South Carolina Nursing Home Blog : South Carolina Nursing Home Lawyer & Attorney : Poliakoff & Associates Law Firm : Elderly Care, Senior Care

ChicoER.com had an article about consumer advocate watchgroups concerned about  Assembly Bill 1629, which changed how nursing homes are paid and provided them with higher payments. The workgroup held a number of meetings. Its efforts were overseen by the state Department of Health Care Services, which was supposed to issue a report to the California Legislature last March.  The workgroup included members representing nursing home owners, the SEIU, the watchdog group California Advocates for Nursing Home Reform (CANHR), senior citizens groups and others.

Requiring more nurses to be on duty in nursing homes is key to improving care.  Nursing homes are required to provide at least 3.2 hours of nurse staffing per patient per day. Some want the minimum raised to 3.5 hours.

Each member of the workgroup produced a list of recommendations for improving care at nursing homes. SEIU and CANHR both recommended raising the minimum nurse staffing level from 3.2 to 3.5 hours.

The union wrote that plans should be made, also, for how to reach the staffing level of 4.1 hours that some experts have recommended.

CANHR recommended that nursing home rate increases should depend on homes' meeting the 3.2-hour minimum.   "We don't think they should be granting any rate increases to homes that don't meet 3.2," said Mike Connors, a CANHR advocate who served on the workgroup.

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Here is a great editorial from the Louisville Courier Journal about the need for nursing home reform and lobbyists' influence.

The real priorities of the General Assembly are on shocking display in the battle over a nursing home reform bill. The measure, House Bill 157, which is intended to set minimum standards for staffing, is similar to laws that exist in 37 states.

But the reform bill's co-sponsor told The Courier-Journal's Laura Ungar that its chances seem dim this session.

Meanwhile, over the past decade the nursing homes' trade group has showered a quarter of a million dollars on Frankfort lawmakers, some of whom are persuaded — surprise — that the reform is unnecessary.

The claim of trade group president Ruby Jo Cummins Lubarsky would be laughable, if it were not so sad. The nursing home bill, she says, is not needed because, “Numbers don't equate to quality. Staffing is very important in a facility, and there is no incentive for a facility to not meet the needs of its residents.”

Ask anyone who has had a friend or relative in a nursing home whether the issue of staffing isn't a major one. Even in the best-run homes, it's not uncommon for aides to be surly, dilatory or lack basic communication skills. And residents, many of whom suffer deep depression, dementia and other conditions, are often incapable of being heard when they complain. The powerful stench of feces and urine often greet the visitor at the door. Residents may lie or sit for hours in wet diapers or on fouled sheets — simply because there is not enough help, or because it's not responsive enough.

Many nursing homes benefit handsomely from Medicare and Medicaid tax dollars. Many are for-profit operations that cut back on staff to pump up the bottom line. Federal regulations are considered inadequate by knowledgeable observers and by all but 13 states.

The elderly in Kentucky deserve better than that. And the legislators holding the bill back should have them on their consciences.
 

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USA Today had a great article on the excessive number of nursing homes that receive taxpayer money but refuse to meet the minimum requirements for quality of care.  The requirements are basic and necessary services, and fundamental safety and food standards. Personal hygiene, responding to call bells, fresh foods, hot water, taking vital signs, etc----basic stuff but because of greed and short-staffing one in five of the nation's 15,700 nursing homes have consistently received poor ratings for overall quality.

More than a quarter-million patients live in homes given another set of low scores within the past year, according to data released today by Medicare, which first released the star ratings of the nation's nursing homes in late 2008. The ratings are derived from inspections, complaint investigations and other data collected mostly in 2008 and 2009.

USA TODAY found that all 50 states and the District of Columbia have homes with poor ratings from one year to the next.  And dozens of those facilities are the only nursing homes for miles.

Late in the Bush administration, the Centers for Medicare & Medicaid Services began assigning nursing homes one to five stars for quality, staffing and health inspections, as well as an overall score. Nearly all homes that repeatedly received few overall stars — one or two stars — were owned by for-profit corporations, the data show.

"The issue is the owners have to take responsibility for the consequences" of poorly performing homes, says Larry Minnix, CEO of American Association of Homes and Services for the Aging.

The newspaper's analysis found the lowest-rated homes had an average of 14 deficiencies per facility, which can include quality-of-life measures and safety violations.

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The Billings Gazette had an article proving that for-profit nursing homes provide less quality care than non-profit nursing homes.  A disproportionate number of Montana nursing homes rated below average by the government are operated by for-profit corporations, an analysis shows.   Almost 60 percent of the state’s skilled-nursing facilities awarded one or two stars by Medicare are for-profit entities, according to information available on the government’s Nursing Home Compare Web site.  For profits tend to cut corners and decrease staffing for profit and bonuses.

Medicare rates nursing homes on a five-star scale using data collected during annual inspections. Facilities are also scored on their staffing levels and how they perform on certain quality measures. Some 26 of Montana’s 90 nursing homes earned one or two stars in the most recent analysis. One star is “much below average” and two stars is “below average,” according to Medicare. 

“I don’t think it means a lot,” said Jerry Smyle, vice president of operations for Lantis Enterprises Inc., which owns 12 for-profit nursing homes in Montana.

Of course, he doesn't.

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I saw this press release from Brown University.  Interesting conclusions based on data.

Hispanic senior citizens are living in nursing homes in ever-increasing numbers, but they face a gap in their quality of care compared to white residents, according to new research from Brown University. 

A team led by Mary Fennell, professor of sociology and community health, found that Hispanic elderly are more likely than whites to live in nursing homes of poor quality. These residences are often faced with structural problems, staffing issues and financial trouble.

Details will be featured in the January 2010 edition of Health Affairs. The research follows up and expands upon a landmark 2007 study, also published in Health Affairs, suggesting that blacks are more likely than whites to live in poor-quality nursing homes. Vincent Mor, chair of the Department of Community Health, was a lead author in that study and is a co-author in the new work looking at nursing home care for Hispanics. Temple University was also a partner in the previous research.

Fennell said the paper is the first full-scale analysis of its kind to attempt to look broadly at Hispanics in nursing homes — what kind of nursing homes they live in and how care at those facilities compares to nursing homes which care mostly for white elderly people. She said the data revealed a sharp disparity in care.

"The most shocking finding is the pervasiveness of disparities in nursing home care that are primarily white, compared to nursing homes that are a mix of whites and Hispanic residences," Fennell said.

Fennell said the findings, in part, reflect a departure from prior patterns of elder care among Hispanic families in the United States. Traditionally, the group has used formal long-term care services less frequently than any other U.S. ethnic group. They had also been less likely than white or black residents to live in nursing homes. In Hispanic households, elder care has traditionally been handled by adult daughters at home, but acculturation and financial issues have forced a growing number of young Hispanic women into work outside the home.

As a result, Fennell said, the loss of home caregivers is occurring even as the growth of the elderly Hispanic population rises dramatically. The authors estimate that more than 5 percent of the current Hispanic population is elderly, a number that is expected to quadruple during the next 10 years. That number should rise to 4.5 million by 2010, according to Fennell and her team.

Fennell and her colleagues found that the overall use of nursing homes has declined since 1985, but the racial/ethnic mix of the national population of nursing home residents has shifted. From 2000 to 2005 — the period of data used in the study — the percent of Hispanic residents increased from 5 percent to 6.4 percent, but the percentage of non-Hispanic white residents dipped from just under 83 percent to 79.4 percent.

Nursing home residents are coming increasingly from the lower end of the socio-economic scale, Fennell said, lacking resources for better quality care in assisted living facilities or elsewhere.

Fennell argues that the impact of substandard nursing home care is a complex issue. Residents admitted to nursing homes have often already endured hospitalizations or a health issue that required expensive, high-level care. Once admitted, the individual is then often caught in a spiral of long-term lower quality of life, multiple episodes of poor health and ongoing chronic conditions without a way out.

"People with resources can get into very good places or alternatives for nursing home care," Fennell said. "Everyone else is left with not-very-good facilities that are not performing well."

Fennell is hoping that both federal and state policy-makers pay attention to the data as they shape health care reform policy.

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Jackson Free Press had an interesting and scary article about presidential contender Haley Barbour's flip flopping on Medicare and history as a lobbyist and Tom Delay's indictment for illegal campaign donations.   When Haley Barbour was head of the Republican National Committee from 1993 to 1997, he loathed Medicare, and tried to gun it down in the GOP “Contract with America.”  By 2000, Barbour had returned to his lobbyist job at Barbour Griffith & Rogers, and had dramatically flip-flopped on Medicare, then lobbying for more federal tax dollars to be directed into the program. 

The Alliance for Quality Nursing Home Care Inc. was formed in 2000 as a corporate coalition of 14 of the country’s largest for-profit nursing home companies to help ease the way for the corporate consolidation of the nursing-home industry.   The coalition opposed Medicare cuts and government regulation of nursing-home standards and consolidation, and, perhaps most vitally, wanted low caps on the lawsuit damages the companies had to pay for abusing and neglecting nursing-home residents. The coalition paid top dollar to ensure the election of candidates who agreed with its agenda.   It directed impressive campaign donations to mostly Republican candidates around the country who would, in turn, honor the wishes of one of the country’s most tenacious industries.

That resolve is how a check for $100,000 written three years ago this week ended up illegally funding Republican candidates for the Texas statehouse.  That’s also how that canceled check ended as a primary exhibit in the case of State of Texas v. Thomas Dale Delay et al.

Unlike Mississippi, the state of Texas has long taken campaign-finance violations seriously, especially donations coming from outside the state to try to tell Texans what to do, and how to vote.  Violation is a felony, punishable by hefty fines and up to life in prison.

Rep. Tom Delay appears to have put considerable effort into circumventing that law. The former bug exterminator from Sugar Land became majority leader of the U.S. House of Representatives by his complicated web of political friends and family members including his own wife, Christine, and daughter, Danielle Ferro.

Delay has run a creative maze of schemes since the mid-1990s to get Republicans elected to office and “keep Republicans in lockstep,” using “threats and incentives,” as The Wall Street Journal characterized his style in June 2004.  He has been investigated five times and brought before the House Ethics Committee for his strong-arming of fellow members of Congress, trying to use donations to a children’s charity for a donor cruise, rewarding check-writers with face time with GOP stars, and other irregularities.

What prompted a grand jury of his home-state peers to indict him in September and again earlier this month on conspiracy and money laundering charges was his Texans for a Republican Majority Political Action Committee, known as TRMPAC.  Delay used the PAC to collect illegal corporate contributions (a third-degree felony) from January 2001 through the end of 2002 from corporations and then slip the money to 2002 candidates for the Texas statehouse (a first-degree felony). Much of the money was used to fund a last-minute campaign blitz—another violation of Texas law.

In return, the donors had a laundry list of demands—including tort reform and a blind eye to their consolidation plans.  The nursing-home industry, with its heavy reliance on government payouts for profits, is ripe for exploitation. And stories about the internal workings of nursing-homes aren’t exactly sexy enough for front page news.

“What we have seen is these corporations evolve to trying to shield themselves from liability or from paying taxes in such a way to finagle the law in ways no one imagined just a few years ago,” said Mississippi Rep. Jamie Franks, a lawyer and Democrat from Mooreville who is leading an effort to more closely monitor Mississippi’s nursing home industry.  “It’s amazing what high-dollar lawyers and high-dollar accountants can do.” He added: “And high-dollar lobbyists. You can throw that in there, too.”

What those high-dollar strategists did in 2000 was form the Alliance for Quality Nursing Home Care Inc., so that the industry giants—for-profit nursing homes that were members of the American Health Care Association—could pool their resources to overcome regulations regarding standard of care and limit lawsuit damages in as many states as possible and, ultimately, on the federal level in order to supersede state law.

The Alliance heavily lobbied the federal government to increase Medicare payments because for-profit nursing homes take more money from Medicare than Medicaid, which tends to sustain their competitors, the non-profit nursing homes. 

In October 2002, the Alliance invested in Delay’s scheme to pack the Texas statehouse (and thus Congress) writing a check for $100,000 to TRMPAC, dated Oct. 18 and signed by Alliance leader Stephen L. Guillard of Harborside Healthcare Corp. in Boston. On Oct. 21, Chris Winkle—then the chief executive of Mariner Health Care in Atlanta—met state Rep. Tom Craddick, R-Midland. They talked about the need to limit liability in lawsuits against nursing homes; then Winkle presented Craddick with the check, which TRMPAC deposited two days later. On Oct. 24, the Alliance contributed another $300,000 to the Texas Association of Business, an employers’ group that is now also under indictment in Texas for allegedly helping collect and launder illegal contributions.

After the 2002 election, in which 21 additional Republicans were elected to the Texas statehouse, Craddick became speaker of the Texas House of Representatives, and the Legislature quickly gave industry its desired “tort reform”—including $250,000 in non-economic damage caps and special provisions to shield nursing homes—that would become the model for industry efforts in other states, such as Mississippi in 2004 (which ended up compromising on $500,000 damage caps).

Ironically, it was one of the alleged conspirators who exposed the scam. The Texas Association of Business, or TAB, could hardly contain its glee over its success, reporting in a newsletter to members that it “blew the doors off the Nov. 5 election, using an unprecedented show of muscle that featured political contributions and a massive voter education drive.” And as the Wall Street Journal reported, its president, Bill Hammond, a former Texas legislator, bragged to the media that the group had used corporate money to finance a $2 million advertising campaign backing Delay’s slate of candidates.

Watchdog groups like Texans for Public Justice in Austin took notice and started following the money, ultimately finding that TRMPAC’s tax return showed that it had raised $1.5 million to help with the state races—and that $600,000 had come from corporate donations. Travis County District Attorney Ronnie Earle started investigating TRMPAC’s activities after Texans for Public Justice filed a complaint based on the revelations on the tax returns.

In September 2004, the indictments began when a Travis County grand jury handed down 32 indictment counts against TRMPAC and TAB and their leaders, as well as against eight companies that had supplied corporate funds, including State Farm Insurance, AT&T, the Union Pacific Railroad and the Alliance for Quality Nursing Home Care. On May 25, 2005, District Judge Joe Hart ruled in a civil case brought by 2002 Democratic candidates against TRMPAC that the use of corporate funds had violated the Texas Election Code.

On Sept. 28, 2005, the grand jury indicted Tom Delay and associates Jim Ellis and John Colyandro for conspiracy in the illegal scheme, and then on Oct. 3, a different grand jury indicted Delay on two new charges of money laundering.

Other friends of TRMPAC and its donors, such as now-Gov. Haley Barbour—who lobbied for the Alliance until he left his hefty stock in Barbour Griffith & Rogers in a reversible blind trust so he could take over the governor’s mansion in Mississippi—are distancing themselves from the beleaguered Alliance, if not from Delay.   It is not in dispute, that Barbour was lobbying in his client’s interest to block Medicare cuts at the same time that his client was presenting a $100,000 check to Craddick. (The $300,000 check from the Alliance to TAB followed a few days later.)

Andrew Wheat, the research director of Texans for Public Justice, balks at the idea that Barbour was not privy to the Alliance’s agenda—especially since his lobbying firm represented three of the corporate TRMPAC donors (the Alliance, Kindred Healthcare and Reliant Energy)—lobbying contracts worth $440,000 to Barbour Griffith & Rogers in 2002 alone. Barbour’s clients gave more money to TRMPAC than any of the other 10 lobbying firms who were represented. He was CEO of Barbour Griffth & Rogers and representing the nursing homes when the Alliance was created in 2000.

The Alliance’s agenda is one that is wreaking havoc in states like Texas, Arkansas and Mississippi, where its members control much of the nursing-home business and are now getting their way, thanks to a nationwide corporate realignment, consumer advocates say. The changes in the historically tightly regulated nursing-home industry are profound.

Franks points to the December 2004 sale of Mariner Health Care for $1.05 billion to National Senior Care, owned by New York real estate investor Harry Grunstein. Harry is Leonard Grunstein's brother.  Leonard Grunstein is partners with Murray Forman.  Harry sold Mariner’s assets to cover the costs of the acquisition, reducing the worth and assets of Mariner to $12 million and, critics say, operating the nursing homes more like rental units. “It basically became a real-estate transaction rather than a group caring for vulnerable adults,” Franks said. He added that, now, the nursing homes seem to be escaping accountability with these transfers. “There is no background check to find out whether they are financially solvent, or good corporate citizens. They simply transfer the license,” he said.

Because it is the licensee that is regulated, the process of stripping that licensee of its assets is essentially a tricky end run, allowing the real-estate owners, such as Grunstein, to escape liability. This, combined with the increased “tort reform” damage caps sought by the Alliance, insulates the corporate owners from the regulatory safeguards that are meant to protect patients and the elderly.   In turn, those licensees are now defaulting on money owed to vendors in states like Mississippi. And because assets are being ripped away from the nursing homes themselves, they end up with little to be sought in lawsuits brought by the vendors looking to be repaid.

One unpaid Mississippi vendor is the law firm Brunini, Grantham, Grower & Hewes in Jackson, which is suing Mariner for $951,915.17 in legal fees for defending the nursing homes. In the complaint, filed in Hinds County Chancery Court, Brunini describes Mariner’s “leveraged buyout” scheme, which it alleges is “fraudulent.”   Franks points to hearings in Arkansas, called by a Republican and a Democrat, that just concluded that the state has ended up with “no” regulatory power over these companies, due to their maneuvering. “This is not partisan,” Franks said. “It’s a consumer issue. It’s about protecting vulnerable citizens and our tax dollars.”

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Long Term Living posted a response to a question submitted to their site on turnover rates and resident longevity/mortality.  It is a great question and the answer was interesting by Susan D. Gilster and Jennifer L. Dalessandro

A reader asks, “Is there a correlation between nursing staff length of service and resident longevity? 

 While we cannot point to a specific piece of research that specifically correlates resident longevity to staff retention, what we do know is that consistent staff and low turnover does result in better care and enhanced resident, family, and employee satisfaction.

Turnover and the impact on residents in assisted living and long-term care have been studied. Nicholas Castle (2007) measured the effect of administrator turnover on the quality of care and determined that leadership turnover leads to many negative outcomes for residents.1  He found that when there is a loss of an administrator there are increasing pressure ulcers, resident catheters and use of psychoactive drugs, deficiencies and citations, and over twice the normal turnover of staff. Sadly, the turnover for administrators in assisted living and long-term care ranges from 43%-70% annually. When an administrator leaves, so does staff—RN turnover rises to 76%, LPN’s to 78%, and certified nursing assistants to 107%!  In addition, turnover often results in increasing workloads for the remaining staff. And it is expensive. An average community housing 200 residents often spends as much as a million dollars per year on staff turnover.

It is clear that staff turnover influences the quality of care, is very expensive, and diverts monies that could have otherwise been spent on care.1 Turnover truly weakens the level of care provided and directly affects residents. Changes in staff distresses residents who develop relationships with caregivers, relying on them for recognition, support, and kindness—only to find that they are gone and a new person has taken their place. Can you imagine, when you are most dependent upon another human being for care, seeing that your needs are addressed and desires met and suddenly they are gone? Now you have to rely on a stranger who may or may not care to know you as a person, ensure that your needs are addressed, or be there when you call?

It is important for those of us working in assisted living and long-term care to remember that we are in the “people business,” and that our product or service, so to speak, is about meeting the needs of people, long term. Unlike acute care settings where time is often limited, long-term care offers the opportunity to meet and know the residents we serve and their families. Human relationships are special and it does not really matter where people come from, what they have experienced, where they live or play. People are all the same at the core. We all need respect, a sense of belonging, to be included, appreciated, valued and loved in order to survive. Consistent, knowledgeable, caring staff that has come to know the resident as a valued person and not a task will provide the kind of care that encourages a desire to live and nurture relationships with others. Regardless of the resident’s ability to participate, being with people each day is what makes life worth living.

Consistency creates a positive environment for staff as well, who enter this field with a desire to serve and genuinely care for others. Encouraging relationships means that leadership must allow for consistent staffing as well as value and reward employees for the good work they do. Leaders must allow employees the time to visit with residents and families, to know them personally, their life, their experiences, accomplishments, needs, and desires. Whether expressed from the resident or shared by the family, staff needs to hear the stories and experience the resident’s reactions and emotions directly. Staff should come to know the resident from many perspectives, and when they do it is a beautiful experience where everyone benefits.

It does not, however, happen by chance. Staff and resident longevity exist when leadership and staff value relationships and respect. This is found only in an organization that is committed to a vision and philosophy of service, where the vision lives in the daily life of all in the facility.

References:

1. Castle, NG; Engberg, J; Anderson, RA: Job satisfaction of nursing home administrators and turnover. Medical Care Research and Review 2007; 64(2):191-211.

 

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There seems to be an increase of nursing home employees abusing, neglecting, stealing, or otherwise taking advantage of the vulnerable residents in their care.  Below are just some of the stories from the past few weeks:

RocNow by Democrat and Chronicle had a story about a CNA who is accused of stealing a credit card from a nursing home patient and then submitting a forged application for public benefits to Monroe County.   Latoya Harding, 28, employed at the Blossom South Nursing and Rehabilitation Center, was arraigned on several charges including fourth-degree grand larceny, offering a false instrument for filing, both class E felonies, and second-degree criminal possession of a forged instrument, a class D felony.

After Harding was fired from Blossom South because of the theft allegation, she allegedly applied for unemployment benefits. Harding allegedly submitted an application with a forged signature of a Blossom South employee and falsely claimed that she was laid off from Blossom South.   Harding is also accused of stealing a credit card from a 90-year-old patient suffering from dementia to pay her own cable, cell phone and utility bills. She also allegedly purchased items from Wal-Mart and made several cash withdrawals.

-----------------------------------------------------------------------------------------------------------------------------Woodtv.com had an article discussing the jail sentence of Michael James White.  He will only spend six months in jail for sexually molesting an 84-year-old resident of a nursing home. The woman is mentally and physically incapicitated.  White admitted to one count of criminal sexual conduct in the 4th degree.  The incident took place this past summer at Metron of Lamont.

-------------------------------------------------------------------------------------------------------------------------------- The Star-Ledger had an article about a nursing home employee arrested on charges he stole about $48,000 by forging employee paychecks, including those of mentally-challenged individuals who worked at the home.  Roel Lopez was responsible for distributing paychecks to mentally-challenged employees. An investigation found that Lopez kept employee paychecks and deposited them into his own account. Lopez also had phantom employees on the payroll, said the release. The thefts occurred over an approximately four-year period.  Lopez was charged with theft by deception and forgery. 

---------------------------------------------------------------------------------------------------------------------------------The Advertiser had an article about another nursing home employee accused of cashing an elderly woman's check at a Lafayette store.  She was arrested and booked into the Lafayette Parish Correctional Center.   Brandy Nicole Wilkins was charged with exploitation of the infirm and 11 counts of money laundering/transactions involving proceeds of criminal activity.

Wilkins, a former employee of Golden Age of Welsh Nursing Home in Welsh, is the second person arrested in connection with the incident. Vercey Lawdins, 26, was arrested on Oct. 13 on the same charges as Wilkins.  Lawdins is accused of stealing a $6,050 check from an elderly resident of the nursing home.  She and Wilkins then allegedly cashed the check at a Lafayette Wal-Mart store and used the money to buy 11 $550 gift cards, Gerdes said.

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Philadelphia Daily News had an article about the Veteran Administration trying to conceal system wide neglect at a VA nursing home.  In a directive, VA officials informed local agency officials that inspection reports are no longer to be released to the public including family members of residents.  The directive came after the Tribune-Review disclosed details of a 2008 report on the nursing home that concluded the VA "failed to provide a safe and sanitary environment for their residents."   Such reports from the Long Term Care Institute - which the VA hired to inspect its facilities - are considered "protected" documents under the provisions of a federal law designed to promote improved quality, the directive states.  The Wisconsin-based institute, according to VA officials, conducted similar inspections of more than 100 VA facilities nationwide. Under last week's order, none of those reports will be made public.

The report cited by the Tribune-Review was released by VA officials in Philadelphia under a public records request.   It described how one veteran had to have his leg amputated after a serious infection had gone untreated for so long that it attracted maggots. It also described blood-stained floors, a fly infestation and life-threatening treatment of veterans dependent on tube feeding.

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The LA Times had an interesting and enlightening article discussing how numerous studies have shown that not for profit nursing homes provide better quality of care than for profit nursing homes.

In the United States, two-thirds of nursing homes are investor-owned, for-profit businesses. The results of an analysis published prove that not-for-profit homes provide higher quality care. The paper, published online in the British Medical Journal, examined 82 studies carried out in the United States and Canada between 1965 to 2003.  Forty studies showed significantly better quality in not-for-profit homes. Nursing homes, whether for-profit or not-for-profit, vary substantially in their management styles, motivations and organizational behavior.  However, the analysis found that nursing home residents in the United States would receive 500,000 more hours of nursing care per day if all not-for-profit institutions provided all nursing home care.

Given the costs of nursing home care and the fears families have about the well-being of their loved ones, more research describing the qualities of superior nursing homes might be in order.

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