Characteristics and Geographic Variability of US-Assisted Living Communities Affiliated With Top-10 Chains

To examine the geographic distribution and organizational characteristics of assisted living (AL) communities affiliated with the 10 largest chains (top-10 chains).

Cross-sectional analysis of secondary data.

A total of 14,735 AL communities operating in 2023 with ≥25 beds across the United States (excluding Alaska, Hawaii, Connecticut, and Washington DC). Data were drawn from a national directory of AL communities, the American Community Survey, the University of Wisconsin and United States Department of Agriculture sources, and Medicare enrollment records.

State-level maps depicted the percentage of AL beds affiliated with top-10 chains. Rates of top-10 chain-affiliated AL beds per 100,000 adults aged ≥65 years were compared with other ≥25-bed AL communities using stacked bar charts. Organizational and market characteristics between top-10 chain-affiliated and other ≥25-bed AL communities were compared using t tests and χ² tests.

Of the 14,735 investment-grade AL communities identified nationally, 14.8% were affiliated with top-10 chains, representing 16.8% of AL beds. The share of top-10 chain-affiliated beds ranged from 2% in North Dakota to 33% in Delaware. Compared with ≥25-bed AL communities, top-10 chain-affiliated communities were more often located in socioeconomically advantaged areas (Area Deprivation Index: 45.3 vs 51.4, P < .001) and urban settings (84.7% vs 72.2%, P < .001). They served a lower proportion of dually eligible Medicare-Medicaid beneficiaries (13.7% vs 28.4%, P < .001) and a higher proportion of residents aged ≥85 years (62.2% vs 55.5%, P < .001).

Top-10 chains appear likely to be located in densely populated, socioeconomically advantaged areas and to serve older, wealthier resident populations than other ≥25-bed AL communities, although exceptions exist. Future research should examine how regulatory and market factors shape these patterns.