Newsday ran a story from the Hartford Courant about how states relying on nursing home chains raise concerns about quality of care provided to the residents.

The article states that large, for-profit chains nursing home chains dominate Connecticut’s market, according to an analysis of federal data released Sunday by the Hartford Courant. Such facilities have lower staffing levels and higher rates of serious patient-care violations than small chains and independently owned homes, according to the newspaper’s review.

"Ownership is certainly a factor in quality of care," Toby Edelman, senior policy attorney with the nonprofit Center for Medicare Advocacy, told the Courant.


He said many of the larger chains have complex organizational structures with multiple layers of management. "They send a lot of money to their corporate offices," he said. "There can be a lot of distance between the owners and the facilities themselves. They’re not on the ground."

The Courant looked at two years of inspection and ownership data from the federal Centers for Medicare and Medicaid Services for the more than 240 licensed nursing homes in Connecticut.  Adjusted for size, homes owned by large chains provided, on average, 16 percent fewer registered and licensed nurses than small-chain and independent nursing facilities, according to the data.

The state’s large-chain homes had a 30 percent higher rate of causing patients harm or putting them in immediate jeopardy, the Courant determined. For the five large chains in Connecticut, which control about one third of the state’s nursing home beds, such serious deficiencies occurred at a 42 percent higher rate than at homes not controlled by large chains.

Information from: The Hartford Courant,

The Dealmakers Forum has an article about Sunrise charting a new course and discussion of how much money they are allegedly losing. 

Sunrise Senior Living was founded 27 years ago by Paul and Terry Klaassen when they opened a small nursing home in Virginia they purchased for just $325,000.   Now, 27 years later, the company manages more than 440 nursing homes in four countries, has revenues under management of more than $2.4 billion, boasts an average same-community occupancy rate that has been at 90% or better for four consecutive quarters and is perhaps the only company in the industry with a national brand name known to the consumer.

Mr. Klaassen will be relinquishing his chief executive officer duties and will become the non-executive chairman of the board. Mark Ordan, who was brought in earlier this year as the chief administrative and investment officer, will take over as CEO. And with this change, an era in our industry will come to a close

The company finally filed its 2007 10-K on July 31—the promised date—and the accounting mess that started two years ago is close to coming to an end.  The 2007 financial statements stated that total operating revenues last year were basically flat with 2006, and the importance of "buyout fees" to the company’s overall financial performance in both 2005 and 2006. In addition, hospice and ancillary service revenues inceased by 64%, but the associated expenses increased by 80%, causing this business category to go from a small profit to an $8.8 million operating loss.

For 2007, Sunrise posted a net loss of $70.3 million, which was after $214.0 million of gains from real estate sales and the company’s share of earnings in unconsolidated communities. These gains and earnings more than offset the combined $166.5 million in unusual cost items such as loss on financial guarantees ($22.2 million), impairment of goodwill and intangible assets ($56.7 million), write-off of abandoned development projects ($28.4 million), impairment of owned communities ($7.6 million) and the accounting and legal cost of the accounting restatement ($51.7 million).

This means that operating EBITDA was a negative $73.4 million, compared with a positive $110.2 million in 2006. That is a downward swing of $183.6 million, caused mostly by the disappearance of the previously mentioned "buyout fees," which were $134.7 million in 2006 and next to nothing in 2007, and represent, we assume, the fees paid by Five Star Quality Care to Sunrise to buy out Sunrise’s management agreements for properties leased by FVE but operated by SRZ.

The other large item was G&A expense, which increased by a whopping 42.5% year-over-year to $187.3 million but should not include all those costs associated with the accounting restatement. If you do the math, this means that without those buyout fees in 2006, operating EBITDA would have been negative in that year as well, although not as large as 2007. We still have trouble understanding how the management model that Sunrise has adopted can work in this industry if a company can’t make money managing more than 440 properties around the world.

The end result is that the entire increase in cash during 2007 came from a net $56.7 million increase in borrowed funds. In addition, the company had a negative working capital of $116.3 million at the end of 2007 due to $222.5 million of short-term debt and the current portion of long-term debt. Although we usually don’t get worked up about working capital for Sunrise, when the bank line-of-credit is reduced (which it was in July) because of breeches in loan covenants, it does make one pay closer attention to some of the details.

So what has happened over the past several years to this giant in the industry? In an effort to make more money and exclude from themselves from liability or accountability, Sunrise entered into tricky financial loans and buyouts to prevent any judgments for neglect to be collected.

In looking back over the past five years or so, it seems that the biggest problem was that Sunrise got a little ahead of itself, believing that it was so good that it could take risks that others might not take, with some competitors accusing the company of a certain degree of arrogance.  In addition,  Sunrise decided to get quite aggressive with accounting interpretations several years ago, and it came back to bite them in a big way. 

But enough of the past and on to the future. As management transitions from Mr. Klaassen to Mr. Ordan, there will be increased attention on cost control, and after the unprecedented increase in overhead expense last year, the company has announced a program to cut between $15.0 million and $20.0 million on an annualized basis beginning in 2009, which will include some "voluntary" employee reductions.

Second, while Mr. Ordan are concentrating on cutting overhead costs, the other complaint we hear is that management is not paying attention to operations at the local level. Quality of care is crucial, especially for the industry leader, and you don’t want what happened in Pennsylvania last year to happen again, anywhere. With less focus on development over the next 12 months, there should be renewed focus on operations. While it is great that Sunrise has grown to 440 properties under management, that itself may be part of the problem. This industry has some great leaders, but when you scratch beneath that, all we hear is that there is a huge management void, and we hear this from operators themselves.


NHC Acquires Charleston, SC Facilities

National HealthCare Corporation (AMEX:NHC)(AMEX:NHC.PR.A), one of the nation’s leading operators of senior care services, announced today that it has added Trinity Mission Health and Rehabilitation of Charleston and Trinity Mission Assisted Living of Charleston in Charleston, South Carolina as affiliates effective August 1. NHC purchased the 132-bed skilled nursing and rehabilitation facility and the 60-bed assisted living facility for $13.25 million.

This acquisition increases NHC’s operations that are owned and managed in the South Carolina region to over 2,000 beds in 13 locations. The administrator for the new facilities, now renamed NHC HealthCare-Charleston and NHC Place-Charleston, is Angela Atkinson. Ms. Atkinson, previously with Trinity Mission of Charleston, joins NHC with 15 years of experience in healthcare administration, including licensure as both an assisted living and nursing home administrator.

“The superior quality of NHC’s services to the senior care community in the state of South Carolina is well known,” Steve Flatt NHC’s Senior Vice President of Development said. “While we have been a strong provider in the Upstate and Midland region for over 30 years, this additional location allows us to better serve the Low Country area as well. We are grateful for the help and cooperation of the staff of the center in making this a smooth transition.”

NHC has plans for more growth in the Low Country of South Carolina as construction is expected to start next month on a 120-bed skilled healthcare and rehabilitation center in Bluffton near Hilton Head Island.

NHC operates for itself and third parties 76 long-term health care centers with 9,772 beds. NHC also operates 32 homecare programs, seven independent living centers and 23 assisted living communities. NHC’s other services include managed care specialty medical units, Alzheimer’s units, hospice and a rehabilitation services company. Additional information about NHC, including the company’s Form 10-K, Form 10-Q, annual report and press releases, is available on our website at

Statements in this press release that are not historical facts are forward-looking statements. NHC cautions investors that any forward-looking statements made involve risks and uncertainties and are not guarantees of future performance. All forward-looking statements represent NHC’s best judgment as of the date of this release.

National HealthCare Corporation
Gerald Coggin, Sr. V.P. Investor Relations, 615-890-2020


I was surfing some of the blogs this morning, and ended up at Legal Medicine where Lauren Ellerman had posted this video from YouTube.  I admit I had not heard about this concept, at least not in this form.  I have heard of the Eden Alternative, but this is the Eden Alternative at its best.  This is what the nursing home industry should strive for – this is the sort of care that all elderly should have access to.  Its certainly the sort of care I’d like to have if necessary, and that I’d want my parents to have, if necessary. 

And you know what the greatest part is?  The way that the hands-on caregivers – the people who are usually on the bottom of the totem pole in a regular nursing home – they become the most valuable, and they love their jobs!  Under their care, the residents are thriving. 

If you’re at all interesting in the future of long term care, this video is a must watch.  If you’ve been in a typical nursing home, and see how it usually works, the video will bring tears to your eyes.  If not, you still cannot mistake the vast improvement between the nursing home and the Green home.

And if you want to know more, just google it, Green Homes – I did – And found this NPR story – among other things.  I haven’t listened to it yet, but I will before the day is out.

I hope that this is the future.

Not a bad thing to have to look forward to.  Certainly not as bad as the alternatives . . .

Online Nursing Home Resource Provided by IQ Nursing Homes.  IQ Nursing Homes announces the launch of their new website, a comprehensive online research tool for nursing home residents and concerned family members.

(EMAILWIRE.COM, July 17, 2008 ) New York – IQ Nursing Homes announces the launch of their new website, a comprehensive online research tool for nursing home residents and concerned family members. A national nursing home directory, up-to-date nursing home news, nursing home deficiency reports, and legal resources for victims of nursing home abuse and elder neglect cases are now just a click away on one easy to navigate site.

With increased life expectancies in today’s society leading to higher numbers of nursing home residents, IQ Nursing Homes recognized the need to create a free, complete online nursing home resource. Careful research is imperative to ensure that the nursing home to which you entrust your loved one’s care is reputable and safe. When you visit IQ Nursing Home’s national directory to locate elder care facilities in your area, you can also check nursing home deficiency reports to make sure the facility you choose provides the best care possible to its residents.

In addition to directories and information, IQ Nursing Homes provides a way for nursing home employees, residents, and their families to combat elder abuse and neglect. These are serious, prevalent problems that can result in physical and emotional suffering. Painful bed sores, broken hips, and even death are among the afflictions the nursing home residents face at the hands of negligent or abusive caregivers. Resources to help individuals recognize and report these problems are available on the IQ Nursing Homes website, including signs and symptoms of abuse and neglect and an anonymous abuse report form.

If abuse is suspected, a free nursing home abuse case evaluation is also available on the site. IQ Nursing Homes has partnered with expert nursing home lawyers and law firms throughout the country with the goal of putting a stop to the victimization of the elderly. By holding negligent and abusive staff members accountable for their actions and making it financially devastating for nursing homes to allow abuse and neglect to occur, this epidemic can be put to an end.

Be IQ Smart. Visit to learn more.

This press release was issued through GroupWeb EmailWire.Com. For more information on unlimited press release distribution service, go to

I know I’m about a week behind on this one, but I think it’s important.  Jane Gross wrote a piece for one of the New York Times blogs about all the decisions that needed to be made for her mother towards the end of her life.  In the piece titled What I Wish I’d Done Differently, Ms. Gross talks about everything from having a geriatrician to selling her mother’s house, and all the uncertainties in between.

She points out, quite correctly that there’s no way to be without uncertainties in situations like this, but that she would have liked to known prior to making some decisions that ultimately limited the choices they had later in regards to her mother’s care.

Something to think about this afternoon . . .

Heather Johnson was kind enough to write a guest post for the blog.  We thank her for her contribution, and appreciate her expert advice.

How to Pick a Nursing Home for an Alzheimer’s Patient

Any family that’s been afflicted by having a member stricken by Alzheimer’s disease knows how immensely difficult and trying it can be. Many times it’s so hard because the person with Alzheimer’s disease is in perfect physical health. This makes the family so much more hesitant to put the relative in a nursing home because it seems like nothing is wrong and we want to believe that. However, we also know that as the disease progresses they can’t perform the daily activities safely and responsibly. It puts such a strain on the family that eventually the only choice is to look for a nursing home. This brings up the major issue of finding a place that can provide the care we demand. It can be an arduous search and here a few tips to help you as you look for that special place:

1. Staff ratios are of the utmost importance. Alzheimer’s disease patients need more direct care than your standard nursing home. Given the unpredictability of the disease and the actions of the afflicted it’s dire that they receive as much dedicated care as possible. Make sure the facility can guarantee at least a ratio of five patients to one caregiver.

2. Pay attention to the building’s architecture. Many Alzheimer’s disease patients have trouble making sharp corners. They do better with rounded hallways that don’t require sharp turns. All hallways should have hand railings to further assist patients with walking.

3. Group activities are important. Check to see that the facility offers small group activities instead of large ones. Alzheimer’s disease patients react much more favorably to working in groups under four than they do in larger groups.

4. Talk to relatives with family members already in the facility. This is sometimes the best way you can determine if the facility is the right place for your loved one. They will shoot you straight and answer your questions directly and honestly instead of a coordinator who needs to toe the company line and always put a positive spin on the facility’s deficiencies.

5. Discover what kind of experiences the patients can expect. There are many new techniques that some nursing homes offer their patients that help alleviate some of the accompanying discomforts that go hand-in-hand with those who suffer from Alzheimer’s disease. Aromatherapy and experimenting with dimmer lighting are a couple examples of ways nursing home deal with the anxiety that many suffer from on a daily basis.


This post was contributed by Heather Johnson, who writes on the subject of Cruise Ship Nursing. She invites your feedback at

RN Karen Mowers has an article in The Daily Star newspaper which discusses how a family should choose a nursing home.  However, many times a person goes into a nursing home from the hospital. In those situations, often the family does not have time and relies on the social services person at the hospital to decide. This is a mistake.  The consumer should have the final say. 

Ms. Mowers has some good tips to assist you in choosing the right nursing home for your loved one.
Begin by researching the nursing homes in your area by reviewing The Centers for Medicare and Medicaid Services’ website,, that provides a section titled "Nursing Home Compare."   Comparisons can be made in relation to quality, staffing ratios, survey reports and fire safety deficiencies.   (This information can be unreliable depending on the enforcement of your state’s regulatory agency)

Contact other resources such as hospital discharge planners, social workers, physicians and your local Office for the Aging or ombudsman (volunteer resident advocate) who can be contacted through the local Office for the Aging as well. 

Formal visits or tours can be scheduled through the Department of Social Services, or you could just stop by and take a look around. Visit with residents, families and staff as you look around, and observe the activities.

Other things to be considered when selecting a nursing home:  Bed availability, staffing, activities, policies, services and fees, preventative care programs, nutritional services, and treatment options.

Karen Mowers, a registered nurse with a Bachelor of Science degree, is director of nursing services in the Fox Nursing Home.

The Columbia Tribune of Missouri has an article about a new study that shows nursing home admission paperwork to be confusing and takes away a resident’s fundamanetal rights without explanation to the residents.

Nursing home admission agreements are confusing, can run 10 pages or more with unfamiliar language, are often signed in moments of distress, and force residents to sign away fundamental rights.

"It’s a situation where they’re worried about health, they’re worried about their family, and often they’ll just sign anything," said Richard Royer, CEO of Primaris, a Medicare quality improvement organization.

A study released today by the not-for-profit National Senior Citizens Law Center evaluated 175 legal agreements signed by residents who entered Missouri nursing homes. The study found many agreements allow facilities to evict residents for almost any reason, limit their rights to be visited by family members and require family or friends to assume personal financial liability for care. All such provisions are in violation of the federal Nursing Home Reform Act of 1987.

The study found that 17 percent of surveyed nursing homes reserved the right to evict someone for any reason even though federal law lists only six valid reasons for eviction. Consequently, patients with Alzheimer’s disease and dementia or residents who complain about the care received are being evicted for being "difficult."

The survey also found that 19 percent of nursing homes required a guarantee asking a family member or sponsor to take financial responsibility for the cost of care. The study argues it’s illegal to require fiscal responsibility and that Medicaid is required to cover expenses when a resident is unable to pay.

The study found 5 percent of agreements instituted visiting hours for residents, also in violation of the federal law.

One of the things not mentioned in the study but is very disconcerting to many residents is the inclusion of an arbitration clause hidden in the admissions paperwork that waives the resident’s right to a jury trial if the resident gets abused or neglected.

The study and a consumer guide outlining the rights of residents are available online at