The document examines activity engagement among residents in residential care communities using data from the 2010 National Survey of Residential Care Facilities. It finds that compared to residents without cognitive impairment, those with severe impairment are less likely to go on outings or talk with family and friends. Residents with mild to severe cognitive impairment have higher participation in leisure activities if they live in dementia-specific settings compared to other settings. The study aims to describe levels of engagement, examine how resident and facility characteristics relate to engagement, and assess if dementia-specific settings are associated with higher engagement for cognitively impaired residents.

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Activity Engagement in Residential Care Settings:
Findings from the National Survey of Residential
Care Facilities
Manisha Sengupta, Sheryl Zimmerman & Lauren Harris-Kojetin
To cite this article: Manisha Sengupta, Sheryl Zimmerman & Lauren Harris-Kojetin (2019): Activity
Engagement in Residential Care Settings: Findings from the National Survey of Residential Care
Facilities, Journal of Housing For the Elderly, DOI: 10.1080/02763893.2018.1534178
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2. Activity Engagement in Residential Care Settings:
Findings from the National Survey of Residential
Care Facilities
Manisha Senguptaa
, Sheryl Zimmermanb,c
, and Lauren Harris-Kojetina
a
National Center for Health Statistics, Hyattsville, Maryland, USA; b
School of Social Work,
University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; c
Cecil G. Sheps
Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill,
North Carolina, USA
ABSTRACT
Assisted living and similar residential care is an important
source of care for elders, including those with dementia.
Meaningful activities may help residents maintain function,
improve self-esteem, and enhance quality of life. Using data
from the 2010 National Survey of Residential Care Facilities,
this study identifies the extent of resident engagement in dif-
ferent types of activities; examines the extent to which cogni-
tive status, other resident characteristics, and residential care
community characteristics relate to activity engagement; and,
among cognitively impaired residents, assesses whether being
in dementia-specific settings is associated with activity
engagement. Compared with persons without cognitive
impairment, those with severe cognitive impairment are less
likely to go on outings (79% versus 36%) and talk with family
and friends (85% versus 72%). Residents with mild to severe
cognitive impairment have higher participation in leisure activ-
ities than other residents if they live in dementia-specific set-
tings (73% higher) than those who do not.
KEYWORDS
Assisted living; dementia;
long-term care;
cognitive status
Introduction
Among older adults, engagement in activities, particularly social activities,
is associated with lower mortality and slower decline in health, function,
and cognition (Barnes, Mendes de Leon, Wilson, Bienias, & Evans, 2004;
Haslam, Cruwys, & Haslam, 2014; Krueger et al., 2009; Mendes de Leon,
Glass, & Berkman, 2003; Mitchell & Kemp, 2000; Olesen & Berry, 2011;
Seeman et al., 2011; Thomas, 2011). In general, activities help create a sense
of worth and maintain well-being; activities that require participation with
others increase self-esteem and enhance the perception of social integration,
CONTACT Manisha Sengupta msengupta@cdc.gov National Center for Health Statistics, Hyattsville,
MD, USA.
This work was authored as part of the Contributor&s official duties as an Employee of the United States Government and is
therefore a work of the United States Government. In accordance with 17 U.S.C. 105, no copyright protection is available for
such works under U.S. Law.
JOURNAL OF HOUSING FOR THE ELDERLY
https://doi.org/10.1080/02763893.2018.1534178

3. companionship, and support (Knapp, 1977; Coleman & Ahola, 1993;
Netz, Wu, Becker, & Tenenbaum, 2005; Stern & Munn, 2010; Bergland &
Kirkevold, 2005; Horowitz & Vanner, 2010; Eakman, Carlson, & Clark,
2010). Engagement in activities among older adults remains important
throughout life, even as individuals move into assisted living and similar
residential care communities (herein called “residential care communities”
[RCCs]). In fact, the opportunity for social engagement is a presumed
benefit of residence in an RCC, given the settings’ aim to foster the devel-
opment and maintenance of social relationships (Assisted Living Quality
Coalition, 1998; Kuhn, Kasayka, & Lechner, 2002). Activity engagement is
also important for individuals with cognitive impairment—which typifies
many of those who live in a RCC—as recognized by the Alzheimer’s
Association’s recommendation for ongoing engagement and involvement in
meaningful activities (Hyde, Perez, & Forester, 2007). However, few studies
have examined activity engagement in RCCs (Polenick & Flora, 2013).
Therefore, it is not known whether residential care has met its intent to
promote engagement, whether variability exists across degrees of cognitive
impairment, and whether some types of RCCs are more successful in this
regard than others. There is reason to expect, for example, that smaller
RCCs provide fewer opportunities for engagement (Zimmerman et al.,
2003); that RCC residents are more engaged when staff members encourage
activity participation and promote family involvement (Dobbs et al., 2005,
119); that men living in RCCs are disadvantaged in terms of engagement
(Park, Knapp, Shin, & Kinslow, 2009); and that individuals with functional
impairment especially benefit from social engagement within the RCC
(Jang, Park, Dominguez, & Molinari, 2014).
National estimates from the 2010 National Survey of Residential Care
Facilities (NSRCF) indicate that almost 750,000 older adults reside in one
of 31,100 RCCs across the nation (Park-Lee et al., 2011), 42% of whom
have some type of dementia or moderate cognitive impairment (Caffrey
et al., 2012; Zimmerman, Sloane, & Reed, 2014). Participation in activities
is associated with delayed nursing home placement irrespective of cognitive
status (Tighe et al., 2008). Residents with dementia were less likely than
those without dementia to engage in private or individual activities (e.g.,
reading, letter writing) and to have visit and telephone contact
(Zimmerman et al., 2003). Given the benefits of participation in activities
and since there are differences in participation by dementia status, the
NSRCF provides an opportunity to use nationally representative data to
examine activity engagement in RCCs on a broader level, and also in rela-
tion to cognitive status and other resident and community characteristics.
Results from this study will broaden our understanding about whether
there are differences in activity participation by dementia status, and
2 M. SENGUPTA ET AL.

4. whether living in a dementia special care setting is associated with
increased participation among residents with dementia.
This examination can be informed by prior work regarding the measure-
ment of engagement itself. The Epidemiologic Studies of the Elderly
(EPESE) measured engagement among community-dwelling older adults
using frequency of visits to theaters, sporting events, shopping, gardening,
meal preparation, card/game playing, trips, paid/unpaid work, and church
attendance (Mendes de Leon et al., 2003), although not all of these activ-
ities may be relevant for residents in RCCs (e.g., paid/unpaid work may
not be relevant in a residential care setting). Using many of these same
items and also those from the classic Tecumseh Community Health Study
(House, Robbins, & Metzner, 1982), a factor analysis of activities (in which
2,078 RCC residents participated) found meaningful groupings consisting
of private activities (e.g., writing letters, working on a hobby), group activ-
ities (e.g., playing cards/bingo/games, attending religious services), and out-
ings (e.g., going out to drink/eat, shopping/browsing in stores); additional
engagement occurred through visits and telephone contact with family or
friends (Zimmerman et al., 2003). In that study, RCC residents participated
most in private activities, followed by group activities and outings.
Despite what is known about the importance of activity engagement and
well-developed measurement strategies or its variability across resident
characteristics, virtually nothing is known about the national scope of activ-
ity engagement among RCC residents, overall or in relation to cognitive
status and other characteristics. Based on prior work, we hypothesize that
the type and amount of engagement will differ depending on resident cog-
nitive status, and will be higher in larger RCCs and those in which staff
members or volunteers promote engagement. Further, for residents with
dementia, we expect that engagement will be higher if they reside in a
dementia-specific unit or community (Grande, 2003; Phillips et al., 1997;
U.S. Congress, Office of Technology Assessment, 1992; Wood, Harris,
Snider, & Patchel, 2005).
Using data from the 2010 National Survey of Residential Care Facilities,
the first nationally representative study of RCCs, this article (a) describes
engagement in different types of activities, overall and by cognitive status;
(b) examines the extent to which other resident characteristics (e.g., demo-
graphics, health status) relate to engagement; (c) examines the extent to
which RCC characteristics (e.g., size, staffing) relate to engagement, con-
trolling for resident characteristics; and (d) assesses whether being in a
dementia special care unit (DSCU) or a dementia-only RCC is associated
with activity engagement among cognitively impaired residents.
Conceptually, the analyses are based on Donabedian’s classic model of
health care (Donabedian, 1988), which posits that structures of care (e.g.,
JOURNAL OF HOUSING FOR THE ELDERLY 3

5. dementia-specific units) and processes of care (e.g., staff members and/or
volunteers promoting engagement) will determine outcomes of care (in this
case, activity engagement). Findings can inform our understanding of activ-
ity engagement, and have implications for strategies to potentially increase
resident engagement in activities and quality of life in RCCs.
Methods
Sample
Data used in this study are from the 2010 NSRCF. The NSRCF is a prem-
iere national data collection effort by the federal government to gather
extensive information about the characteristics of RCCs (e.g., assisted living
residences, board and care homes, congregate care, enriched housing pro-
grams, homes for the aged, personal care homes, and shared housing estab-
lishments) and individuals living in these settings. To be eligible for
participation, communities had to be licensed, registered, listed, certified,
or otherwise regulated by the state to provide room and board with at least
two meals a day, around-the-clock on-site supervision, and help with per-
sonal care such as bathing and dressing or health-related services such as
medication management; and also to have four or more licensed, certified,
or registered beds. RCCs with no current residents, or licensed exclusively
to serve severely mentally ill or intellectually or developmentally disabled
populations, were excluded. Nursing homes are also excluded unless they
had a unit or wing meeting the preceding definition and residents could be
separately enumerated.
The NSRCF used a stratified two-stage probability sampling design. The
first stage was the selection of RCCs, and the second stage was the selection
of current residents. Of the 3,605 sampled communities, 2,644 were eligible
for participation, and administrators from 2,302 RCCs agreed to partici-
pate. Within these communities, data were collected for 8,094 residents
through in-person interviews with RCC directors or staff (residents were
not interviewed). The first-stage community-level weighted (for differential
probabilities of selection) response rate was 81%, and the second-stage resi-
dent weighted response rate was 99%. For more information on the survey
and sampling design, methodology, and institutional/research ethics
approval, see Moss et al. (Moss, Harris-Kojetin, & Sengupta, 2011).
Measures
Activity engagement (the outcome under study) used items included in pre-
viously established and published measures, including the EPESE studies
and previous RCC studies (Mendes de Leon et al., 2003; Zimmerman et al.,
4 M. SENGUPTA ET AL.

6. 2003). In the NSRCF, respondents (an RCC staff member who knew the
sampled resident best) read from a card showing a list of activities and
reported whether the sampled resident participated in each activity at least
twice a month, regardless of whether or not the activity was arranged by
the staff. The list included nine groups of activities: (a) cards, board games,
bingo, puzzles; (b) arts or crafts, such as sewing, knitting, painting, quilting,
flower arranging; (c) exercise or sports; (d) playing or listening to music,
or singing; (e) spiritual or religious activities; (f) shopping or trips; (g) leav-
ing the community grounds; (h) talking with friends or family; and (i)
going out to the movies, dining out, or out to other social activities.
Although some of these activities could be done alone, engaging in these
activities may provide not only personal meaning and fulfillment, but also
the opportunity for social proximity and socialization.
In order to reduce the number of variables, activity engagement was
operationalized in three separate domains.1
Using the same grouping as
Zimmerman et al. (2003), three activities were grouped as activities outside
the grounds or outings (shopping or trips; leaving the community grounds;
and going out to the movies, dining out, or out to other social activities),
and five activities were classified as leisure activities (cards, board games,
bingo, or puzzles; arts or crafts; exercise or sports; playing or listening to
music or singing; and spiritual or religious activities). Because talking with
friends or family did not have a specific activity component and was differ-
ent from the other activities, it was analyzed as an individual activity. In
these analyses, therefore, engagement was measured using a set of dichot-
omous variables (with “yes” or “no” responses) based on the groupings of
(a) outings, (b) leisure activities, and (c) talking with family and friends, all
occurring at least twice a month. The measures of activity engagement did
not take into account the intensity of activities (e.g., amount of time spent,
level of engagement, level of complexity or challenge), nor did they specify
the exact frequency of the activities other than being done at least twice
a month.
Cognitive impairment was determined based on the nine-item Minimum
Data Set Cognition Scale (MDS-COGS) (Zimmerman et al., 2007;
Hartmaier, Sloane, Guess, & Koch, 1994). Measured on a 10-point scale
with higher scores indicating greater impairment, the MDS-COGS assesses
impairment over the last 7 days in relation to memory (long-term and
short-term), orientation (ability to locate own room, being aware he/she
lived in a RCC, recognizing staff faces or voices, knowing current season),
decision-making ability, ability to make self understood, and needing assist-
ance with dressing. As validated for use in RCCs and used in other RCC
1
Factor analysis was also used as a tool to group the activities, and results confirmed the same groupings.
JOURNAL OF HOUSING FOR THE ELDERLY 5

7. Table 1. Characteristics of residents and characteristics of residential care communities in
which they lived: United States, 2010.
Characteristics
Percent
or mean
Standard
error
Resident characteristics
Cognitive impairmenta
None 28.1 0.8
Mild 29.6 0.7
Moderate 24.1 0.6
Severe 18.2 0.6
Age
<65 years 10.6 0.6
65–74 years 8.5 0.4
75–84 years 27.3 0.7
85 years or older 53.7 0.8
Gender, female 69.6 0.7
Race–ethnicity, non-Hispanic White 94.0 0.4
Medicaid recipient 19.3 0.8
Health status
General health
Excellent or very good 20.7 0.7
Good 37.3 0.8
Fair or poor 42.1 0.8
Depression diagnosis 27.7 0.7
ID/DD, mental health problems, spinal cord/traumatic
brain injury
11.6 0.6
Hearing impairment 14.4 0.5
Vision impairment 16.0 0.6
Fall that caused an injury (last 12 months) 15.1 0.6
Nursing home or rehabilitation admission (last 12 months) 7.3 0.4
Average number of impairments in activities of daily living
(range 0–5)b
1.9 0.0
Residence
Shared a room 25.5 0.8
Resided in DSCU or RCC that only served residents
with dementia
14.1 0.7
Activity participation (regularly participates in these activities at
least twice a month)
Leisure activities 89.0 0.5
Outings 61.3 0.8
Talking with friends or family 82.2 0.7
Community characteristics
Sizec
Small (4–10 beds) 10.5 0.2
Medium (11–25 beds) 9.3 0.2
Large (26–100 beds) 52.5 0.8
Extra-large (>100 beds) 27.8 0.8
For profitc
74.6 1.2
Located in metropolitan statistical areac
82.5 0.9
Percent of residents with short-term memory problemsc
None 13.0 0.8
1–50% 55.5 1.4
More than 50% 31.5 1.3
Percent of Medicaid residentsc
None 60.3 1.3
1–50% 22.8 1.2
More than 50% 16.9 1.0
Staffing
Average aide hours per resident dayd
2.7 0.1
Average number of hours worked by activities director (in
a week)d
27.9 1.0
(continued)
6 M. SENGUPTA ET AL.

8. studies, cognitive impairment was classified as none (score of 0), mild
(score of 1–2), moderate (score of 3–5), or severe (score of 6 and higher)
(Zimmerman et al., 2007, 2014).
Other resident characteristics included characteristics expected to relate to
the ability to be engaged with activities (Jang et al., 2014; Park et al., 2009;
Zimmerman et al., 2003; Zedlewski & Schaner, 2005). These included
demographics; health status (general health; diagnosis of depression, intel-
lectual or developmental disabilities [ID/DD], serious mental health prob-
lems [e.g., schizophrenia], spinal-cord injury, or traumatic brain injury;
hearing or vision problems); history of a fall that caused an injury; nursing
home or rehabilitation admission in the previous 12 months; and residence
(whether resident shared a room/apartment, and for those with cognitive
impairment, whether the resident lived in a DSCU or in a RCC that only
served residents with dementia). Functional impairment was measured as
the total number of limitations (difficulty performing without assistance or
equipment) in five activities of daily living (ADLs): bathing, dressing, trans-
ferring, toileting, and eating.
Characteristics of the RCC may reflect a facility’s capacity to provide
opportunities for and/or encourage activity engagement, consistent with the
Donabedian framework of health care quality. Characteristics of the RCC
under study included descriptive characteristics (size, ownership, location);
resident case mix (percent of residents with short-term memory problems,
receiving Medicaid); staffing (aide hours per resident day, hours worked by
an activities director, volunteer and personal care aide involvement provid-
ing recreational activities); and restrictive admission and discharge policies
related to cognitive impairment (to not admit or to discharge residents
with moderate to severe cognitive impairment). In addition, residence in a
DSCU, measured on an individual basis, constituted another structure of
care under study.
Table 1. Continued.
Characteristics
Percent
or mean
Standard
error
Volunteers provide recreational activitiesc
45.4 1.4
Personal care aides provide recreational activitiesc
74.3 1.3
Policies: Restrictive dementia policiesc,e
57.7 1.4
Note. Source: CDC/NCHS, National Survey of Residential Care Facilities, 2010.
a
Cognitive impairment was determined based on the nine items in the Minimum Data Set Cognition Scale
(MDS-COGS; Zimmerman et al., 2007; Hartmaier et al., 1994).
b
Functional impairment was measured as the total number of limitations (difficulty performing without assist-
ance or equipment) in five activities of daily living (ADLs): bathing, dressing, transferring, toileting, and eating.
c
Variables presented as percent of residents living in residential care communities with each of these
characteristics.
d
Variables presented as average for all residential care communities.
e
Restrictive admission and discharge policies related to cognitive impairment, measured as policies to not admit
or to discharge residents with moderate to severe cognitive impairment.
JOURNAL OF HOUSING FOR THE ELDERLY 7

9. Table 2. Resident participation in activities, by resident and residential care community char-
acteristics: United States, 2010.
Characteristics Leisure activities Outings
Talking with
friends/family
Percent Standard Percent Standard Percent Standard
Resident characteristics error error error
Cognitive impairment
None 88.6 1.0 78.6 1.3 85.2 1.2
Mild 89.5 0.9 65.5 1.3 85.1 1.0
Moderate 89.8 0.9 55.1 1.5 82.2 1.2
Severe 87.4 1.0 35.6 1.7 72.3 1.5
Age
< 65 years 88.6 1.4 78.8 1.8 76.7 1.9
65–74 years 81.9 1.9 64.9 2.3 72.6 2.2
75–84 years 88.4 0.9 61.9 1.4 83.9 1.0
85 years or older 90.4 0.6 56.8 1.1 83.7 0.9
Gender
Male 86.3 0.9 64.2 1.3 78.9 1.1
Female 90.1 0.6 59.9 1.0 83.5 0.8
Race–ethnicity
Hispanic, non-White 88.9 0.5 60.9 0.9 76.5 2.5
Non-Hispanic White 89.3 1.7 66.3 2.5 82.5 0.7
Medicaid recipient
Yes 88.4 1.2 64.8 1.6 77.8 1.4
No 89.1 0.6 60.5 0.9 83.1 0.8
General health
Excellent or very good 93.1 0.8 76.8 1.5 86.8 1.2
Good 90.4 0.8 65.9 1.2 83.9 1.0
Fair or poor 85.5 0.8 49.4 1.2 78.2 1.0
Depression diagnosis
Yes 89.3 0.9 62.1 1.3 83.6 1.0
No 88.8 0.6 60.9 1.0 81.5 0.8
ID/DD, mental health problems,
or spinal-cord/traumatic brain injury
Yes 88.9 1.3 72.7 1.8 74.3 1.9
No 88.9 0.5 59.7 0.9 83.1 0.7
Hearing impairment
Yes 88.3 1.2 57.2 1.9 81.8 1.4
No 89.0 0.6 61.9 0.9 82.1 0.8
Vision impairment
Yes 89.0 1.2 55.7 1.9 81.9 1.6
No 88.9 0.5 62.3 0.9 82.1 0.7
Fall that caused an injury (last 12 months)
Yes 90.8 1.1 58.2 1.9 85.2 1.3
No 88.6 0.5 61.7 0.9 81.5 0.8
Nursing home or rehabilitation
admission (last 12 months)
Yes 89.7 1.7 59.0 2.7 87.0 1.8
No 88.9 0.5 61.4 0.9 81.7 0.7
Number of impairments in
activities of daily living
Mean 2.0 0.0 1.6 0.0 1.9 0.0
Median 2.0 0.0 2.0 0.0 2.0 0.0
Shared a room
Yes 88.2 0.9 61.7 1.5 78.4 1.4
No 89.2 0.6 61.0 0.9 83.4 0.8
Resided in DSCU or RCC that
only served residents with dementia
Yes 92.4 1.1 46.6 2.2 78.4 1.7
No 88.4 0.6 63.6 0.9 82.7 0.8
Community characteristics
Size
Small ( 4 to 10 beds) 85.1 1.2 61.4 1.5 76.8 1.4
(continued)
8 M. SENGUPTA ET AL.

10. Analyses
All analyses were conducted using survey procedures in STATA software
(release 14) that took into account the complex sampling design of the
NSRCF (using design variables and weights). The unit of analysis for all
analyses was the resident, and all residents within a RCC had the same val-
ues for RCC characteristics, such as ownership, average aide hours per resi-
dent day, and average hours worked by activities directors. Univariate
analyses described the characteristics of the resident (including activity
engagement) and RCCs (Table 1). Bivariate analyses using chi squared and
t-tests were conducted to examine the association between activity engage-
ment and resident and RCC characteristics (Table 2). Because activity
engagement was operationalized as three separate domains, each domain
was assessed in a separate analysis. Two sets of multivariate analyses were
performed. The first set of logistic regression models analyzed whether
Table 2. Continued.
Characteristics Leisure activities Outings
Talking with
friends/family
Medium (11–25 beds) 92.3 0.7 64.0 1.4 83.7 1.1
Large (26–100 beds) 90.2 0.7 61.5 1.1 85.0 0.9
Extra-large (>100 beds) 86.9 1.2 59.6 2.0 78.1 1.8
Ownership
For profit 88.5 0.6 60.6 1.0 81.6 0.8
Not for profit 90.2 1.0 63.1 1.7 83.6 1.4
Located in metropolitan statistical area
Yes 88.2 0.6 60.3 0.9 81.8 0.8
No 92.3 0.9 65.5 1.6 83.6 1.5
Percent of residents with short-term
memory problems
None 89.4 1.2 73.6 1.8 82.4 1.8
1–50% 88.5 0.7 62.7 1.1 82.4 1.0
More than 50% 89.5 0.8 53.5 1.5 81.5 1.2
Percent of Medicaid residents
None 88.9 0.6 60.0 1.1 82.7 0.9
1–50% 90.2 1.0 60.2 1.7 83.2 1.4
More than 50% 87.4 1.4 66.7 1.9 78.6 1.7
Average aide hours per resident day
Mean 2.7 0.1 2.6 0.1 2.7 0.1
Median 1.9 0.1 1.9 0.1 1.9 0.1
Average number of hours worked
by activities director (in a week)
Mean 28.5 1.0 27.6 1.2 28.6 1.0
Median 0.0 1.3 10.0 1.5 12.0 1.3
Volunteers provide recreational activities
Yes 90.2 0.7 62.7 1.3 85.3 1.0
No 87.9 0.7 60.0 1.1 79.4 1.0
Personal care aides provide recreational activities
Yes 88.8 0.6 60.9 0.9 82.5 0.8
No 89.4 1.0 62.2 1.8 81.0 1.6
Policies: Restrictive dementia policies
Yes 88.8 0.7 57.7 1.1 79.9 1.0
No 89.1 0.8 66.0 1.2 85.0 1.0
Note. Source: CDC/NCHS, National Survey of Residential Care Facilities, 2010.
JOURNAL OF HOUSING FOR THE ELDERLY 9

11. Table 3. Adjusted odds ratios of engagement in different types of activities, by resident and
residential care community characteristics: United States, 2010.
Characteristics
Leisure activities Outings
Talking with
friends/family
OR CI OR CI OR CI
Resident characteristics
Cognitive impairment (reference: none)
Mild 1.0 0.79–1.36 0.8 0.63–0.93 1.1 0.87 – 1.39
Moderate 1.1 0.77–1.48 0.6 0.47–0.72 0.9 0.72 – 1.23
Severe 0.8 0.56–1.14 0.3 0.25–0.42 0.5 0.39 – 0.71
Age (reference: 65 years)
65–74 years 0.6 0.39–0.88 0.7 0.48–0.91 0.7 0.54 – 1.02
75–84 years 1.0 0.64–1.46 0.7 0.509–0.927 1.4 0.98 – 1.88
85 years or older 1.2 0.78–1.84 0.5 0.40–0.73 1.3 0.94 – 1.88
Female 1.3 1.06–1.58 1.0 0.83–1.09 1.2 1.10 – 1.42
Non-Hispanic White 0.8 0.53–1.10 1.0 0.76–1.30 1.1 0.81 – 1.45
Medicaid recipient 1.0 0.74–1.49 0.9 0.741–1.085 0.8 0.64 – 1.07
General health (reference: excellent
or very good)
Good 0.7 0.50–0.91 0.7 0.57–0.85 0.9 0.67 – 1.09
Fair or poor 0.4 0.29–0.52 0.4 0.37–0.54 0.6 0.51 – 0.82
Depression diagnosis 1.1 0.89–1.35 1.1 0.95–1.26 1.2 1.04 – 1.47
ID/DD, mental health problems,
spinal cord/traumatic brain injury
1.2 0.84–1.73 1.1 0.88–1.46 0.7 0.52 – 0.89
Hearing impairments 0.9 0.66–1.13 1.1 67.000 0.9 0.71 – 1.11
Vision impairments 1.0 0.81–1.35 0.9 0.78–1.10 1.0 0.83 – 1.30
Fall that caused an injury 1.3 0.96–1.72 1.2 1.04–1.49 1.3 1.07 – 1.67
Nursing home or rehabilitation
admission (last 12 months)
1.1 0.77–1.68 1.2 0.92–1.47 1.5 1.07 – 2.00
Number of impairments in
activities of daily living
1.2 1.02–1.43 0.6 0.576–0.725 0.8 0.72 – 0.96
Shared a room 1.0 0.77–1.18 1.0 0.84–1.13 1.1 0.88 – 1.27
Community characteristics
Size (reference: small,4–10 beds)
Medium (11–25 beds) 2.0 1.49–2.65 0.8 0.63–0.94 1.3 1.00 – 1.64
Large (26–100 beds) 1.5 1.11–1.97 0.7 0.56–0.85 1.2 0.93 – 1.57
Extra-large ( 100 beds) 1.1 0.74–1.53 0.6 0.45–0.78 0.7 0.50 – 0.98
For profit 0.9 0.70–1.17 1.1 0.89–1.30 1.1 0.85 – 1.39
Located in metropolitan statistical area 0.7 0.51–0.89 1.0 0.80–1.14 1.0 0.80 – 1.34
Percent of residents with short-term
memory problems (reference: None)
1 – 50% 0.8 0.61–1.16 0.8 0.66–1.05 1.0 0.75 – 1.36
More than 50% 1.0 0.70–1.41 0.8 0.62–1.05 1.1 0.78 – 1.54
Percent of Medicaid residents
(reference: None)
1 – 50% 1.1 0.86–1.46 1.0 0.84–1.20 1.1 0.84 – 1.37
More than 50% 0.9 0.62–1.33 1.1 0.89–1.46 1.1 0.77 – 1.44
Aide hours per resident day 1.1 1.00–1.14 1.0 0.97–1.06 1.1 1.01 – 1.14
Number of hours worked by
activities director (in a week)
1.0 1.00–1.01 1.0 1.00–1.00 1.0 1.00– 1.00
Volunteers provide recreational services 1.2 0.98–1.54 1.2 1.04–1.44 1.4 1.14 – 1.75
Personal care aides provide recreational services 0.8 0.64–1.06 1.0 0.87–1.24 1.1 0.85 – 1.34
Restrictive dementia policies 1.1 0.86–1.36 1.1 0.92–1.29 0.8 0.68 – 1.06
Note. Data adjusted for age, sex, race-ethnicity, health, Medicaid status, selected diagnoses, activity limitations,
hearing and vision problems, falls, nursing home admissions, size of RCC, metropolitan statistical areas status,
organizational characteristics, room sharing, percent of residents using Medicaid and residents with memory
problems, volunteers and personal care aides providing recreational activities, staffing hours, and restrictive
dementia policies. CI ¼95% confidence interval. Source: CDC/NCHS, National Survey of Residential Care
Facilities, 2010.
p .05; p .01; p .001.
10 M. SENGUPTA ET AL.

12. cognitive status, other resident characteristics, and RCC characteristics
related to engagement. Using a hierarchical approach of first examining
only resident characteristics and then adding community characteristics,
adjusted odds ratios and 95% confidence intervals (CIs) were calculated.
Adding community characteristics did not significantly change the odds
ratios, so the final models that included both resident and community
characteristics are presented (Table 3). A second set of logistic regression
models included only residents who had cognitive impairment and exam-
ined the association between engagement and whether a resident was in a
DSCU or an RCC that served only residents with dementia; these models
included all of the variables in the first set of models, as well as a variable
indicating whether the resident was in a DSCU or dementia-only RCC
(results not reported in a table).
Cases with missing data on any of the variables were excluded from the
analytic sample. In this process, the sample was reduced by 3.3%. In total,
7,829 residents were included in the multivariate analyses, resulting in a
weighted sample of 703,821 individuals (weights were used so that the sam-
ple was representative of the national population and took into account the
probability of selection and nonresponse adjustment). Cases with and with-
out missing data did not differ in terms of age, race/ethnicity, and sex, nor
did results from logistic regression models using the analytic sample
derived from each group differ, either in direction or in level of
significance.
Results
Most residents were 85 years of age or older (54%), female (70%), and non-
Hispanic White (94%). About 42% had moderate or severe cognitive
impairment (see Table 1). Over 40% (42%) were in fair or poor health;
about one-quarter had depression (28%); between 12 and 16% had ID/DD,
mental health problems, or spinal-cord/traumatic brain injury; hearing or
vision problems; or a fall that cased an injury in the last 12 months. About
7% of the residents had a nursing home or rehabilitation admission in the
12 months prior to the survey, and they averaged having two ADL limita-
tions. Less than one-fifth used Medicaid to pay for long-term care services
(19%). About a quarter (26%) of the residents shared a room with another
person, and 14% were in a DSCU or a RCC that only served individuals
with dementia. Finally, the vast majority of residents participated in leisure
activities (89%) and talked with friends/family (82%); fewer engaged in
activities outside the RCC (61%).
In term of structures and processes of care, a majority of residents lived
in RCCs that were large or extra-large (80%), for-profit (75%) and in a
JOURNAL OF HOUSING FOR THE ELDERLY 11

13. metropolitan statistical area (83%). About 32% of residents were in RCCs
where more than half of the residents had short-term memory problem. A
majority of residents (60%) were in RCCs that did not have any residents
using Medicaid to pay for long-term care services. In terms of staffing, per-
sonal care aide hours averaged 2.7 hours per resident per day, and an activ-
ities director spent on average 28 hours per week in the RCC. Personal care
aides more often participated in recreational activities (74% of residents
were in RCCs where aides provided recreational activities) than did volun-
teers (45% of residents were in RCCs where volunteers provided recre-
ational services). Finally, 58% of residents were in RCCs that had restrictive
dementia policies related to admission or discharge (did not admit or dis-
charged residents with moderate to severe cognitive impairment).
The vast majority of individuals with severe cognitive impairment
engaged in leisure activities (87%) and talked with family and friends
(72%); however, a minority went on outings (36%) (Table 2). The resident
and community characteristics presented in Table 2 are included in the
adjusted analytic models presented in Table 3, which examines the relation-
ship between resident and community characteristics and activity engage-
ment when controlling for all variables. It displays adjusted odds ratios
from logistic regression models showing the association between participa-
tion in each of the three groups of activities and resident and community
characteristics. Key findings are evident in four key areas.
First, cognitive status was consistently and significantly related to activity
engagement only in relation to participation in outings. Adjusted odds
ratios decreased with increasing cognitive impairment, such that those with
severe impairment had odds 70% less (odds ration [OR] = .3; CI = .25–.42)
than those with no impairment to engage in outings. Similarly, talking with
friends and families was significantly less for residents with severe cognitive
impairment (OR = .5, CI = .39–.71) compared to those without cognitive
impairment. Second, race/ethnicity and socioeconomic status (being a
Medicaid recipient) did not relate to activity engagement, but males were
consistently less likely to participate in activities other than outings.
Third, findings indicated significantly and consistently less engagement
in activities as general health and function (defined by number of ADL
impairments) worsened, with the exception of leisure activities in relation
to ADL function. Residents with more impairments were more likely to
engage in leisure activities. Residents with a history of a fall that caused
injury, who had been in a nursing home or received rehabilitation, and
who had depression were significantly more engaged with friends and fam-
ily and in some other categories. However, those with ID/DD, mental
health problems, and spinal-cord/traumatic brain injury were less
so engaged.
12 M. SENGUPTA ET AL.

14. Fourth, in terms of structures and processes of care measured by com-
munity characteristics, residents in small RCCs were less likely to engage in
leisure activities than residents in medium and large RCCs, and more likely
to engage in outings than residents in larger RCCs. On the other hand,
case mix (memory-impaired and Medicaid) did not relate to activity
engagement. Similarly, no significant relationships were found for aides
being involved in activities or the number of hours worked by an activity
director. However, the number of aide hours per resident day and having
volunteers involved in recreational services did relate to more engagement
with friends and family (and, in terms of volunteers, also outings).
In a separate set of models using the same three activity engagement out-
come variables and controlling for the same resident and community char-
acteristics as in Table 3, analysis was limited to residents with mild to
severe cognitive impairment. It found that the odds of participation in leis-
ure activities were higher among residents who lived in dementia-specific
settings than among those who did not (i.e., 73% higher [OR =1.73; CI
=1.20–2.50], table not shown).
Discussion
Overall, the majority of RCC residents participated in leisure activities
(89%), talked with friends/family (82%), and went on outings (61%). While
only 2% of residents did not participate in any activity, the fact that nearly
20% of residents did not talk with friends/family at least twice a month is
interesting—especially when previous research found that RCC residents
value long-standing relationships and desire even more such connections
(Tompkins, Ihara, Cusick, Park, 2012). However, these data do not indi-
cate whether a resident had family or friends to connect with; living in a
long-term care setting itself may limit how and where a person can interact
with family and friends (Bonifas, Simons, Biel, Kramer, 2014). Compared
with residents who did not talk with family/friends at least twice monthly,
those who did were more likely to be women, more likely to have fewer
functional limitations, and less likely to be in fair or poor health and have
ID/DD, mental health problems, or spinal-cord/traumatic brain injury.
Supporting the importance of structures and processes of care, residents
were 1.4 times more likely to talk with family/friends if they were in RCCs
where volunteers provided recreational services. In addition, almost 40% of
residents do not go on outings, which is notable in that outings are consid-
ered the activity that brings most diversity into standard daily routines—
with one study reporting that RCC residents see them as a means to
“escape the day-to-day sameness” (Park et al., 2009).
JOURNAL OF HOUSING FOR THE ELDERLY 13

15. Not surprisingly, and as found in earlier studies (Schroll, J
onsson, Mor,
Berg, Sherwood, 1997), results suggest that persons with cognitive
impairment were significantly less likely than those without to go on out-
ings and to talk with family and friends. That said, a significant propor-
tion of residents with moderate and severe impairment continued to
engage in leisure activities (87–90%), outings (36–55%), and talk with
friends/families (72–82%). However, these data do not speak to the nature
of that engagement, which in other studies has been found to be quite
passive (Theurer et al., 2015). Consequently, it is important to consider
the true nature of activity engagement, especially for persons with cogni-
tive impairment.
In terms of demographic characteristics, adjusted analyses found no
racial differences in participation in any of the three activity types; this
finding is inconsistent with similar work in nursing homes, in which racial
and ethnic minorities (and by extension, those on Medicaid) (US Census
Bureau, 2013) are broadly less socially engaged than White residents (Li
Cai, 2014). The fact that the RCC sample is largely White (94%) may have
limited the ability to detect significant differences in other areas of activity
engagement, but even trends in that direction do not appear evident.
Because minority representation in RCC tends to be clustered (i.e., African
Americans residents tend to concentrate in predominantly smaller, African
American RCCs; Howard et al., 2002) it may be that these settings are suc-
cessfully offering opportunities for culturally sensitive engagement. On the
other hand, males are significantly less likely to engage in all activities other
than outings—a finding that follows from earlier quantitative work
(Zimmerman et al., 2003) and qualitative work (Park et al., 2009) indicat-
ing that men report a lack of common interests with women, that RCCs do
not provide activities men desire, and that men especially enjoy outings.
These NSRCF findings, along with previous studies, may be useful to
inform programing designed for male residents. “Gender clubs” have been
successful in this regard, and have benefitted both men and women (Gleibs
et al., 2011).
Overall, residents in worse health and with more ADL impairments are
significantly less likely to participate in all activities—the one exception
being that those with more functional impairment are actually more likely
to participate in leisure activities. There is evidence that social engagement
within an RCC is especially beneficial for residents with more functional
limitations (Jang et al., 2014); thus, the finding that they are so engaged is
important. These results may be used to inform programing to engage
more functionally impaired residents, a suggestion supported by other
work indicating that the more activities are offered, the more residents are
engaged (Zimmerman et al., 2003). It would be remiss to not comment on
14 M. SENGUPTA ET AL.

16. the seemingly contradictory finding that residents with a history of a fall
are more engaged; however, fallers tend to be more functionally able
(B€
uchele et al., 2014), so the finding is actually in the expected direction.
Finally, RCC residents who require nursing home or rehabilitative care, or
who are depressed, are more engaged with friends/family; there is ample
literature that family members continue to function as informal caregivers
after their relative moves to a RCC (Cohen et al., 2014; Gaugler Kane,
2007; Port et al., 2005).
In terms of community characteristics, and contrary to our hypothesis,
residents in larger RCCs do not consistently engage in more activities
across the board. That is, no consistent relationship with size is evident in
terms of talking with friends/family, and residents in larger RCCs are
more engaged in leisure activities than residents in 4- to 10-bed RCCs;
they are less engaged in outings (which, as noted earlier, may be more
desired by residents). The size of an RCC is a key and evident structure
of care; because RCCs have become larger over time, this is a notable
finding. Interesting, it has similarly been suggested that residents in
Green House homes (which have fewer than 12 beds), are likely less
socially engaged because effort must be taken to more actively provide
structured activities and promote engagement (Zimmerman
Cohen, 2010).
Also somewhat contrary to our hypothesis is the finding that having per-
sonal care aides provide recreational activities is not generally related to
activity engagement. But supporting our hypothesis is that more aide hours
overall relates to increased engagement with friends and family, as does
having volunteers provide recreational activities, which relates to increased
engagement with friends and family as well as outings. Research in nursing
homes indicates that residents depend on activities to be organized by the
staff and others (Tak, Kedia, Tongumpun, Hong, 2015), and in the case
of RCCs, the role of volunteers may be especially important. Along with
size, staffing is a key variable in the structure–process–outcome
relationship.
Finally, we hypothesized that among residents with cognitive impair-
ment, those living in dementia-specific settings would be more likely to be
engaged than those not in such settings. This is supported by higher
engagement in leisure activities among residents in DSCUs; in this regard,
the structure of and processes inherent in DSCUs are important to note.
Given that it is more challenging to go on outings with residents who are
more cognitively impaired, and that conversation with friends/family is
more challenging, the lack of significant relationships by setting for these
two engagement types is not surprising.
JOURNAL OF HOUSING FOR THE ELDERLY 15

17. The findings reported in this article are based on the first-ever national
survey of RCCs that collected extensive information on RCCs and resi-
dents, and so is able to validate, refute, and extend related work con-
ducted on smaller samples. Nonetheless, some limitations must be
acknowledged. The first is that the data were reported by staff members,
and it cannot be assured that the extent of activity engagement was as
reported. Hence, the distributions may be prone to error. However, unless
there was systematic bias in reporting (which is not anticipated), the asso-
ciations between variables are likely to be robust. Also unknown is
whether the extent of engagement reflects whether or not a given activity
was offered, and the extent to which “engagement” connotes engagement
in the active sense of the word. Nonetheless, there is evidence that passive
engagement, such as listening to music, can benefit even residents with
severe dementia (Eggert et al., 2015; Holmes, Knights, Dean, Hodkinson,
Hopkins, 2006). Further, the frequency or intensity of engagement in
these activities was measured at a gross level—at least twice a month—
which is not intended to convey that such a cutpoint suggests a bench-
mark. For some of the activities (particularly leisure activities and talking
with friends or family), participation twice a month may constitute a low
bar. On the other hand, outings are likely to occur less often than other
activities, so it is helpful to have a standard metric. Whether doing any of
these activities at least twice a month can be considered as engaging is
debatable, but it provides a starting point to examine this topic that has
not been explored before using national data. Also, the article reports on
a host of activities, some of which can be done alone and some which
require participation with others. Although some activities have a social
connotation—for instance, dining out or going to the movies—the data
do not confirm whether an isolated activity is done alone or is socially
engaging. These data do not offer any information about the family and
friends available for interaction. It is possible that placement in a long-
term care setting may limit the possibility of visiting with and talking
with family and friends, who may themselves have limited mobility and
health. Another limitation is the age of the data (the data were collected
in 2010); however, this data set is the only available nationally representa-
tive data with information on activity engagement among residential care
residents living in residential care settings with four or more beds.
Despite the limitations, the national data reported in this article establish
that RCC residents tend to be engaged in activities, including some activ-
ities that may be socially engaging (e.g., group outings), and identify resi-
dent and RCC characteristics (structures and processes of care) associated
with activity engagement.
16 M. SENGUPTA ET AL.

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