Best Skilled Nursing Design 2023: A Tree-Inspired Building Redefines Care With a Small-House Model, More Staff

The Forest at Duke (TFAD), recently introduced a new building at the heart of its campus in Durham, North Carolina​.

The five-story building embraced the small-house model, with 10-bed households forming neighborhoods, each with a unique personality. The staff and caregivers were integrated into this model, fostering a sense of community. Family-style meals became a norm, and even TFAD leadership participated in meal preparation and sharing. The property was built at a cost of $40,000,000 and is spread out over 109,655 square feet.

The metaphor of a tree within a forest guided the design, influencing everything from structure to color palette, Greg Gauthreaux, project designer with Perkins Eastman Architecture Firm told Skilled Nursing News.


“We thought about what makes a tree – the roots of the trunk and the canopy, and we thought of the building in those terms, too,” he said. “So, kind of the base of the building and the way that it interacts with the ground, the way it engages the ground, the way that the building is set into the grade – it’s on a hill.”

The design manifested in a physical space that encouraged connectivity, interaction, and a unique living experience. Residents could move freely around the building, creating a sense of community rarely seen in similar projects, he said.

Positioned at the heart of the campus, the building was intended to create a sense of connectivity and bridge connections to future developments.


The project achieved its vision so effectively that it recently received recognition in the skilled nursing/post-acute category of the 2023 Architecture & Design Awards presented by Senior Housing News, a sister publication of Skilled Nursing News.

The concept

The genesis of The Forest at Duke Small House lies in collaborative planning workshops that involved stakeholders ranging from the CEO to housekeeping staff, Gauthreaux said.

“The Forest at Duke had an existing 90-bed facility that was sort of dated and it was based on this older model of care,” he said. “It was kind of determined that the bones of that [older] building just weren’t going to provide what they needed to provide, the care that they were looking for.”

Gauthreaux said these factors influenced the team to ultimately move to a new building.

“They had already started this kind of culture change that aligns with the small model of care [that is] very resident focused,” he said. “The staff was very energized for this, but they just didn’t have the spaces and the resident rooms weren’t, weren’t sized to allow what they wanted to do.”

The metaphor of the tree was also key in the conceptualization of the facility.

“The trunk being kind of the core of the project where all the resident rooms are, and then the canopy being kind of the more expressive, colorful, where you find flowers and the foliage and things like that, that was where we splashed color,” he said. “The way the windows dance across the facade kind of create this dappled light effect.”

The construction

The duration of construction was approximately 22 months, during which the team navigated challenges like Value Engineering – efforts that focus on keeping a project on budget. Whiting Turner was the construction company. Gauthreaux said adjustments, including changes to roof forms and material, were made to ensure that critical aspects, like ceiling lifts and finishes, were not compromised.

“We did make some changes to sort of value engineer the project to come in on budget that ultimately didn’t have an impact on the resident experience,” he said. “These were things like changing some of the roof forms to be a little bit more efficient or dialing in the extent of some of the materials to save some money so that we could maintain things like ceiling lifts in the resident units, and all of the finishes that made their experience memorable.”

Yet Gauthreaux said the team purposely tried to avoid making an impact on the interior of the building.

“There were some procurement things that were a little bit challenging just with the climate that we’re in. So things like generator procurement and material procurement, things going out of stock. So, we had to make some adjustments based on things sort of not being made more common with carpet and textiles and things like that.”

There weren’t a lot of changes that occurred during the construction process, Gauthreaux said, which he credits the leadership at The Forest at Duke for taking time to go over every nook and cranny of the building.

“We took a 3D model and walked through step-by-step how a nurse helped transition a resident from the bed to the toilet to the shower to the sink and we walked through every little thing,” he said. Can you reach the towel, right? Can you reach this switch? And we moved things around through that exercise to make sure it was dialed in.”

The completion

Gauthreaux said the industry is trending towards smaller house designs. The project’s success lies in its embrace of a tighter structure with only 10 beds per household, fostering an intimate and interactive environment, he said.

“The staffing ratio is [such that] you have far more nursing to resident ratio than you would at other facilities and they cook everything in the household,” he said. “So, there isn’t a main kitchen that is carried over. They cook breakfast, lunch and dinner within the house in all nine households, which a lot of communities struggle with.”

Gauthreaux said Anita Holt, CEO of The Forest at Duke, did not “skip a beat” during the process of transitioning residents to the new building.

“She was even in there, scrambling eggs and cooking lunch for these residents,” he said. “So, the staff really took it upon themselves to make this project successful. And they weren’t willing to drop the ball. They did absolutely everything that they could to make sure that this was a successful transition.”