Project Summary Injuries are a leading cause of emergency department visits among older adults. Individuals with Alzheimer's disease and related dementias (ADRD) are at particular risk of injuries, primarily due to falls. Lower levels of direct care staffing are related to injuries in nursing homes. Currently, nothing is known regarding the relationship between direct care staffing levels and injury-related emergency department (ED) use in assisted living (AL) communities. Approximately 40% of the 800,000 individuals in AL communities have ADRD. Although AL communities provide housing, personal care, at least two meals a day, and oversight 24 hours a day, they are not required to provide round-the-clock nursing services. Also unlike nursing homes, AL communities are regulated at the state level rather than the federal level. As a result, direct care staffing levels and policies are variable among and within states. The goal of the proposed project is to examine whether direct care staffing levels and policies are associated with injury-related ED use among AL residents with ADRD. For the first aim, we will examine whether AL direct care staffing levels are associated with injury- related ED visits among AL residents with ADRD. Specifically, using 2007 to 2019 of Ohio's Biennial Survey of Long-Term Care Facilities linked to Medicare claims, we will examine the relationship between changes in direct care staffing levels and injury-related ED use among AL residents with ADRD in the state of Ohio. For the second aim, using a database of state staffing regulations, we will examine how states' changes in policies related to minimum direct care staffing levels affect injury-related ED use among Medicare-enrolled AL residents with ADRD between 2007 and 2019.The project is expected to improve the delivery of care to the residents who live in AL communities with ADRD. States and AL communities can use the information gained from this study to inform policies and practices related to direct care staffing levels.