Provider Battles for Skilled Nursing Innovations in New High-Rise

With skilled nursing besieged from all sides, there is a pressing need for fresh designs and improved services. Recognizing this, a non-profit provider in Wisconsin has gone to great lengths to bring an innovative offering to the Milwaukee market, highlighting that it’s possible — but often difficult — to push the envelope in skilled nursing.

Less than a decade ago, Saint John’s on the Lake constructed a 21-story tower on its urban campus just north of downtown Milwaukee. Now, the continuing care retirement community (CCRC) is planning to build another tower, at 22 stories, to meet increased consumer demand and to update its health care offering.

Its skilled nursing wing dates back to 1979, and despite renovations over the years, the space still had too much of an institutional feel, Saint John’s on the Lake president and CEO Renee Anderson told Skilled Nursing News. After the new tower is built, the aging three-story health care wing will be torn down.


The design of the new addition will have an upscale residential feel, with some notable innovations in the 50 skilled nursing units. By working with an environmental gerontologist, the design team — including architecture firms Eppstein Uhen and Blitch Knevel — created a novel bathroom layout.

“We’ve designed a trapezoidal shower, with controls in a different place, without a fixed bench, that enables a resident — whether they’re independent, or sit or stand or need some assistance or full assistance — to function in that space safely, and shift to a dignified experience instead of one in which not only is the resident wet, but the caregiver is wet and the room is wet,” Anderson said.

The toilet also has been positioned in a new way to facilitate transfers.


Getting approval for the new bathroom layout was challenging. After the Wisconsin Department of Health rejected six variances that Saint John’s filed, the CCRC went to the Department of Safety and Professional Services, which is the ultimate arbiter of the building code.

“We were granted a hearing, and we provided copious documentation, numerous videos. We built a full-scale mockup of the bathroom in our garage so that the inspectors could come and see it and touch it and ask questions and watch a resident work in the space, so that they would understand it, and ultimately we prevailed,” Anderson said.

While happy to now move forward, Anderson did learn some frustrating lessons along the way. In particular, she points to the fact that Saint John’s had to jump through hoops — including having a paraplegic individual spend two hours in the mock-up, demonstrating how the set-up would work for him — to prove that the bathroom would be compliant with the Americans with Disabilities Act (ADA). Saint John’s on the Lake must be ADA-compliant, even though the law was originally designed with the needs of young Vietnam War veterans with disabilities in mind.

“[Someone] young, able, strong — [such as] a paraplegic with upper body strength,” she said. “That’s not the population we serve.”

In addition to having re-designed bathrooms, the new SNF rooms will no longer open onto a long corridor but onto common spaces.

“Our vision is to create a model that both enables memory and supports mobility, so that when residents walk out of their room, they see things that are happening and within a reasonable distance, so that they are willing and able and motivated to walk and participate,” Anderson said.

Ongoing improvements a must

Overall, the new tower is slated to include the skilled nursing residences, 24 units designated for assisted living under Wisconsin’s community-based residential facility (CBRF) license, 16 “catered living” apartments similar to assisted living, and 79 independent living apartments that will be licensed so that staff can provide services as needed to support aging in place. Construction is set to begin this spring, with a spring 2020 opening anticipated.

Saint John’s on the Lake is working with Piper Jaffray to finance the project, which has a budget of about $120 million. It will be financed largely through tax-exempt bonds, as well as a short-term bank loan to be paid off by resident entrance fees. The average entrance fee for the proposed expansion is around $660,000 with a monthly fee of $4,437, compared to an entrance fee of about $431,000 and monthly fee of about $3,500 for existing units. About 91% of the units in the new tower are already on deposit and under contract, Anderson said.

The community is riding some of the economic tailwinds that the CCRC sector as a whole is enjoying at the moment, and that is helping make the new addition possible, she said.

However, she also pointed to the community’s long-standing financial management strategies. It’s a topic she’s well-versed in, having been Saint John’s director of finance for 11 years prior to stepping into her current role six years ago. Fitch Ratings gives Saint John’s on the Lake a BBB+ rating.

The steady improvements in the campus are also part of Saint John’s approach of strategically investing in physical plant updates.

“If an organization feels strapped or struggling, [physical plant improvement] often goes by the wayside, but I think it’s the last thing that should go, because it will impact your occupancy, and revenue slide is a lot harder to turn around than getting expenses under control,” she said.

Written by Tim Mullaney

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