Telling My Story: Part 1

Despite being the owner of this blog, I’ve been mostly quiet about my own dealings with the nursing home industry related to the horrible care experienced by my mother at  four nursing homes and one assisted living facility where she resided during the last five years of her earthly life.  My mother died on January 1st of this year and I’ve needed time and space to process my grief — not to mention my rage — when it comes to the circumstance surrounding my mother’s abuse, abandonment, neglect and negligence she had to endure.

But enough silence. Now it is time for me to share my story, which I’ll share over the space of several posts to this blog.  It may take me a matter of weeks or months, but I will share all of my story/my mother’s story in this space.

Before I discuss the abusive and mediocre institutions and care givers who came into contact with my mother, I want to take the balance of this post to share my profound sense of gratitude for specific individuals who truly went above and beyond the call of duty to care for and advocate for my mother during the time she spent living in nursing homes.

Ebony was a certified nursing assistant (C.N.A.) at the first nursing home, located in Louisville, where my mother lived for six weeks back in 2005.   She was always curteous and kind to my mother.  She was hard working, honest and focused on providing the highest quality of care to my mother and all of the residents entrusted to her care.

Linda was a C.N.A. at a nursing home in Jeffersonville, Indiana that ended up on Medicare’s list of the 100 Worst Nursing Homes in the US.  Her excellent care of my mother and other residents proved to me that even in the worst of facilities you can still find outstanding nursing staff.  As a new hire to the facility in question, she told me how long-term C.N.A.’s at the facility assured her during training that she “did NOT have to” provide showers or other personal care to her residents, yet she COULD easily get away with documenting that she provided such care.  Linda had a core of decency that would not allow her to follow such unethical advice.  She worked incredibly hard for my mother and all the other residents assigned to her care.

Phillys was a nurse at that horrible Jeffersonville nursing home where Linda worked.  Phyllis took her own money to buy clothing for my mother and seaonal decorations and games for the unit she worked.  She would come in on her days off to deccorate the unit.  She went out of her way to provide appropriate activities for my mother and other residents when the nursing home’s management and activities staff failed to do their jobs to ensure that residents did more than just eat and sleep.

Barbra was a nurse at the Jeffersonville nursing home that had the courage to tell me, as a family member, the TRUTH about the deciet and corruption of the facility’s owner.  Her loving and caring spirit were evident in all the dealings she had with my mother and the other residents entrusted to her care.

Linda was a C.N.A. at the Bedford, Indiana nursing home where my mother lived the last fifteen months of her life who took her own money to buy my mother a Bible.  She purchased this treasured gift when she learned that my mother had started crying during a worship service one Sunday evening.  When asked why she was crying, my mother said it was because she missed her “Holy Bible”.  Linda was alway loving and kind to my mother and to me as a family member.

In the meantime, I feel that I must mention that the true “core of evil” within the nursing home industry (and perhaps most corporate entities) is greed.  Greed places the love of money above the need to provide high quality care.  Greed gives corrupt nursing home adminstrators all the excuse they need to justify under-staffing  (which endangers resident care and safety) so they can receive obscenely large salary bonuses.  Greed is the motivation behind the hostility and dishonesty of nursing home management and staff toward loving family members like myself — to these people telling half-truths and outright lies to family members is acceptable behavior if it protects oneself from legal liability.

I’ll add to this post soon as I continue to recognize the indiviudals who provided my mother with outstanding care and advocay during the time she lived in various nursing homes.

 

Unspeakable Horror at North Carolina Nursing Home

Words can not begin to express our sorrow and shock over the news of the senseless tragedy that unfolded on Sunday, March 29 at Pinelake Health and Rehab (www.peakresourcesinc.com/nursing/pinelake.html) in Carthage, North Carolina.

As you are probably already aware, a gunman barged into the nursing home Sunday morning and went on a shooting rampage that killed seven residents and a nurse who cared for them.

Authorities said Robert Stewart also wounded three other individuals, including the Carthage police officer who confronted him in a hallway and stopped the brutal attack. Officials said the massacre could have been bloodier if the officer had not managed to subdue Stewart.

The victims included Pinelake residents:

• Tessie Garner, age 88
• Lillian Dunn, age 89
• Jessie Musser, age 88
• Bessie Hendrick, age 78
• John Goldston, age 78
• Margaret Johnson, age 89 and
• Louise Decker, age 98.

The nurse who was killed, Jerry Avent, L.P.N., was only 39 years old.  One Internet report we read tonight stated that he was shot nearly 30 times! This nurse and the officer who subdued the gunman are truly heros of  the highest caliber.

Please join me in praying for the surviviors (residents, management, staff and resident families). Please pray for crisis rounselors, community members and all other individuals impacted by this horrible crime.

Please pray for the safetyof ALL nursing home residents. Unlike hospitals, most nursing homes do not have security guards on duty. Some nursing home units (and some entire nursing homes as well) are protected only by a key pad entry system. Should such a system be mandatory for all nursing home facilities to protect residents and staff?  Should other security measures be required of facilities?  I don’t ask these questions to infer that nursing homes are knowingly neglegent regarding safety, but rather to raise the question of what (if anything) can be done to prevent similar tragedies from ever happening again.

And for all of the victims of Sunday’s shooting, we pray…

“Eternal rest grant unto them O Lord,
And let perpetual Light shine upon them.
May their souls and the souls of all the faithful departed,
Through the mercy of God,
Rest in peace. In Jesus’ name. Amen.”

 

Help Wanted: Nursing Home Administrator

Here’s a Help Wanted ad that I’d like to see…NOT because I would want the applicant to meet these qualifications, but because given the various nursing home administators I’ve dealt with over the past few years, I suspect these ARE the REAL job requirements!

HELP WANTED: NURSING HOME ADMINISTRATOR

Our facility welcomes applicants who meet the following criteria:

***  You are able to lie effortlessly to residents, family members and employees.
***  You have little if any honesty or decency in how you deal with residents.
***  You are able to document in writing total lies based on meetings with residents, family members and employees.
***  You feel comfortable instructing your nursing staff to chart absolute lies — just so long as doing so prevents your facility from being sued for neglect or abuse of residents.
***  You are able to become extremely defensive when anyone, anywhere makes even the smallest suggestion on how to improve the quality of care in your facility…and are able to do so immediately upon hearing any such suggestion.
***  You will place personal greed ahead of resident’s safety when making staffing level decisions (after all: the more short-staffed your facility, the bigger your quarterly bonus!).
***   You will be a total rubber stamp for you facility’s owner whenever they order cuts in staffing or anything else that cheapens the quality of resident care — since all of these moves are designed to improve the profit margin of your facility.

APPLY TODAY BY CALLING:  1-(800)-NO-ETHICS.

 

The Evil Of Nursing Home Understaffing: An Inside View

I am frequently shocked by accounts I hear about how badly UNDERstaffing that exists in many nursing homes.  I’m a family member, so it is easy for nursing home owners and management to dismiss my concerns (and those of other family members) by claiming our expectations are too high. Management acts as if we family members are too dumb to realize that their facility does have “adequate staffing” — yet we often  witness our loved one (and other residents as well) not having their needs met, because the resident-to-staff ratio is woefully INadequate.

So please don’t take my word about the evil of nursing home UNDERstaffing.  Instead, please take the word of a newly-hired Certified Nurses Aide-In-Training.  Her insider account of the facility where she works should make you angry and to realize that ALL of us have a responsibility to work to bring about ethical and sane staffing standards.

This visitor to our blog wrote the following, her name and location are kept confidential for the purposes of this account…

“I just started working at a nursing home as Certified Nurses Aide “in training” –read: no formal training.

On my own on a recent night I was the only aide working and was responsible for the care of 45 residents. The only other nursing staff member on duty in this unit was the nurse (who couldn’t be bothered about resident’s needs).

I ran all night, couldn’t keep up, just wanted to keep the residents clean and comfortable. So many! 3/4  of the residents are incontinent, 1/2 have motion sensors on them due to fall risk. 1/3 needed some extra compassion, and more every night with signs of infection. I cry every time I walk out. I get yelled at and shunned because I take too long, when all they want is a drink, a clean blanket, and maybe even a hug. I thought that was what anyone needed, but apparently, only if they can get it themselves. I have NO TRAINING and I was ALONE for an eight hour overnight shift. In addition to direct resident care, I also have to wash wheelchairs and chart those bowel movements.

Again, I have NO formal training yet, aside from the training I have given myself through research and hands on care. I followed a couple of aides around for a few days, only one of them was actually certified.

I have spent a total of four days in training for “corporate understanding”, which involves travelling to another town to hear about how great this company is, then going home to work a night shift.

I had two nights of “supervised” work, which meant that depending on who I was supervised by, I was either on my own or frantically looking for someone that knew what to do. However, I have been walking around in the same scrubs that certified aides wear, and when a resident sees me, they think help has arrived. I quickly learned to give up on finding someone else (more experienced) and just help them any way I can.

I spent the night trying to get her to help me with a resident that was screaming and pulling at her catheter, only to find that the nurses “help” was to go into the room and tell the resident, “Shame on you!”

I literally ran up and down the halls, trying to help everyone, trying in earnest to turn everyone every two hours, change everyone when soiled, strip and make beds with people still in them, lift and transfer residents alone on my own and dress them all starting at 3:30am to be gotten out of bed no later than 5:00am.

I tried to inform the nurse about a resident who had recently had a medication change and could no longer transport themselves to bathroom.  The resident was vomiting and had diarrea.  The nurse ordered me to “stop taking so long in there”.

A resident on Hospice needed a bed bath, I gave it, hour later, thought he may have been dying since he was panting and grunting. I went in to check on him and he took my hand and wouldn’t let go.. The nurse’s response, “That’s because you messed with him”.

This is all tip of iceberg. I thought I wanted to be a nurse, I have a good head for medicine, and a big heart. Now I think that that may be why I cannot go into this field. I will fight tooth and nail before admitting my mother to a nursing home. I know there are times it is needed, but people need it so they can get BETTER care, not so they can be institutionalized, ignored and treated like a piece of meat.

These resodemts don’t need much, but what they need is so important!  Why couldn’t management hire two more nurses aids on third shift?  I only get minimum wage for crying out loud!

I want to quit, and yet, who else will do this?”

 

Can You Just “Feel The Love”?!?

Most of the messages sent to me by readers of this blog express appreciation for it’s content. But every few months I usually receive feedback that is a little (or a LOT) less than “appreciative” (understatement) of the informaiton and opinions posted on Nursing Home Reality.

As a general rule, most critics of my blog self-identify as employees of nursing homes. They are quick to point out that they feel “attacked” by what I’ve posted. Yet if one were to really understand what is posted here I would hope that 1) I do not paint all nursing home staff as bad or incompetent individuals and 2) I have much respect for the hard work done by nurses and nurses aides who work in long-term care facilities.

My most recent “love letter” comes from a woman who identified herself as a nurses aide who has worked in the long-term care industry on and off for nearly 40 years.  Her comments and my response follow…

READER:
„«  You have so many rules for people who are
„«  willing and able to do a job that you have no
„«  intentions of ever doing, nor are you capable.

BLOG OWNER:
I’ve done my best to take care of my mother.  At the same time, due to my physical limitations and her need for around-the-clock care, I allowed her admission to a nursing home with the hope that she would receive a far higher level of care than I could possibly provide for her. This is NOT because I didn’t care. This IS because I wanted her to receive an appropriate level of care.

Then again, what are you complaining about?  If you work in a nursing home, people like my mother are helping to pay your salary.

READER:
„«  People who work in nursing homes, work
„«  very, very hard throughout their shift!

BLOG OWNER:
Yes, many do.  But from my personal observation, many don’t.  Many (especially those who work nights and weekends, when management is not around) appear to give the LEAST amount of care that they can get by with.

I don’t know the percentages of “good” caregivers vs. “mediocre” ones vs. “awful” ones, but I do know that my mother has often had to wait 30 or more minutes to be taken to the rest room.  On at least a dozen occasions during the 4 1/2 years that my mother lived in and out of nursing homes, I personally witnessed her have to wait OVER ONE HOUR (and a few times OVER TWO HOURS) to be taken to the restroom from the time her call light was activated.  Oh and did I mention the one nursing home that allowed my mother to go 10 to 14 days without having a bowel movement?  That isn’t just “neglect”, that is downright CRIMINAL.

READER:
„«  They max out their bodies lifting, pulling, and pushing.

BLOG OWNER:
Isn’t that part of the job description (e.g., transferring non-ambulatory residents)?  There are Hoyer lifts and other devices to assist the transferring of residents from one piece of furniture to another, thus miniming the wear and tear on the caregiver.  If the facility is too cheap to provide these devices for the staff, that is NOT the fault of the resident.

READER:
„«  They clean up more bowel movement and
„«  other bodily fluids than you have most likely
„«  seen in two years time, many times with the
„«  resident cussing at them and even trying to
„«  hit or spit at them.

BLOG OWNER:
Again, isn’t this part of the job description?  If you don’t like doing the job, please (for the sake and safety of your residents) find ANOTHER line of work!

As to the residents cussing and trying to “hit or spit” at their caregivers, why does this happen?  Could it possibly have something to do with the APPROACH of the caregiver?  My mother didn’t
scream or act out against most of her caregivers.  She usually only
screamed when they raised their voices at her or IGNORED her right to refuse treatment (which she had the LEGAL right to refuse).

READER:
„«  They rush to get 35 or more people up and
„«  cleaned up, changed and dressed, while the
„«  other residents are laying on their call lights.
„«  Many time these are the residents that have
„«  already been cared during another shift that
„«  feel they have not received enough of our
„«  time and attention. It gets very hectic to put
„«  it mildly!

BLOG OWNER:
Thank you for supporting my viewpoint: Most nursing homes are NOT adequately staffed!  Then again, why would you think that it would OK to IGNORE the needs of a resident just because they were given care on a previous shift?  If you are speaking of an 8 hour shift or 12 hour shift, it is NOT too much to expect nursing home residents NEED assistance on EVERY shift, especially if they are not ambulatory or have dementia.  Again, this is part of the job description (e.g., to provide care to every resident assigned to them on every shift, as needed).

READER:
„«  Nurses aides get little respect and
„«  credit from the nurses, who are
„«  often abusive and snippy toward them
„«  (some exceptions though) and also
„«  little respect from resident’s families or
„«  the residents themselves. Low pay, risk to
„«  their health, poop-stainned uniforms and
„«  shoes that they can rarely afford to replace
„«  often enough.

BLOG OWNER:
Again, I TOTALLY AGREE with you.  From what I’ve seen at most of the nursing homes where my mother lived, aides were treated as
second-class (or worse) employees by nurses, nursing supervisors and administrators.  This isn’t the fault of the resident or the family
members.  For the record, I’ve been on the receiving end of verbal
abuse by nurses aides and nurses.  On two occasions during the past
year, after visiting my mother I returned to my vehicle to find that
someone (a caregiver?) had let the air out of one of my tires!  I’ve
also heard from at least one nurse that they have had their automobile vandalized by a CNA that they had written up for bad job performance. I also know of at least one aide that was found to have stolen the property of some of her co-workers.  And I can’t tell you of the number of times I’ve heard stories about nurses and nurses aides who have stolen money, jewelry and other belongings from their residents.

READER:
„«  There are several residents that
„«  don’t belong in a nursing home but
„«  rather in a mental ward, and I am
„«   not referring to Alzheimer’s Disease/
„«  Dementia patients either.  They have
„«  mental issues.

BLOG OWNER:
When were you trained to diagnose mental disorders?  I don’t doubt that some nursing home residents have mental problems other than Alzheimer’s or other types of dementia.  But it is NOT the fault of the resident that they aren’t in a different type of facility.  There are very few facilities that offer long-term care of mentally ill individuals and most insurance will only pay for hospitalization to “stabilize” the mental health problems.  So nursing homes becomes a catch-all facility for persons with both physical and mental disorders.  But that is NO excuse for abuse or neglect of persons who have emotional problems beyond their control.

READER:
„«  If the worst thing a nurses aide does
„«  is to smoke outside on one of
„«  their few breaks, you should
„«  congratulate her!

BLOG OWNER:
For the record, I don’t care if a CNA or nurse smoke on their break –
what they do while on their break is none of my business.  However, as a family member, it becomes my business if the nursing staff are taking an EXCESSIVE amount of time on their breaks, since doing so risks the safety of my loved one.  You are NOT paid to smoke.  You are NOT paid to talk on your cell phone.  You ARE paid to care for your residents.

Again, to clarify, I’ve never claimed that “all” nursing home caregivers are bad or incompetent individuals. I have great respect for the very hard work that many of them do day in and day out.  To be sure, I believe that most nurse’s aides are underpaid given the amount of hard physical work they are expected to do. And I’m totally on the side of  both nurses and nurse’s aides who share my concern about the gross understaffing of most nursing homes. Indeed I hope more caregivers will joing family members like myself to pressure the owners and administrators of long-term care facilities to provide adequate staffing. And, in those states who lack minimum staffing requirements, I hope that caregivers will join me in pressuring legislators to pass legislation that will mandate appropriate staffing levels in long-term care facilities.

 

Advocacy For Those “Held Hostage”

David Goud of Louisville, Kentucky knows personally what goes on in nursing homes since he has worked in the industry. During last year’s battle to pass legislation that would mande minimum staffing in Kentucky’s nursing homes (a battle that was sadly lost to the well-financed nursing home lobby), he wrote a powerful letter to THE COURIER-JOURNAL, the daily newspaper in Louisville.  David Groud wrote:

I applaud Bernie Vonderheide for his advocacy for the residents held hostage in most nursing homes. I have had the misfortune to witness first hand the neglect and abuse that the elderly of our city endure on a daily basis.

Having worked in two nursing homes in Louisville, I can say that not only is there not enough nursing staff available to meet basic needs, but the quality of care given to residents would be comparable to an animal shelter.

It is also difficult to police nursing homes, because state inspections and investigations are rarely unexpected. Nursing homes know when they are to be audited and call in more staff than usual to give a better show of quality.

A civilized society should give better care to its elderly. At present, one can expect better quality care at a fast-food counter than at a nursing home.

My sincere thanks to David Goud for being an articulate, outspoken advocate on behalf of nursing home residents, in Kentucky and elsewhere!

 

An Inside View of UNDERstaffing

The following post submitted by a registered nurse currently working in a nursing home setting offers a pointed reminder of the seriousness of what happens when corporate greed is allowed to dictate minimum staffing standards…

I am an RN in a nursing home licensed for just over 200 residents that offers skilled, intermediate and personal care. This facility has four nurses stations/units. I work on a unit with 38 residents. Many of these individuals have dementia.

My unit is allowed four nurses aides and an LPN on day shift, 3 nurses aides and an LPN on evenings, 1 – 2 aides and an LPN on nights.

While I try hard to understand the “budget” for staffing on my unit, my repeated requests for additional help has been ignored. In August I had eight (8) resident falls on my unit and they all happened on evening shift. My unit’s LPNs are frequently out of time compliance on distributing medications.

I would like to see mandatory staffing based not only on the number of residentts, but also on their needs. This is especially important on a unit that has residents with many needs.

 

What Do These Caregivers Get Paid To Do?!? Really?!?

On a recent Saturday evening, after spending several hours visiting my mother who now lives in a nursing home located in south-central Indiana, I discovered a sight that was quite disturbing. If what I’m about to share doesn’t upset you, it really should!

Standing outside the main entrance to the nursing facility were ALL THREE of the nurses aides who were on duty at that time. They were standing outside taking their smoke break together! Inside was JUST ONE nurse, in the middle of distributing medications, responsible for a unit with approximately 35 residents! Only one caregiver for 35 residents is, to my way of thinking, a case of neglect. For the nearly three dozen residents what I observed is (at best) a serious injury just waiting to happen!

At worst the situation I’ve described is a potentially (harmful or even fatal) medication error waiting to happen. Besides it certainly seems totally unfair to expect JUST ONE nurse to be responsible for responding to all wheelchair alarms, bed alarms and patient call lights — while distributing medication to the residents.

And obviously this situation was unfair to my mother and the nursing home residents.

Is it “unfair” to demand that smokers take their smoke breatks outside the building? After all it hasn’t been all that long ago that smoking employees were allowed to smoke inside nursing homes (not to mention hospitals). Because of the risk associated with second-hand smoke, I don’t find it unfair to require all smokers (both staff and residents) to smoke outside the building.

This incident that took place in June 2008 was NOT the first time that I’ve witnessed first hand this kind of criminal neglect in a nursing facility. EVERY long-term care facility where my mother has lived over the past four-plus years  (e.g., 5 nursing homes and one assisted living facility) have had employees who smok that have left their residents with inadequate staffing levels for several minutes at a time!

One nursing home unit where my mother lived had a nurse who averaged three smoke breaks per HOUR (per the observation of a newly-hired nurses aid)! Many of the times this particular nurse was on duty (night shift: 7:00pm – 7:00am), she was the ONLY staff member on what was a “locked unit” — meaning that if a resident’s alarm were to sound, NO other staff member in the building could have heard it, let alone responded to it!

If I didn’t know any better, I’d think that the caregivers in question (both nurses and nurses aids) think that they are PAID TO SMOKE (OUTSIDE the building), rather than take care of residents (who live INSIDE the building).

I’ve also witnessed many of these same caregivers answering PERSONAL (non-emergency) cell phone calls while caring for my mother (including while they were supposed to be “transfering” my mother from her wheelchair to the toilet, which is NO time to risk a resident’s safety!).

I’ve also personally witnessed still other nursing staff members act as if they are paid to do nothing but sit on their butt and gossip with co-workers! Can they not gossip on their own personal time?

As of this writing my mother has lived in long-term care facilities in two states: Kentucky and Indiana. These are two of the 17 states that have not yet mandated a minimum staffing level to care for nursing home residents. Indiana and Kentucky leave it up to each facility to interpret the wrecklessly-written federal regulation that reguires these facilities to provide an “adequate” staffing level to care for their residents.

Does ONE caregiver for 35 residents sound “adequate” to you? I hope not!

Whatever happened to a decent work ethic? Whatever happened to to having (and ENFORCING) a rule for smokers that ONLY ONE staff member can be outside the building (for any reason) at any given time? Oh wait, ALL of the nursing homes where this smoking concern has been observed already HAVE such a rule in place. The problem: either most supervisors are themselves smokers (who breat the rule themselves) OR don’t want to anger their smoking employees by enforcing an UNpopular rule.

It seems to me that nursing homes should have a policy to NOT hire management who smoke and/or hire non-smokers only. While these might sound like radical concepts, until the day comes when the legislators of Indiana and Kentucky grow a spine and require sensible minimum staffing levels, nursing homes should become part of the growing number of businesses that LEGALLY discriminate against smokers.

Which is more ethical: discriminating in hiring against a smoker or allowing inadequate staffing levels that endanger nursing home residents?

 

Whatever Became of A “Decent Work Ethic”?!?

My thanks to D.L. for sharing the following account of nursing home neglect and poor work ethics with us. Whether it’s nursing home staff taking an excessive number of smoking breaks, talking on their cell phones while on duty, or standing around gossipping with co-workers instead of caring for the needs of the residents assigned to their care, this sort of inappropriate behavior is an all-too-common problem found in many nursing homes.

It seems to me that having a “daily allotment” of wash rags, is an example of corporate greed could endanger the health and safty of residents. Does the state know about this policy?

I encourage D.L. to share all of this information with her area long-term care Ombudsman and/or the administrator of the facility where her sister resides.

 

This past Sunday when I visited my sister at the nursing home she is in, at 11:20am when I arrived, the housekeeping/laundry supervisor was sitting in a chair in the tv room playing the “Wii” video game that had been bought for the residents to use. At 12:30pm he was still in the chair. I heard later that he was supposed to be mopping the floor.When we went to give our sister a shower, which we do twice a week, there were no clean wash cloths. An aide told us they had been told they had used their “alloted amount for the day” and couldn’t have any more clean ones until the next morning.Later in the day, when residents got their supper trays, the only silverware in the napkins was a fork and a straw. The sad thing is the residents had SOUP for supper. Staff had to find plastic spoons for the residents to eat with.

Wouldn’t the time of the housekeeping/laundry supervisor been better spent washing laundry instead of playing with the Wii?

 

God Bless, Bernie!

May God richly bless our friend Bernie Vonderheide, founder of Kentuckians for Nursing Home Reform, for his hard work on behalf of creating positive changes in nursing homes within the Commonwealth of Kentucky! His commitment is truly inspiring and his organization is one that I urge all of my fellow Kentuckians to support.

Bernie shares the following words of encouragement as we start this blog…

Congratulations on starting an important educational blog.

One of the biggest problems in nursing home reform is that most people do not understand the problems unless that have been there and actually seen it.  That is why education is such an important part of our mission.

We encourage everyone to share their experiences with the public through this new blog.

Looking forward to being a daily reader, and congratulations once again.

Thanks Bernie for those thoughtful words!

Allow me to remind you that while Bernie and others of us are very much public figures in the area of nursing home industry reform, we will respect your request for anonymity should you chose to share your story for publication. We will also keep your e-mail address completely confidential.