Help me choose: Structural Systems in Skilled Nursing

This article was originally posted at as part of their Experts blog round-up.


For a few months I have been working on a CCRC project that involves, among other things, replacing a skilled nursing wing with a state-of-the-art health center. The client, who successfully operates several private-pay communities around the country, has a strong development department, has hired a highly respected national architect, and purposefully advances this project with some very clear goals and objectives. But we recently had a conversation that seemed both simple and late given the state of the project. The broader team engaged had some fundamentally different views of how to build the core structure of the building.

By the time a project is nearing the permit and groundbreaking as this one is, typical conversations are about budget tweaks, selecting finish materials, picking out FF&E, finalizing a construction and move-in schedule, and closing on financing. To have a debate about something as basic as the structure (usually one of the first major decisions) made me think this basic, core design choice might not be as easy as I think. All sides had great points that led to entirely different conclusions, and each conclusion had major ramifications on the design, construction, and operations of the building. Here are some guidelines we use to help make the decision.

Building codes

Almost universally, skilled nursing carries an Occupancy Classification of I-2 (Institutional grade 2). This class of buildings applies to any building of more than five residents which need help responding to an emergency, and, therefore, have some level of care 24 hours a day. The I-2 designation carries many implications but for structural design, the primary one is that the elements of the building that bear the load (hold it up in the air) must be “noncombustible." That is to say that they would withstand a fire. Exceptions exist in some states for single-story I-2 less than 9,500 square feet, but generally speaking you cannot build skilled nursing out of wood, nor from unprotected steel. This leaves viable options as protected steel, masonry, concrete, and load-bearing steel-stud.


Certainly the economics of a project are significant. As much as people, none more than I, like to focus on resident comfort, staff efficiency, and marketability, we have to deal with the reality of budgets. Speaking broadly, costs of structural systems are, in increasing order: wood, steel stud, masonry, steel, and concrete. Regional practices, discussed later, can move choices around by a slot, but this order holds true most often. Each particular system has ramifications on the cost of associated systems (for example, a steel structure will require a ceiling to be installed below it but a concrete frame could theoretically be textured and painted on the underside of the structure itself) so working through the other cost ramifications are important.

Future flexibility

I find many owners of skilled nursing communities have a hard time grappling with this topic. Skilled nursing is so purpose-built that thinking abstractly about future changes to the building seems unnecessary. But at the increasing pace of change, we advise our clients to think about how a SN space might be repurposed. The farther afield from skilled nursing they see the options, the more weight I put on flexibility of the structure. Some structural systems are essentially impossible to move or reconfigure whereas others are relatively easy. Steed stud and masonry walls usually support the floor(s) above at specifically locating bearing conditions that run the length of those walls. This means those walls are very difficult to move if a space needs to be opened up. By comparison, concrete and structural steel use point-loaded columns that, while not easy to move, are perhaps 24-inches square and have no affect on the walls that surround them.

Open space

Given a preference, having some larger, more generous open spaces would be desirable in almost any type of building, skilled nursing included. A dining room or activity room with a little “elbow room” is a clear positive. But the skilled population probably appreciates that openness less than other senior populations. Anecdotally, we've seen heavy dementia populations generally prefer to gather in more intimate rooms actually. But if you have needs that call for open rooms of 30' or more, structural steel or concrete are better choices than masonry or steel studs.


Planning the myriad tasks associated with a healthcare project is complicated and varies widely by the specifics of a given building. But there are general concepts that hold true. One of those concepts is that the critical path (the linked activities that determine the overall duration) always runs through the structure. This means that every day you can take out of the structure schedule is a day off the overall project. The intricacies of each system are too long to explain here but know that wood, steel stud, and concrete will usually take longer (in a skilled nursing building) than masonry or steel. And field-erected masonry walls with an off-site precast concrete floor assembly will usually be the quickest way to get a structure in the air.

Regional practice

The more development teams work together and the more those teams move around the country or a region, the more the team should spend time considering what the subcontractor market in the project location does most commonly. Even if the team identifies, for example, steel studs as the best choice, if there are only one or two firms in the market that do that type of work then the project runs the risk of low manpower or higher cost.

Other implications like how to support the HVAC distribution, LEED, sound transmission, building height restrictions, energy codes, and commodity prices should be considered as well. Admittedly this is complicated. But a good design team with input from the construction market can work through these variables.