McKnight's Long-Term Care News, March 2019, page 32, Feature 1

In the four Green Houses at Saint Elizabeth Community, the laundry rooms are just down a hall from the main living and dining areas, out of sight but not off-limits to residents and their families.

Equipped with small commercial Speed Queens, they are designed to mimic the feeling of a home laundry, right down to resident-selected detergents and easy controls.

Chief Operating Officer Matt Trimble chose side-by-side 30-pound washers for the Warwick, RI, homes when they were constructed in 2017. A pair of stacked, 45-pound capacity dryers completed each of the operations, which are designed to serve up to 12 residents per household.

“The beauty of it is, we have commercial machines, but they look and feel residential,” he says.

The majority of the laundry is still done by direct care staff because few residents are physically able to do it. But the choice is each resident’s to make, and smaller machines put family members at ease if they want to do a quick load of wash while visiting.

Saint Elizabeth runs four of the nearly 300 Green Houses operating in the U.S. today. As they and other alternative skilled nursing settings gain market share, providers are reconsidering laundry operations to improve back-of-the-house service.

Appropriately outfitting a laundry room with efficient equipment and strategies for safe garment handling is as much about cleanliness as it is about caregiving. Making the right selections depends on a variety of factors, ranging from resident characteristics and population size to capital and machine capacity.

“In some facilities, basic equipment may be the best fit,” says Bill Brooks, UniMac’s North American sales manager. “In others, leveraging a higher level of technology to measure and monitor the laundry can pay dividends. There is no one-size-fits-all methodology. The best advice I can offer is to work with an experienced laundry equipment distributor, someone knowledgeable about the long-term care industry.”

The book on LTC laundry

Trimble wanted hot wash capabilities, but he also wanted to combat long-term care’s notorious laundry issues: lost items and over-processed clothes that come back stained, shrunken or stretched beyond repair.

Pat Armstrong, Ph.D., a professor of sociology and women’s studies at York University in Toronto, literally wrote the book on laundry in long-term care.

“Wash, Wear, and Care: Clothing and Laundry in Long-Term Residential Care,” reflected her  10-year study of care homes in six nations based largely on in-depth site visits.

“The three things we heard about all the time were staffing levels, food, and clothes and laundry,” Armstrong says. “[Clothing] is the last piece of you that you bring into a long-term care home. It’s major in terms of keeping your identity. Laundry is so understudied, but it is so important.”

A high-quality setup can help residents keep track of their clothes, keep them in good shape and inspire confidence in family members. Even in otherwise clean and orderly buildings, lost and worn clothing is a major pet peeve.

Facilities large and small can improve laundry performance and streamline their processes by identifying the best technologies for their particular needs.

Start with how laundry is handled and how much needs to be done at one time.

“To obtain the best productivity and cleanliness, we typically use the rule of one pound of washing, per resident, at a max capacity,” says Michael Zaccaretti, operational excellence manager with Healthcare Services Group. 

Bigger not better?

Though a bigger machine might feel like a better value, it doesn’t always equate to efficient use.

Look for options such as customizable cycles that accommodate specific linen types and allow different fill levels to reduce water use; robust temperature controls and soaking and cool-down times for fabric care; and multiple hook-ups for cleaning agents.

Multiple smaller machines also can provide flexibility in on-premise long-term care. When laundry arrives in dribs and drabs, staff can start one load or designate times for linens versus personal items.

“This ensures all resources are maximized, including labor, as only full loads are processed and staff isn’t waiting around for enough pieces to fill a load in a larger machine,” Brooks says. 

Another way to avoid delays, Zaccaretti says, is choosing a machine with a spin cycle powerful enough to effectively rinse linens and cut down on extra drying time. It’s also important to use the machines as they were designed.

Katie Hurley, lead chemist for Ecolab, says setting an appropriate load goal for every cycle is a good starting point.

“If a machine is underloaded, foam and too much water can prevent sufficient mechanical action,” she says. “The linens won’t rub against each other to help loosen soil, plus water and energy are wasted. If a machine is overloaded, not every linen piece will be thoroughly wetted or exposed to cleaning chemistry.”

A proper load would have about 85% of its capacity in linens. For example, a 65-pound machine should be loaded with 55 pounds of linen, Hurley says.

Technology advances

The pressure is on for technology upgrades: Alliance has invested some $300 million in advances over the last five years.

“Our small and mid-size washer-extractors [45- and 65-pound capacity] cannot only be configured with our UniLinc Control for unparalleled flexibility and machine operation data … but when paired with our TotalVue system, managers gain the pinnacle of data collection and reporting,” Brooks says. “This level of information gives them the insights necessary to gauge the health of their laundry as well as identify areas for improvement.”

Some distributors with knowledge of skilled nursing standards also will perform laundry operating cost analysis that compares current setup and equipment upgrades — and potential investment versus efficiency or labor savings — in facility-specific numbers.

Built-in options like data tracking that report problems to select employees outside the laundry room can help improve practices inside it.

Even in large facilities with a large-scale laundry operation, managers can quickly respond to error codes or track longer-than-expected wash cycles. And the faster they get laundry treated, the more likely it is to get clean.

“You think about the amount of time for laundry staff to come up and take away laundry,” says Deborah Wiegand, director of operations for The Green House Project. “People are sometimes incontinent. And what is one thing that really offends people? Odor. There are so many advantages — perceptions, odors, infection control — that come from smart laundry handling.”

In Sweden, Armstrong encountered two homes with a small washer and dryer unit in each resident’s bathroom. When care workers helped residents dress in the morning, they could toss a basket of wash, separated by color, or on gentle, as needed.

When items aren’t commingled — and if they’re not soiled — there is no need to use harsh chemicals such as bleach.

Armstrong says the practice helped with infection control, and reduced demands on workers who otherwise would have to lift more. Linens, however, could still be taken to larger machines where boiling water and more powerful chemicals go to work.

She witnessed one “posh” facility in Texas that offered a similar split between commingled linens washed by dedicated laundry staff and personal items cleaned nearby by care staff.

While that approach is uncommon in the U.S., Green House models come close to it.

Divide and conquer

A former administrator at a 300-bed skilled nursing facility, Wiegand says she has seen Green House strategies starting to influence laundry practices at traditional facilities.

Sometimes, that just means adding an extra washer and dryer set somewhere on the main floor, rather than requiring every soiled item to head to the basement.

“We work with the regulations to create efficiencies,” Wiegand says. “We also do a lot of education and training, and as the model has grown, we’re sharing a list of appliances and strategies that work.”

Armstrong’s study didn’t examine technical capabilities of washers, instead examining social and labor-related impacts of the routine practices. But she encourages those shopping for long-term care to check out a building’s approach to laundry, its facilities and equipment before committing.

“Laundry tells you a lot about their approach to care,” she says. “The conditions of the worker are often the conditions of care. And we know laundry (is) essential to care.”


When choosing a machine size for your operation, consider how many pounds of linen you expect to go through per day, how frequently the linen arrives in the laundry room, and whether linens from different residents can be combined. Consider the following scenarios:

Example 1: An operation needs to wash 350 pounds of linen each day with linen arriving every few hours, and 75 pounds of that is five residents’ personal items that are designated for isolated washes. With each resident’s personals only 15 pounds, this could most efficiently be run in a homestyle washer, so the operation might choose to have one or two. That leaves 275 pounds of linen throughout the day for commercial machines. Remembering that proper loading is 85% of capacity, it might be wise to use two machines with a 40-pound capacity each. That would allow for eight appropriately sized loads per day, either run in parallel or in series, depending on the rate of incoming soiled linen and the availability of labor.

Example 2: Consider an operation needs to run 700 pounds of linen per day, delivered in the morning, and does not launder personal items. This operation might choose two or three commercial machines at 165 pounds to achieve five appropriately sized loads that cover the increased demand quickly.