and an internal think tank led by a senior executive works on how caregivers are recruited and trained.
“Just as we dedicated a think tank led by one of our top executives to deal with vaccinations, deal with the pandemic, we're doing it today for workforce development,” source
Ask aboutWhat the telemedicine program did to emergency room trips, and what her workforce think tank has changed since 2021.
Founder and CEO, Frontier Senior Living · Dallas, Texas; 25 open communities as of July 2026, down from more than 120; about 1,500 people
Greg rebuilt Frontier after owners moved most of its management contracts away. He wrote one staffing and care model to Oregon's assisted living rules, which he calls the strictest in the country, so every community staffs, measures, and prices care by minutes the same way in any state. He renegotiated every vendor price and added more training for staff. Now he's targeting 5 to 10 new developments and 5 to 10 new management contracts over the next 12 to 16 months.
“We have one model that meets all states at a far higher level than anyone expected,” source
Ask aboutWhat pricing care by the minute has shown him about which residents the old rates undercharged, and whether the Oregon-standard model holds up as he signs new contracts.
Founder and CEO, Phoenix Senior Living · Roswell, Georgia; 55 assisted living and memory care communities in 10 states, 2,812 associates at the end of 2025; founded 2014
Jesse dropped the standard regional structure of separate sales, clinical, and operations leaders and runs each community like a small business, with regional directors supporting five to seven properties, in-house business intelligence, and a larger clinical quality team. In 2026 Phoenix added radar-based fall detection that works without cameras or wearables, and an AI concierge as the first contact for families.
Ask aboutWhat a community leader can now decide alone that they couldn't before, and what the fall detection data has changed in care plans.
Founding Principal and CEO, Anthem Memory Care · Lake Oswego, Oregon; memory care only, about 20 communities in nine states, 1,200+ employees; founded 2007
Isaac built Anthem to develop memory care buildings, then took over running them itself, hiring a chief operating officer in 2013 to build an operations division from scratch, because he wanted control of how dementia care is delivered. In 2025 and 2026 he put AI tools into sales calls, monthly financial review, and executive work across his leadership team.
Ask aboutHow memory care differs from assisted living as a business, and where AI has given his community leaders time back.
Founder, Chairman, and CEO, Distinctive Healthcare / Distinctive Living · Freehold, New Jersey; about 2,500 employees, 46 communities in 2025; closed the purchase of another operator, Validus Senior Living Management, in April 2024; founded 2021
Joe set up a four-person in-house analytics team that re-tiered and re-priced levels of care to match what residents need, and built owned on-site home health so residents can stay in place as their needs rise.
Ask aboutWhat the analytics team found about how care was being priced, and how residents and families took the change.
CEO and Co-founder, Ignite Medical Resorts · short-term rehab and skilled nursing, about 30 locations, about 3,500 staff
Tim replaced building-by-building admissions with central intake, referral, and case management across 32 facilities, which Ignite says saved about $900,000 a year and cut referral response time by 80%. Ignite also builds new high-end skilled nursing buildings from the ground up, which most of the industry has stopped doing, and opened two more in 2025.
“By centralizing our admissions and case management departments, we were able to realize approximately $900,000 in annual savings.” source
Ask aboutWhy build new skilled nursing buildings when most operators won't, and what the in-house AI work is aimed at first.
Founder and CEO, Arrow Senior Living Management · St. Charles, Missouri; manages 44 communities in seven Midwestern states (April 2025); about 1,900 people
Stephanie is changing how frontline caregivers get through their day. A 2023 company hackathon produced The Archer, an in-house app where employees communicate, swap shifts, and share care information, and in 2025 she split leadership roles to bring new ideas to the communities. Arrow says one integrated assessment process saves 15 hours of caregiver time a month.
“It's pretty important to improve how we work, and that's going to be important to future-proofing the product that we're offering residents,” source
Ask aboutWhat The Archer has changed in how a caregiver's shift runs, and how Arrow measures whether it's working.
Ten leaders outside the list are making similar changes
These leaders aren't on the list. Most run nonprofits or family firms, and each has made a change worth asking about.
Jon Fletcher
President and CEO, Presbyterian Homes and Services · St. Paul, Minnesota; nonprofit; nearly 8,000 team members, 61 communities; CEO since February 2025
Jon leads a plan to make 60% of the organization's homes affordable to middle-income residents, and co-owns Genevive, a geriatric primary care practice, which runs Medicare Advantage plans for residents with the health insurers Medica and UCare.
“Change that lasts comes from alignment, not just ambition.” source
Ask aboutHow a nonprofit of 8,000 people decides what to change first, and how the middle-income target is going.
Tom Grape
Founder, Chairman, and CEO, Benchmark Senior Living · Waltham, Massachusetts; privately held; more than 7,200 associates, almost 70 communities
Tom replaced Benchmark's care records, HR, and sales systems in 2024, calling it foundational infrastructure, and began testing value-based care with Curana Health and Serviam at its Alexandria, Virginia community.
“We have to realign our organization to embrace value-based care, to understand what value-based care is” source
Ask aboutWhat replacing every core system at once taught him, and how far he plans to take value-based care.
Jill Wilson
President and CEO, Otterbein SeniorLife · Lebanon, Ohio; nonprofit; about 1,900 employees
Jill joined the operator-owned Perennial Advantage health plan at nine sites in January 2023, and runs neighborhoods of small homes for 12 residents each with no institutional schedules.
“We are excited to collaborate with an organization that shares our longstanding commitment to a values-based care model” source
Ask aboutWhat small homes do to staffing and turnover compared with a traditional building.
Larry Gumina
CEO, Ohio Living · Ohio; nonprofit; among the 20 largest nonprofit senior living organizations
Larry co-founded the Perennial Consortium, an operator-owned Medicare Advantage plan that began enrolling in 2020, and added a pharmacy and a medical group as business lines.
“Simply put, we're providing the care at the bedside, so we should be compensated accordingly,” source
Ask aboutWhat six years of owning a health plan have shown about which operators can make it work.
Sean Kelly
CEO, Front Porch Communities and Services · Southern California; nonprofit; about 3,000 employees, 19 senior living and 32 affordable communities; CEO since 2023
Sean brought in the Disney Institute to rebuild staffing and culture from late 2023, created a chief culture officer role, and bought a development firm, Arch Consultants, in 2025 to bring building in house.
Ask aboutWhat a hospitality company taught a nonprofit care organization, and what didn't transfer.
Jesse Jantzen
President and CEO, Lifespace Communities · Iowa; nonprofit; more than 3,600 team members, 16 life plan communities
Jesse put more than $17 million into a pay reset with many double-digit raises in late 2021 after listening sessions with staff, and is now positioning Lifespace to take over other nonprofits.
“A common theme from our listening strategy was the need for a more competitive pay structure, and we responded.” source
Ask aboutWhat he means by the shift from staff shortage to staff capability, and what Lifespace is changing to build it.
Kristin Ferge
President and CFO, Capri Communities · Waukesha, Wisconsin; founded 1992; about 1,200 employees, managing 43 communities BizTimes
Kristin moved care staff to a four-day, 32-hour week at full pay from January 2023 with help from a $907,000 state grant. By 2026, the company says, pay in those communities ran about 20% higher, offset by better retention and less agency and overtime.
“When we look at the number of applicants for a position, the volumes went up tremendously.” source
Ask aboutWhether the four-day week pays for itself without the grant.
Joshua Jennings
CEO, The Dover Companies (Cedarhurst Senior Living) · St. Louis, Missouri; nearly 60 communities
Joshua launched Dover Health, its own home health and hospice company, in March 2024 and then bought a Chicago-area agency. Dover also owns its construction company and a pharmacy.
“We're changing how we communicate and build trust” source
Ask aboutWhich owned service has changed residents' experience most, and which was hardest to run.
Ken Young
President and CEO, United Church Homes · Marion, Ohio; nonprofit; 90+ communities in 15 states; CEO since 2025
Ken is building a middle-market line by unbundling: a $99-a-month care coordination subscription called NaviGuide, and self-serve bistros in place of included dining.
“Create a culture of experimentation, learn from failures and partner with innovators.” source
Ask aboutWhich experiments failed, and what a la carte pricing has taught him about what residents value.
Tim Gary
Founder and CEO, Galerie Living · Atlanta, Georgia; about 650 employees; owner, developer, and operator of five Village Park and Corso communities; founded 2017
Tim built his own operations and health data platform, Fynn, in a separate sister company with a hired tech team. He also put a hotel-style management layer over care, made training mandatory for every worker through Galerie University, and tracked staff workloads to catch burnout early.
“pouring tons of money into building our Fynn platform, which helps reduce the employee turnover rate and create more efficiencies.” source
Ask aboutWhy he built software instead of buying it, and whether Fynn is meant to be sold to other operators.
The wider field
Big owners and vendors shape what founders can do
A few large owners, public operators, and vendors shape what the founders above can do. They own many of the buildings, and they set norms for pay, data, and technology.
Large owners and operators
Welltower The largest owner of senior housing, it now pays some operators in Welltower shares instead of incentive fees and caps their executives' salaries.
Discovery Senior Living Privately held and now the largest operator, with 46,608 units in the 2026 ASHA 50. Its CEO, Rick Hutchinson, chairs ASHA for 2026-27.
Brookdale A public company and for years the largest operator. Its HealthPlus clinical model targeted 150 communities by the end of 2024.
Sonida A public operator that matches staffing to resident needs with its own software. It cut staffing to a record-low 40.4% of revenue in Q2 2026.
Erickson Senior Living Runs its own Medicare Advantage plan with UnitedHealthcare, rated five stars by Medicare six years in a row.
Sunrise Agreed to a majority investment from the investment firm BDT & MSD, with management putting in its own money. The deal is expected to close in 2027.
Companies selling the tools
Curana Health Puts doctors and nurse practitioners inside senior living communities and runs Medicare Advantage plans for residents. It says it works with more than 1,000 communities.
SafelyYou Sells AI video that detects falls in memory care. It raised $43 million in January 2025.
Inspiren Sells room sensors that track the care delivered and what residents need. It raised $35 million in March 2025.
August Health Sells care records software built for assisted living. It raised $29 million in August 2025.
Sage Sells a care platform for senior living and nursing homes. It raised $65 million in March 2026.
How families find a community
Referral services collect up to a month's rent for each family they place
Notable change
Operators are filling more rooms without paying referral fees
Referral services charge communities up to a full month's rent and care for each move-in. Cap Times A few investor-backed owners now control the biggest brands. Sonida says 67% of its July 2025 move-ins came from its own leads, SHN and Brookdale moved money from paid referral services to its own advertising. SHN
So what: An operator that fills its own rooms keeps that fee.
Many families shopping for assisted living start with a referral service. The service is free to the family. The community pays it, only when the family moves in, and the fee can reach a full month's rent and care.
85-100%of the first month's rent and care, a typical referral feesource
$12,000top fee for a single dementia care referralsource
Up to 40%of an operator's monthly leads can come from A Place for Momsource
15,000senior living and home care providers in A Place for Mom's network, 2026source
Three of the five ways families reach a community charge the community a fee
So what: A move-in that arrives through a referral service can cost a community most of a month's rent and care. Ask an operator how many move-ins come from its own marketing: the answer tells you how much of its growth it controls and what each new resident costs.
The community pays the channel a fee when the family moves inNo referral fee
FamilyA family looking for assisted living. Referral services are free to the family.
→
National referral websites and call centersCommunity pays a fee
A Place for Mom; Caring.com (owned by SilverAssist); Seniorly (owned by CareScout, part of the insurer Genworth)
Win families through search, review sites, ads, and now AI answers. An advisor passes each family to several communities or connects them by phone.
A move-in fee, often 85% to 100% of the first month's rent and care. Cap Times
Local advisor franchisesCommunity pays a fee
CarePatrol (230+ territories); Oasis Senior Advisors (130+ locations, owned by SilverAssist); Assisted Living Locators
A local owner meets the family, often tours communities with them, and builds ties with hospitals and doctors who send families.
A move-in fee; the family pays nothing. CarePatrol
Independent placement agentsCommunity pays a fee
Small local agencies, many belonging to the National Placement and Referral Alliance (NPRA)
Work one local market, often taking families that hospitals, doctors, and care managers send them.
Professionals who refer without a feeNo referral fee
Hospital discharge planners, doctors, and Aging Life Care managers (care managers whom families hire)
Recommend communities they trust after a hospital stay or an assessment. Communities earn these through local relationships.
No fee. Unpaid referrals produced 40% of assisted living and memory care move-ins in a 2016 study of 2 million leads. Senior Housing News
The community's own marketingNo referral fee
The operator's website, search ads, phone line, tours, and residents who recommend friends
The family finds the community on its own. Large operators have been moving money here from paid referral services.
Staff and advertising. Sonida says 67% of its July 2025 move-ins came from leads it generated itself. Senior Housing News
→
CommunityThe community the family moves into
Fee level per the Wisconsin Assisted Living Association, quoted in the Cap Times (June 2025). Unpaid-referral share from Enquire Solutions' 2016 benchmark, reported by Senior Housing News.Show as a table
Channel
Examples
Fee from the community?
What the community pays
Source
National referral websites and call centers
A Place for Mom; Caring.com (owned by SilverAssist); Seniorly (owned by CareScout, part of the insurer Genworth)
Yes
A move-in fee, often 85% to 100% of the first month's rent and care
A family fills in a web form or calls. The referral service asks about care needs, budget, and location, then sends the family's details to several communities in its network. A Place for Mom now also connects some families to a community by phone. The community that wins the move-in pays the fee; the others pay nothing. Cap Times Mike Pochowski of the Wisconsin Assisted Living Association puts the fee at 85% to 100% of the first month's rent and care, and says the fee gives referral companies a reason to steer families toward pricier care.
Because each family goes to several communities, most leads don't turn into move-ins for any one of them. A sales vice president at Priority Life Care, an operator, told Senior Housing News in 2023 that the industry closes 4% to 5% of referral agency leads. SHN Families hear from every community that gets their details. Jeff Balleau, who runs a local referral agency in Missouri, says his father got "40 calls in a day" after signing up. Missouri Independent
A few owners now control the biggest referral brands
A Place for Mom Based in New York, it says its network is the largest in the country and had nearly 900 employees in 2024. The investment firms General Atlantic and Silver Lake bought it in 2017, and Insight Partners led a $175 million investment in 2022. CEO Tatyana Zlotsky (profile below) says it has 20 million users.
SilverAssist Bought Caring.com, the second national referral website, in January 2026. It already owned Oasis Senior Advisors, a franchise of local advisors with more than 130 locations, so one company now runs both a national website and local advisors.
CareScout (Genworth) The long-term care insurer Genworth's care unit bought Seniorly in October 2025 for about $15 million. Genworth says Seniorly connects families to more than 3,000 communities.
CarePatrol Says it is the largest senior care advisor franchise, with more than 230 territories in 43 states and Canada and $42 million in system revenue so far in 2026. It belongs to a senior care franchise group backed by the investment firm The Riverside Company.
Assisted Living Locators A Scottsdale, Arizona, franchise of local advisors. Executive Home Care, which Riverside also backs, bought it in 2022.
Operators are building their own marketing to rely less on referral fees
Brookdale moved money to its own channels. Brookdale, then the largest US operator, blamed softer occupancy growth in the third quarter of 2024 on fewer move-ins from two paid referral services, and shifted marketing dollars to its own advertising. CEO Cindy Baier also pointed to Google changes that "deprioritize" referral sites' content. SHN
Sonida says most of its move-ins now come from its own leads. Of its July 2025 move-ins, 67% came from leads it generated itself, which CEO Brandon Ribar says arrive at "no extra cost." SHN
A Place for Mom is changing how it works with operators. Since late 2024 its advisors connect families to communities live instead of passing on a lead, and it hired a former operator CEO as its chief community relations officer. SHN
Referral services now compete to appear in AI answers. A Place for Mom says it now writes for the AI tools families use for research rather than for Google keywords. SHN
Lawmakers are pushing referral services to tell families who pays them
In 2024 a Washington Post analysis found that more than a third of the communities A Place for Mom named "Best of Senior Living" in 28 states had been cited by state inspectors for neglect or substandard care in the previous two years. In June 2024, Senator Bob Casey, then chair of the Senate Special Committee on Aging, wrote to the company. He said it misled families about commissions, didn't make clear that it lists fewer than half of US facilities, and turned away families who rely on Medicaid. He also cited the company's own figure that nearly 40% of families paid about $1,000 a month more than they had budgeted. NBC News
States regulate referral services one by one. Most laws require the service to tell families that the community pays it, and how much.
A disclosure statement at the time of referral and rules on what agencies may not do. It also lets communities pay agencies by the volume or value of their referrals
Disclosure of financial ties. A Place for Mom opposed both and hired seven lobbyists in Missouri
Six leaders run the main referral brands
Tatyana Zlotsky runs the largest service. The five below her run its main rivals: the new owners of Caring.com and Seniorly, and the three largest local advisor franchises.
Tatyana Zlotsky
CEO, A Place for Mom · New York; owned by the investment firms General Atlantic and Silver Lake since 2017; CEO since May 2024
Tatyana joined A Place for Mom as chief marketing officer in 2019 after nine years at American Express. As CEO she has had advisors connect families to communities live instead of handing off leads, hired a former operator CEO to manage community relationships, and in November 2025 moved the company's marketing from Google keywords toward the AI tools families now use for research. Senator Casey's letter about the company's commissions arrived about six weeks after she took over.
“It's no longer about these keyword strategies.” source
Ask aboutHow A Place for Mom shows operators the fee is worth it when families arrive already informed, and what changed after the 2024 Senate letter.
Greg bought the Oasis Senior Advisors franchise in 2023 and Caring.com in January 2026. He pitches the combination to operators as the alternative to lead selling: national web traffic routed to local advisors, with clear rules on which referral gets credit for a move-in.
“SilverAssist aims to address what's fundamentally broken in the senior living referral industry.” source
Ask aboutWhat share of Caring.com's families now reach a local Oasis advisor, and whether operators see more move-ins from those families.
Samir Shah
President and CEO, CareScout (Genworth) · Richmond, Virginia; owned by the public long-term care insurer Genworth; CEO of all of CareScout since May 2026
Samir joined Genworth from J.P. Morgan in 2023 to build CareScout's network of rated home care providers. In October 2025 CareScout bought Seniorly for about $15 million, so Genworth, which pays long-term care insurance claims, now also owns a senior living referral service.
“Families deserve trusted partners when planning for care, whether at home or in senior living communities, and this acquisition deepens our ability to be that partner” source
Ask aboutHow an insurer-owned referral service stays credible to families and to the communities that pay it.
Keith Kuhn
Brand President, CarePatrol · Troy, Michigan; franchise owned by Best Life Brands, backed by The Riverside Company; 230+ territories; president since October 2025
Keith co-founded the business that became CarePatrol in the 1990s, left in 2000, and returned as president in 2025 after more than 35 years in health care leadership. CarePatrol says its franchisees helped more than 10,000 families in 2026 and that system revenue is up 9% on last year.
“The need for trusted senior care guidance continues to grow, but what makes this performance especially meaningful is seeing that demand translate into successful local businesses for our franchisees” source
Ask aboutWhat a CarePatrol advisor checks about a community before placing a family there.
John runs the Oasis franchise and chairs the board of NPRA, the placement agents' trade group. NPRA says its 2025 lobbying won a Texas law that lifted long-standing caps on referral fees, and it now has lobbyists in five states. NPRA
“Through this acquisition, we are expanding our ability to localize digital referrals and connect families with our network of expert local senior advisors” source
Ask aboutWhere he thinks the line should sit on telling families who pays the advisor and how much.
Felicia Sanders
Brand President, Assisted Living Locators · Scottsdale, Arizona; franchise owned by Evive Brands, backed by The Riverside Company; president since December 2024
Felicia took over from the brand's founder, Angela Olea, in December 2024. She came from franchise operations at Woodhouse Spas, Massage Envy, and Mrs. Fields rather than from senior care. Franchising.com
“Our advisors are the superheroes of this brand, showing up every day to guide families through some of life's most important decisions” source
Ask aboutWhat she saw from outside senior care that placement insiders miss.
Trade-offs
Seven trade-offs divide the operators you'll meet
Most leaders on our list have picked a side on several of these. In our reading, asking which side they picked, and why, gets to their strategy faster than asking about trends.
1Investors value the buildings while operators sell care
Welltower, the largest owner of senior housing, now pays some of the operators that run its buildings in Welltower shares and caps their executives' salaries. SHN
Many operators now call the business health care. Fee Stubblefield of The Springs Living: "This is truly a healthcare service." SHN
AskAre you a real estate company that provides care, or a care company that happens to run buildings?
2Full buildings raise prices as the middle market falls behind
Rents for current assisted living residents rose 5.3% in the year to June 2026. NIC
NORC projects that nearly three in four middle-income seniors won't be able to afford assisted living in 2033 without selling their home. NORC
AskWho is your product not for today, and would you change the work to reach them?
3Residents need nursing home care without nursing home funding
In a 2026 survey, 81% of senior living professionals reported rising acuity, and only 12% said staffing was consistently sufficient. SHN
Assisted living is taking on work nursing homes used to do, without nursing home staffing or Medicare payment.
AskWhere's the line where you tell a family their parent needs a nursing home?
4Taking on health risk pays more and can lose more
Operators that own a Medicare Advantage plan or take full risk keep the savings when residents stay out of the hospital, and absorb the losses when they don't.
Partnering is safer, but leaders of National Church Residences say outside medical groups have kept most of the savings. NIC
AskWould you rather own the health risk or share it, and what would change your mind?
5Operators choose between paying referral fees and building their own marketing
Referral services charge up to a full month's rent and care for each family that moves in, and nothing for those who don't. Cap Times
An operator's own marketing saves the fee but costs staff and advertising. Sonida says 67% of its July 2025 move-ins came from its own leads. SHN
AskWhat would it take for you to stop paying referral fees altogether?
6Higher pay cuts turnover and squeezes margin
Pay and benefits already take 56% of operating budgets. Ziegler
A third of assisted living staff leave each year, SHN and replacing them costs money too. Capri Communities pays care staff 40 hours' wages for a 32-hour week. SHN
AskWhich raise or schedule change paid for itself, and which didn't?
7Investor money offers scale at the price of control
Investors are back: senior housing sales topped 230 deals a quarter in the first half of 2026, LevinPro LTC and the investment firm BDT & MSD agreed to take a majority stake in Sunrise. PR Newswire
The leaders on our list still control their firms, so taking outside money would change who decides how the work is done.
AskWhat would an investor have to agree to before you'd take their money?
Before a first conversation
Operators want to talk about staffing and sicker residents before technology
In the 2026 executive forecasts in Senior Housing News, the issues CEOs raised most often were, in rough order: workforce, the gap between demand and new supply, margins and affordability, residents arriving with more needs, a more demanding boomer customer, health care partnerships, capital, AI, and state regulation. SHN forecast, part 2 AI interest is high and use is early: in a 2026 McKnight's survey, 40.5% of operators were beginning to explore it and 8.3% had several systems fully in place. McKnight's
The biggest open argument is about identity. Omar Zahraoui of NIC, the National Investment Center for Seniors Housing and Care: "Senior housing is, after all, both real estate and an operating business." Fee Stubblefield, CEO of The Springs Living: "This is truly a healthcare service." SHN In our reading, most leaders on our list have already picked a side, and asking which one is a good way in.
Seven mistakes mark an outsider
Calling it a nursing home, or calling communities "facilities." Operators describe the nursing home label as a stigma they are still fighting. They say communities, residents, and care teams.
Assuming Medicare pays. It doesn't pay for rent or personal care. Medicaid pays only for care, only through state waiver programs, and only for about one resident in six.
Treating it as only real estate or only health care. It's both, and most leaders on our list have a view on the balance.
Assuming the resident is the only buyer. Adult children help make most move-in decisions, but operators who sell only to the children tend to lose the resident's trust.
Assuming full buildings mean easy money. Rate increases mostly cover rising costs, and margins vary widely by operator.
Assuming A Place for Mom works only for the family. Communities pay it for each move-in, and many operators want to depend on it less.
Opening with AI tools. Residents are wary of AI, and operators judge technology by whether it removes work. The care model is the better opening.
Nine questions get a founder talking about the work
Lifespace's CEO says the issue is no longer a shortage of staff but their capability. Does that match what you see? What does a great caregiver or community director do now that they didn't do five years ago?
Residents are arriving later and sicker. Where did that show up first in your buildings: medication, night shifts, falls? What did you change?
Are you more of a hospitality company, a care company, or a real estate company today, and has that answer changed since you started?
With occupancy near 90% across the industry, where does margin come from for you: price, staff productivity, charging the right level of care, or residents staying longer?
How many of your move-ins come from your own marketing rather than paid referral services, and what does a move-in cost you each way?
If you could take one hour of paperwork off every caregiver's shift, which hour would it be?
What do you know about a resident in the first 90 days that predicts a move-out or a hospital trip, and who sees it in time to act?
Is there a version of your product a middle-income family could afford? What would have to change about the work to make it pay?
Capital is flowing back into the sector. What kind of growth would you turn down?
Where they gather
Six events bring these leaders together before June 2027
The NIC conferences draw owners and investors, and the Argentum conference draws operators. Senior Living 100 is invitation-only and limited to CEOs and senior executives.
Operators get their news from two daily trade sites and NIC's numbers
Senior Housing News and McKnight's Senior Living are where operator CEOs read about their peers, and NIC's occupancy and margin figures are the numbers they quote. Reading a week of both before a first call shows which deals, hires, and staffing fights are on a CEO's mind.
Two pieces to read first
The Margin Test (NIC, September 15, 2026). Buildings are fuller than they have been in years, but assisted living margins only climbed back toward their 2018 level by 2025, and NIC points to staffing costs. Most operator CEOs are working on that margin squeeze.
CTO Hotline, July 2026 (Ziegler and LeadingAge CAST, August 6, 2026). The yearly survey of senior living technology leaders, including how ready they are to put AI to work. The full report needs a free sign-up.
Interviews with senior living operators and the people who sell to them, several a week.
Free
Glossary
Twenty-five terms come up in the first ten minutes
ADLs
Activities of daily living: bathing, dressing, toileting, eating, and moving around. How many a resident needs help with sets the care level and the price.
Acuity
How much care a resident needs. "Acuity creep" means residents arriving with higher needs over time.
Levels of care
Tiered monthly care charges added on top of rent, set by an assessment of each resident.
Census
The number of occupied units or residents. Operators watch it every day.
Move-ins, move-outs
The flow of residents in and out. Residents leave for a hospital or nursing home, or die, which keeps the typical stay near two years.
Lead
A family's contact details passed to a community's sales team. A referral service often sends one lead to several communities.
Referral fee
What a community pays a referral service when a family it sent moves in, often 85% to 100% of the first month's rent and care.
Referral agency or placement agent
A service that matches families with communities. The community pays it, not the family. NPRA, the National Placement and Referral Alliance, is the agents' trade group.
In-place and street rates
In-place is what current residents pay after their annual increase; street (or asking) is the price quoted to new families.
NOI
Net operating income: what a community earns after operating costs and before debt. Owners and REITs judge operators on it.
REIT
Real estate investment trust. Welltower and Ventas are the largest owners of senior housing buildings.
RIDEA
A structure, named for a 2007 law, in which a REIT shares in a community's operating profit and risk and hires an operator to run it, instead of collecting fixed rent.
Triple-net lease
The older alternative to RIDEA: the operator rents the building and pays taxes, insurance, and upkeep.
Operator
The company that runs the community day to day, whether or not it owns the building.
Private pay
Residents paying from income, savings, or a home sale. The main way assisted living is paid for.
Medicaid waiver
A state program (usually called home and community-based services, or HCBS) that pays for care services, never rent, for eligible low-income residents.
Middle market
Seniors with too much money for Medicaid and too little for private-pay assisted living. Also called the forgotten middle.
Memory care
Secured assisted living for people with dementia, with specially trained staff. Some states now license it as its own category.
CCRC or life plan community
A continuing care retirement community: one campus with independent living, assisted living, and nursing, usually under a long-term contract with an entry fee.
I-SNP
Institutional special needs plan: a Medicare Advantage health plan for people who need nursing-home-level care. A few operators now own or co-own one.
Value-based care
Payment tied to keeping people healthy and out of hospital, so a provider shares in the savings instead of billing per service.
Universal worker
A staffing model in which one caregiver handles personal care and household tasks such as meals and laundry for a steady group of residents.
Agency labor
Temporary staff from outside agencies. They cost more than employees, and heavy use signals a staffing gap.
NIC MAP
The data arm of the National Investment Center for Seniors Housing and Care, the standard source for occupancy, rents, and supply.
Argentum, ASHA, LeadingAge
The trade groups: Argentum for assisted living operators, the American Seniors Housing Association (ASHA) for larger owners and operators, and LeadingAge for nonprofits.
Read more
Two pieces explain value-based care deals and the limits of public money
Assisted Living Facilities: Information on Federal Spending and Medicaid Coverage (GAO) The Government Accountability Office (GAO) found at least $12 billion in federal Medicare and Medicaid spending on services in assisted living in 2024, and wide differences in what state Medicaid programs cover. State Medicaid officials and national groups told GAO that coverage limits and limited provider participation restrict access.
