SharonStone1HA599_Final_Capstone_Unit9FinalSubmission

Running Head: IOWA QUAD CITIES NURSING HOME COST AND QUALITY OF CARE
1
Correlating the Cost and Level of Quality of Care in Nursing Homes in Davenport and
Bettendorf, Iowa
Sherry S. Stone
A Capstone Presented in Partial Fulfillment
of the Requirements for the Degree
Master of Healthcare Administration
KAPLAN UNIVERSITY
December 2016

IOWA QUAD CITIES NURSING HOME COST AND QUALITY OF
CARE 2
Abstract
This Capstone will feature the cost and level of quality of nursing homes in Davenport and
Bettendorf, Iowa. Because long term care and its (high) cost is inevitable, the presiding inquiry
is if the level of quality of care correlates with the cost of that care. The accessible population to
be discussed is the residents of nursing homes in Davenport and Bettendorf. The sampling frame
for this research includes nine nursing homes in Davenport and Bettendorf. Only nursing homes
offering skilled care are being evaluated. To measure quality of care levels, all information
gathered from the CMS Nursing Home Compare Web site was comprised into tables using four
categories: General Information, Staffing, Penalties, and Quality Measures, and the data was
composed into a numerical scoring system developed by the researcher. Each measure of care
was compared to the national average for that sub-category, and issued points, to compute an
overall quality of care score for the nursing home. The collected data of the cost per day of the
facilities and the information from the CMS Nursing Home Compare Web site was analyzed and
correlated to the hypotheses. Upon the conclusion of this research, it is indicated that there is no
correlation between the cost and level of quality of care in nursing homes in Davenport and
Bettendorf, Iowa.

CARE 3
Dedication
For my beautiful, super-smart, caring, and talented daughter, Kyla, thank you for inspiring me to
be a better person, mom, friend, and to strive for greatness every day. Your dedication to dance
piano, prayer, reading, kindness and love is well beyond your nine years. Thank you for praying
with me each night, and for your lovely affirmations of hoping Mommy gets her homework done
and gets a good grade!
For my husband, Mike, thank you for helping to do more than your fair share for our family by
making dinner, doing laundry and extra chores, being a chauffeur, sacrificing time spent with
me, and much more so I could continue my research each night and weekend. Your
encouragement means more than you will know.
For my parents and sister-in-law, Shauna, thank you so much for also helping chauffeur Miss
Kyla to dance, tumbling, and piano lessons. To my person, Mindy, thank you for our talks.
For my brother, Steve, your dedication and success through medical school and residency has
always been an inspiration to me. You truly inspire me to be a better student and person.
To my mom, I cannot possibly say thank you enough. For everything. Your cheerleading and
congratulatory offerings when I finished a paper or maintained my 4.0 was so welcomed and
genuinely appreciated, even if I am a grown woman! Thank you to all my family and friends for
your support and encouragement and understanding my occasional absence of Sunday family
lunches while completing coursework to earn this Master of Health Administration.

CARE 4
Acknowledgements
I would like to acknowledge my grandparents, Weldy – God rest his soul, and Elizabeth, for
inspiring me to continue to seek knowledge of care for the elderly. I started as a CNA in nursing
homes and the hospital, and was taught to treat every resident like s/he was my grandparent. I
stepped into the role of a home-based caregiver for my grandma after she suffered an accident,
and subsequently three brain surgeries and an affected left side. Taking care of Grandma, and a
few years later Grandpa too, I learned a lot about myself along with caring for precious lives,
whose ultimate goal was to stay at home. Once Grandpa became so ill that he and Grandma
were moved into a nursing home – which meant not farming and not being in the home he was
born in and helped build with his own father – I experienced the mantra of “treat every resident
like s/he was your grandparent” first-hand. When I was at the nursing home every day of
Grandpa’s final days, I wanted the CNAs to answer his call light faster. I wanted the nurses to
give him more medication so he was comfortable. I wanted the dietary staff to cook him
something he could keep down. I wanted the hospice visitors to do their business quickly and let
us be. I wanted the laundry ladies to stop coming into his room at inopportune times of family
togetherness or prayer with the pastor while he was dying. Because of this experience, I want to
be the best nursing home or hospice administrator there could ever be, and treat every resident
like s/he is my grandparent, and to appreciate and respect the time they share with their families.
Finally, I would like to acknowledge my Capstone professor, Dr. Kimberly Perkins, for helping
to guide me through this class, research, and Capstone. Your brilliance and your cool demeanor
was so welcomed and appreciated. Thank you so much.

CARE 5
Table of Contents
Abstract ........................................................................................................................................... 2
Table of Contents............................................................................................................................ 5
List of Tables .................................................................................................................................. 7
List of Figures ............................................................................................................................... 10
Background ................................................................................................................................... 14
General Problem Statement....................................................................................................... 14
Specific Problem Statement ...................................................................................................... 16
Purpose Statement..................................................................................................................... 18
Research Questions ................................................................................................................... 18
Hypotheses ................................................................................................................................ 18
Definition of Terms................................................................................................................... 19
Literature Review.......................................................................................................................... 23
Overview of Literature Concept 1............................................................................................. 23
Method .......................................................................................................................................... 37
Research Method and Design Appropriateness ........................................................................ 37
Population.................................................................................................................................. 38
Sampling Frame ........................................................................................................................ 39
Data Collection.......................................................................................................................... 40
Data Analysis ............................................................................................................................ 41
Findings......................................................................................................................................... 45

CARE 6
Limitations ................................................................................................................................ 45
Use and Application of Findings............................................................................................... 46
Conclusion .................................................................................................................................... 51
References..................................................................................................................................... 55

CARE 7
List of Tables
Table 1. Centers for Medicare and Medicaid Nursing Home Compare General Information
Ratings.
BHC Lutheran GoodSam Kahl MC
Dav
MC
Utica
Masonic Ridge-
crest
St.
Mary
Overall
rating
1 4 4 2 2 5 4 5 1
Health
inspection
1 3 3 1 1 3 3 3 1
Staffing 2 4 4 4 4 4 4 4 4
Quality
measures
3 2 3 3 3 5 4 5 1
Sprinklers 1 1 1 1 1 1 1 1 1
Health
deficiencies
-1.8 3.2 6.2 -5.8 1.2 3.2 3.2 5.2 -7.8
Complaints -12 0 -1 -4 -7 -2 -3 -2 -22
Reported
incidents
-4 -2 -4 -10 -2 -2 -3 -3 -3
Fire
deficiencies
0 0 0 0 0 0 0 0 0
TOTAL -9.8 15.2 16.2 -8.8 3.2 17.2 13.2 18.2 -24.8
Table 2. CMS Nursing Home Compare Staffing Information Ratings.
Dav
MC
Utica
Masonic Ridge-
crest
St.
Mary
Licensed
N. Staff
0 0 0 1 0 1 1 1 1
RN 1 0 0 0 0 1 0 0 1
LPN/LVN 0 1 0 1 1 0 1 1 1
CNA 0 1 1 1 1 0 1 1 1
Physical
Therapy
0 0 0 0 0 1 0 0 0
TOTAL 1 2 0 3 2 3 3 3 4

CARE 8
Table 3. CMS Nursing Home Compare Penalties Information.
Dav
MC
Utica
Masonic Ridge-
crest
St.
Mary
Federal
fines
-1 0 -1 -1 -1 0 -1 -1 0
Federal
payment
denials
-1 0 0 0 0 0 0 0 -2
TOTAL -2 0 -1 -1 -1 0 -1 -1 -2
Table 4. CMS Nursing Home Compare Quality Measures Information Scores.
Dav
MC
Utica
Masonic Ridge
-crest
St.
Mary
1+ falls 1 1 0 0 1 0 0 2 2
UTI 1 0 0 -1 0 0 0 -1 2
Pain 0 0 0 0 -1 2 2 1 0
Bedsores 0 1 1 2 1 1 2 2 1
Incontinence 1 1 0 1 0 0 0 1 1
Indwelling Catheter -1 -1 -1 1 1 1 1 0 -1
Physically
Restrained
2 2 2 0 2 2 2 2 1
Mobility worsened 1 1 0 2 1 1 1 2 0
Lost too much
weight
0 1 0 0 2 0 0 1 0
Depressive
symptoms
2 1 0 2 2 2 -1 2 1
Antianxiety/antihyp
notic meds given
0 0 1 1 1 0 0 1 0
Influenza vaccine
given
1 1 1 0 1 1 2 1 1
Pneumococcal
vaccine given
0 2 1 1 1 1 1 1 1
Antipsychotic meds
given
2 0 2 1 1 2 1 1 1
TOTAL 12 11 8 11 13 14 12 17 9

CARE 9
Table 5. Total Quality of Care Score.
Dav
MC
Utica
Masonic Ridge-
crest
St.
Mary
TOTAL 1.2 28.2 23.2 4.2 17.2 34.2 27.2 37.2 -13.8

CARE 10
List of Figures
CMS Nursing Home Compare
Category
Desired Result from CMS Researcher’s Scoring
System in Points
Nursing Home Overall Rating 5 Stars 5
Health Inspection 5 Stars 5
Staffing 5 Stars 5
Quality Measures 5 Stars 5
Automatic Sprinklers Yes 1
Health Deficiencies Zero *See below
Complaints Zero Each complaint received a
score of -1.
Reported Incidents Zero Each reported incident
received a score of -1.
Fire Deficiencies Zero Each instance of fire
deficiency received a score
of -1.
Figure 1. Centers for Medicare and Medicaid Nursing Home Compare General Information
Ratings for Long-term Care Residents. *The average number of health deficiencies reported by
CMS (2016) in the US is 7.2. If the nursing home had deficiencies above 7.2, this is a negative
outcome. 7.2 was subtracted from the (higher) amount of deficiencies and represented as a
negative number. For example, a nursing home with 10.3 health deficiencies would have a score
of -2.1. If the nursing home had below 7.2 deficiencies, this number is subtracted from 7.2 and
represented as a positive score. For example, a nursing home with 3 health deficiencies would
have score of 4.2.

CARE 11
Nursing Sub-category Desired Result from CMS Researcher’s Scoring System
in Points
Licensed Nursing Staff Higher amounts of time The points are awarded here
by comparing the national
RN Hours Higher amounts of time average to the given nursing
home. If the given nursing
LPN/LVN Hours Higher amounts of time home is at or above the
national average for staffing
CNA Hours Higher amounts of time covered, it has been awarded
1 point. If the nursing home
Physical Therapy Hours Higher amounts of time is below the national average
for staffing covered, it has
been given zero points.
Figure 2. Centers for Medicare and Medicaid Nursing Home Compare Staffing Information for
Long-term Care Residents.
Penalty Issued CMS Desired Result Researcher’s Scoring System
in Points
Federal fines Zero Each fine issued received a
score of -1.
Federal payment denials Zero
Figure 3. Centers for Medicare and Medicaid Nursing Home Compare Penalties Information for
Long-term Care Residents.

CARE 12
Indicated Quality Measure CMS Desired Result Researcher’s Scoring System
in Points
1+ Falls Lower percentages are better. Points awarded have been
compared to the national
UTI Lower percentages are better. average. If the QM rated at
more than twice the national
Pain Lower percentages are better. average in negative terms, it
was given a score of -1. If
Bedsores Lower percentages are better. the QM rated between 0-49%
below the national average in
Incontinence Lower percentages are better. negative terms, it was given a
score of 0 (zero). If the QM
Indwelling catheter Lower percentages are better. rated at or between 1-49%
above the national average in
Physically restrained Lower percentages are better. positive terms, it was given a
score of 1. If the QM rated at
Mobility worsened Lower percentages are better. more than twice the national
average in positive terms, it
ADL help needs increased Lower percentages are better. was given a score of 2.
Lost too much weight Lower percentages are better.
Depressive symptoms Lower percentages are better.
Anti-anxiety/anti-hypnotic
meds given
Lower percentages are better.
Anti-psychotic meds given Lower percentages are better.
Physically restrained Lower percentages are better. A score of 2 was given for
zero use of physical
restraints.
Influenza vaccine given Higher percentages are better. A score of 2 was given for
100% compliance with
Pneumococcal vaccine given Higher percentages are better. administering vaccines.
Figure 4. Centers for Medicare and Medicaid Nursing Home Compare Quality Measure
Indicators for Long-term Care Residents.

CARE 13
Davenport or Bettendorf, IA Nursing Home Total Quality of Care Score Issued by the
Researcher
Bettendorf Health Care Center 1.2
Davenport Lutheran Home 28.2
Good Samaritan Society 23.2
Kahl Home for the Aged and Infirmed 4.2
ManorCare Health Services Davenport 17.2
ManorCare Health Services Utica Ridge 34.2
Iowa Masonic Health Facilities 27.2
Ridgecrest Village 37.2
St. Mary Healthcare and Rehabilitation
Center
-13.8
Figure 5. Total Quality of Care Score Issued by the Researcher to the 9 Davenport and
Bettendorf Nursing Homes.

CARE 14
Correlating the Cost and Level of Quality of Care in Nursing Homes in Davenport and
Bettendorf, Iowa
This manuscript will highlight that long-term care is costly, with the average price in the
state of Iowa to live in a nursing home being $175 per day (Iowa Nursing Homes 2016), or
$63,875 per year. The amount of the cost with the level of quality of care for nursing homes in
Davenport and Bettendorf, Iowa will be correlated. Level of quality of care will be measured by
using the information available on the Medicare.gov Nursing Home Compare Web site.
Background
The following section will discuss the background of long term care. According to
Cellucci, Wiggins, and Farnsworth (2014), long term care is an array of services such as home
health care, adult day care, assisted living, and nursing home care. This manuscript will focus on
nursing homes. A nursing home is a facility to house and care for people who can no longer
adequately care for themselves, and per the U.S. National Institute on Aging, nursing homes are
for anyone who requires constant care (Nursing Homes 2016). Bojazi and Tacchino (2016)
reported that approximately 70% of the aging population will someday need long-term care, with
nursing homes being especially essential for the frail elderly (Ness, Ahmed, and Aronow 2004).
There will always be costs associated with long-term care living; this informative will examine if
the level of quality of care increases with higher costs.
General Problem Statement
The general problem is that, according to a U.S. News and World Report, the cost of long
term care can be staggering (Mullen 2013). Per Bojazi and Tacchino (2016), the U.S. average
cost for nursing home care is $80,300 per year (p. 2). If one desires a private room in a nursing
home, the average price per year is $92,378 (Wibberley 2016). This can vary greatly up or down

CARE 15
depending on location. If one prefers the assistance of a home health aide for their long-term
care needs, the average price per year for these services is $46,332 (Wibberley 2016). Medicine
has become advanced and people are making healthier lifestyle choices, which means longer
lifespans. The public has misconstrued perceptions about the actuality of their long-term care
needs. According to an Associated Press-NORC Center for Public Affairs Research survey, only
25% of people over the age of 40 believe they will need long-term care someday, when the fact
is that 70% of Americans aged 65+ will require long-term care services (Kane 2013). Kane
(2013) explains that this gap in numbers shows how most Americans are not doing enough to
plan and save, and the survey shows that only 35% of Americans have saved funds for long-term
care needs (para. 7).
When people age, they become feeble and tend to need more assistance. According to
the National Council on Aging (2016), 92% of adults aged 65+ have one chronic disease, and
77% have two or more chronic diseases (Healthy Aging Facts 2016). Per information given by
the Family Caregiver Alliance’s National Center on Caregiving (2015), about 68% of people
above age 65 will need assistance with two ADLs, and 30% will need assistance with three
ADLs (Selected Long-Term Care Statistics 2015). Eyesight capabilities decrease, with 15
million people over the age of 50 developing age-related macular degeneration (Murphy and
Svoboda 2015). Approximately 20% of people over the age of 65 will need assistance with
transportation (Jeszneck 2015). Cognitive and physical capacity will decrease for adults aged
65+, effecting their ability to drive (Kang and Kim 2016). Per a report by the National Council
on Aging (2016), an elderly person is treated in an emergency room for a fall every 15 seconds,
and every 29 minutes, one will die because of a fall (Healthy Aging Facts 2016). As people age,

CARE 16
safety must become a focus with seven out of every ten Americans aged 65+ needing long term
care.
Approximately 10,000 Baby Boomers reach age 65 every day (Murphy and Svoboda
2015), and 70 million Baby Boomers in the US will be reaching retirement, and then old, age
(Wibberley 2016). As reported by the CDC (2012), chronic health conditions have been steadily
on the rise for Baby Boomers since the year 2002 (Johnson 2015). In the year 2010, 40 million
people were aged 65+; 5.5 million of these people were aged 85+, considered as the “frail
elderly”, needing significantly more care, specifically long-term care such as a nursing home
(Freundlich 2014). By the year 2050, it is projected that 88 million people will be aged 65+,
with 19 million of that number being aged 85+ (Freundlich 2014). That is roughly a 350%
increase in the number of frail elderly from the year 2010. The U.S. Department of Health and
Human Services (2014) projects that of the 70% of Americans receiving long-term care, the
average length of stay will be three years, and that planning to pay for services will “remain a
key policy question for lawmakers in the years to come” (Benz et. al. p. 2).
Specific Problem Statement
The specific problem is that the cost of long term care can be staggering, with the average
cost to live in an Iowa nursing home at $175 a day, or $63,875 per year (Iowa Nursing Homes
2016). This is below the national average of $80,300 per year as reported by Bojazi and
Tacchino (2016). If an Iowan lives in a nursing home for the three year average as stated by
DHS, he will be paying approximately $191,625 for (those three years of) care. A Government
Accountability Office (2015) analysis found that adults between the ages of 55 and 64 have
accumulated around $104,000 in retirement savings, which calculates to $310 a month if the

CARE 17
funds were invested into a lifetime annuity (Parker 2016 para. 1). The $310 that needs to last a
month would not even pay for two full days in an Iowa nursing home.
According to Jennifer Agiesta, director of polling for the Associated Press (2013), people
underestimate the cost of long-term care, and 37% believe that Medicare will pay the costs of
nursing home care (Kane 2013). Medicaid, a state-run program, paid 62.3% of the total U.S.
cost of long-term care in the year 2011, or $131.4 billion (Freundlich 2014). However, not all
nursing homes are Medicaid certified, nor accept Medicaid. In this manuscript, Medicaid will be
spoken of in regards to people aged 65+. For those nursing homes who do accept Medicaid, it
must be deemed “medically necessary” by a physician for the resident to reside at the nursing
home (Dickey 2016). Medicaid does not automatically pay for all nursing home costs, though,
and a set of guidelines must be followed. If a resident’s income or assets is over the Iowa
Medicaid income level, he must first “spend down” those assets and income before Medicaid
will begin to pay for the nursing home care (Dickey 2016).
Among all states, Medicaid spending is expected to grow 4.4% in fiscal year 2017,
compared to the 2.9% in 2016 reported by the Kaiser Family Foundation, with a total of
Medicaid spending forecasted to grow 4.5%, while enrollment for Medicaid is projected to grow
3.3% for FY 2017 (Mongan 2016). The money must come from somewhere, and States are
planning to reduce the amount of Medicaid dollars spent for nursing homes due to the Affordable
Care Act (ACA) provisions, therefore almost every state is pushing for long term care services to
be in-home or community-based settings (Mongan 2016).
Regarding the 37% of Americans who believe Medicare will cover their long-term care
costs, they are mistaken. Medicare will only cover a small portion of nursing home costs.
According to the Medicare.gov Web site (2016a), Medicare states that it does not cover costs of

CARE 18
custodial care in a nursing home, which is more of an ADL service, however it will cover skilled
care, such as intravenous medications (CMS). Medicare will also cover brief nursing home
stays, followed by 3+ day hospital stay that was covered under Medicare Part A (Centers for
Medicare and Medicaid).
Purpose Statement
The purpose of this research is to determine whether a relationship exists between the
cost of residency and level of quality of care in nursing homes located in Davenport and
Bettendorf, Iowa. Since people will continue to need long term care, the cost of that care will
constantly be in question.
ResearchQuestion
Because long term care and its (high) cost is inevitable, the presiding inquiry is if the
level of quality of care correlates with the cost of that care. The following question will be
researched in nursing homes in Davenport and Bettendorf, Iowa, geographically defined as the
Iowa side of the Quad Cities (Quad Cities CVB 2016).
RQ1: How does the cost of residency in nursing homes in Davenport and Bettendorf,
Iowa relate to the level of quality of care?
Hypotheses
H10: There is no correlation between the cost and level of quality of care in Davenport
and Bettendorf, Iowa nursing homes.
H1A: There is a correlation between the cost and level of quality of care in Davenport and
Bettendorf, Iowa nursing homes.
If H10 is validated, no correlation of the cost and level of quality of care in Davenport and
Bettendorf, Iowa nursing homes will be observed. If H1A is validated, higher costs of nursing

CARE 19
homes will be correlated with a higher quality of care in nursing homes in Davenport and
Bettendorf, Iowa.
Definition of Terms
Absenteeism. When an employee does not show up to work for a scheduled shift is
known as absenteeism (Castle and Ferguson-Rome 2015).
ADLs. Activities of daily living such as bathing, dressing, grooming, and toileting are
ADLs (Medicare.gov 2016).
Affordable Care Act (ACA). Signed by President Obama in 2010, the legislation’s full
name is the Patient Protection and Affordable Care Act (known widely as the ACA) is a federal
healthcare reform act that is meant to make healthcare more affordable for U.S. citizens and limit
healthcare spending, but has hundreds of provisions to address healthcare concerns, is the
Affordable Care Act (obamacarefacts.com).
Agency staff. Nursing staff who is employed with a staffing agency, not with the
nursing home itself, are known as agency staff (Castle and Engberg 2007).
Baby Boomers. The people in the generation who were born following WWII, between
the years 1945 and 1964, are called Baby Boomers (Census.gov).
Bedsores. Also known as pressure ulcers, are injury to skin and tissue that has been in
prolonged contact with a surface, such as a bed, are bedsores (MayoClinic.org).
CDC. The Centers for Disease Control and Prevention, part of the Department of Health
and Human Services, is the CDC (CDC.gov).
Centers for Medicare and Medicaid Services (CMS). A branch of the Department of
Health and Human Services that administers Medicare, Medicaid, CHIP, and the Health
Insurance Marketplace is the Centers for Medicare and Medicaid Services (CMS.gov 2016).

CARE 20
Certified nursing assistant (CNA). A person who is an assistant to a licensed nursed
that provides patient care in the form of taking patient vital signs, measuring and charting patient
input and output, transfer assists, and giving aide to patient ADLs is a certified nursing assistant
(MedicalDictionary.com).
Chronic health conditions. Diseases and conditions that last longer than three months
and cannot be cured are chronic health conditions (U.S. National Center for Health 2016).
Clostridium Difficile (C-diff). An infection attacking the lining of the intestines that
causes frequent diarrhea and abdominal pain is clostridium difficile (WebMD.com).
Department of Health and Human Services (DHHS). A U.S. federal department
concerned with the health and well-being of people is the Department of Health and Human
Services (thefreedictionary.com/DHHS).
Elder mistreatment. A generalized term encompassing the abuse, neglect, and
exploitation of elderly people is elder mistreatment (Falk et al. 2012).
Electronic Health Record (EHR). A real time source of information about patients or
residents for healthcare providers that is stored electronically, rather than on paper is an
electronic health record (Davis and LeCour 2014).
Frail elderly. Adults who are aged 85 years and older are considered the frail elderly
(Freundlinch 2014).
Government Accountability Office (GAO). An independent, nonpartisan organization
that oversees the proper spending of how the government spends U.S. taxpayers’ dollars is the
Government Accountability Office (gao.gov).

CARE 21
H. Pylori. Helicobacter Pylori is an infectious disease that lives in a person’s digestive
tract, often causing ulcers, sores, and sometimes stomach cancer, and is known as H. Pylori
(WebMD.com).
Health information technology (HIT). A branch of healthcare concerning the
electronic and technology aspect of patient care is health information technology (Davis and
LeCour 2014).
Home health aide. A nursing assistant who works with people in their homes to help
with activities of daily living is a home health aide (Medicare.gov 2016).
Iowan. A person who lives in the state of Iowa is called an Iowan (dictionary.com).
Licensed practical nurse (LPN). A person who has completed a one-year college-level
nursing program and holds licensure in practical nursing, working under the supervision of a
registered nurse to provide basic nursing care to patients is a licensed practical nurse
(MedicalDictionary.com).
Long-term care. An array of services such as home health care, adult day care, assisted
living, and nursing home care, that help people with activities of daily living comprise long-term
care (Cellucci et. al. 2014).
Long-term care ombudsman. A state-appointed person who is an advocate for nursing
home residents is a long-term care ombudsman (ltcombudsman.org).
Macular degeneration. A type of vision loss when the macula, part of the retina,
degenerates is called macular degeneration (WebMD 2016).
Medicaid. A state government run health insurance program covering low-income adults
and children is called Medicaid (Medicare.gov).

CARE 22
Medicare. A federal health insurance program for qualifying younger people, adults
aged 65+, the severely disabled, and people in end stage kidney failure is called Medicare
(Medicare.gov 2016).
MRSA. Methicillin-resistant Staphylococcus aureus is an infection caused by staph
bacteria that has become highly resistant to treatment and medications, and is known as MRSA
(mayoclinic.org).
Nursing home. A facility that provides 24-hour a day, long-term care for people who
need custodial- and skilled care is a nursing home (CMS.gov 2016).
Personal protective equipment (PPE). Garments such as gloves, gowns or eyewear
intended to protect the wearer from contamination or infection are known as personal protective
equipment (OSHA.gov).
Registerednurse (RN). A person who has graduated from a college-level nursing
program, is trained to provide patient care, and has passed a national licensure exam is a
registered nurse (MedicalDictionary.com).
Senator. A person who is elected by a state’s people that is a representative in the U.S.
Senate, which is a legislative body of the U.S. Congress, is a senator (merriam-webster.com).
Urinary tract infection (UTI). A bacterial infection of the urinary tract that is common
in residents of long-term care facilities is a urinary tract infection (Mayo Clinic 2016).
U.S. Department of Health and Human Services. A department of the U.S. Federal
Government who works to protect and heighten the health and well-being of Americans is the
U.S. Department of Health and Human Services (HHS.gov).

CARE 23
Literature Review
The following section is the literature review. Nursing home quality of care will be
explained from several indicators of quality, such as instances of resident infections, falls and
injuries, bedsores, pain levels, mobility, incontinence, and staffing levels. Legislation that deals
specifically with nursing homes will be discussed, such as the Nursing Home Reform Act of
1987, provisions of the Affordable Care Act considering nursing homes and long-term care, and
resident rights. Nursing home staff such as CNAs, LPNs, and RNs and the level of staffing that
is mandated by law will be overviewed.
Nursing Home Quality of Care
This literature review section is material regarding nursing home quality of care, briefing
the reader to what constitutes the quality of care received by the resident of a nursing home. The
Nursing Home Compare Web site offers information on every Medicare and Medicaid certified
nursing home in the United States, reporting an overall rating of the facility, health and safety
inspections, staffing levels, quality measures, and if the facility has received any penalties or
fines (CMS 2016b). Quality of care in nursing homes may be determined using various
indicators, which can include instances of resident infections, falls and injuries, bedsores, pain
levels, mobility, incontinence, and staffing levels (CMS 2016c). Any resident of a nursing home
who is utilizing Medicare and Medicaid imbursement will have an assessment, followed by the
creation of a care plan (Roach and Dexter 2010).
The occurrence of falls in the nursing home is a prevalent issue, with an average of 1.6
falls per resident per year (Vlaeyen et al. 2015). Nursing home residents are more prone to falls
due to their ailments or diseases, decreased mobility, number- and types of medications,

CARE 24
dementia, vision or hearing loss, and use of restraints (Leland, Gozalo, Teno, and Mor 2012).
The frail elderly population is more at risk of falls due to their multiple risk factors (Colon-
Emeric et al. 2013), as well as newly admitted residents since they are not as well known by the
staff (LeLand et al. 2012). Residents with dementia are almost two times more likely to fall than
residents without dementia (van Doorn et al. 2003). The effects of falls can be physically and
psychologically detrimental, and almost half of nursing home residents fall two or more times
per year (Vlaeyen et al. 2015). Every year, 4% of falls will cause injuries resulting in fractures,
with 11% of falls causing soft tissue damage or other injuries (van Doorn et al. 2003). The
Nursing Home Compare Web site reports that the national average of residents who fall and
experience major injury (per fiscal year) is 3.3%, with the Iowa average at 3.6% (CMS 2016b).
When measuring this quality in a nursing home, the facility would want the lowest percentage
possible. From a study that took place by the Scientific Institute for Quality of Healthcare
(2014), the researchers found that only 5% of at-risk residents received adequate preventive care
for falls (Van Gaal et al. 2014).
Up to 3 million serious infections occur each year in residents of long-term care facilities,
and approximately 380,000 people die (yearly) from these infections (CDC 2015). Any
resident’s diagnosed UTI infection will require treatment, which will have a cost range of $749
to $1,007 per instance (Freeman-Jobson, Rogers, and Ward-Smith 2016). Along with promoting
the health of the residents, the cost is another reason that prevention is so necessary.
Precautionary measures could include proper hygiene and hand-washing, emptying the bladder
regularly, drinking plenty of fluids, and using indwelling catheters only when prescribed by the
physician. Residents should have pitchers of fresh water and cups available in their rooms
always. If a UTI does occur, the caregivers should be trained to know the signs and symptoms,

CARE 25
then begin the process of diagnosing, followed by necessary treatment (Freeman-Jobson et al.
2016). The Nursing Home Compare Web site shows that the national average number of
residents acquiring UTIs (per fiscal year) is 4.6%, with Iowa residents at 5.5% (CMS 2016b).
When measuring levels of quality, the nursing home would want to have the lowest percentage
possible. In the Scientific Institute for Quality of Healthcare study, the researchers found that
only 41% of at-risk residents received adequate preventive care for UTIs (Van Gaal et al. 2014).
Another prevalent infection in nursing home residents is Clostridium difficile (C-diff)
because of their age and exposure to antibiotics (Hunter et al. 2016). C-diff is infectious, foul-
smelling, abdominally painful, and can cause frequent diarrhea or loose stools. C-diff is one of
the U.S.’s top antibiotic-resistant conditions and affects adults aged 65+ five times more often
than younger people (Hunter et al. 2016). Because it is so infectious, upon contact with the
resident, nursing staff will need to adorn necessary personal protective equipment (PPE) and
wash their hands thoroughly upon completion of patient care and removal of PPE. Nursing staff
should also ensure the resident is washing his or her hands frequently and properly. This will
reduce the spread of infection throughout the nursing home. A nursing home should strive to
have zero instances of C-diff infections.
Bedsores, also known as pressure ulcers, are a preventable condition in which the
prevention of should be priority for nursing home staff (Roach and Dexter 2010). The Nursing
Home Compare Web site states the national average number of residents (per fiscal year) with
bedsores, or pressure ulcers, is 5.7%, with the number in Iowa nursing homes being 4.0% (CMS
2016b). The facility should strive to have the lowest possible percentage to indicate the
infrequency of bedsores for their residents. The Scientific Institute for Quality of Healthcare
researchers found that only 20% of at-risk residents received adequate preventive care for

CARE 26
bedsores (Van Gaal et al. 2014). If a bedsore does develop, consistent documentation and
frequent communication between the physician and nursing staff will aid in the improvement of
the resident’s outcome (Roach and Dexter 2010).
An important aspect to consider is that falls, UTIs and other infections, and bedsores are
all preventable. Nursing homes with a high level of quality care will have lower instances of
these events than will nursing homes with a lower level of quality care. A tool for helping to
identify quality measures is the adoption of a health information technology (HIT) system, such
as a form of an electronic health record (EHR) (Alexander, Madsen, Miller, and Wise 2016). In
a study conducted by Alexander et al. (2016) the researchers found that quality measures are
positively impacted when nursing home staff has the proper means available to track resident
conditions. An example from their research is the starting number of residents with a UTI
decreases with the increased use of an EHR (Alexander et al. 2016). IT systems were also
positively identified as a successful tool for preventing falls when nursing home staff can view
and share resident information, patterns, and a fall-risk prevention plan (Colon-Emeric et al.
2013). These findings indicate that as nursing home staff has appropriate resources for tracking
resident conditions, resident health and quality of life will improve.
All healthcare facilities should respect and follow bioethical considerations and
guidelines, for this will help enhance quality of care. Very simply, ethics is knowing right from
wrong, good from bad, and choosing to do what is right and good. According to the “medical
indications principle”, it states that with granted informed consent, the physician should do what
is medically indicated so “more good than evil will result” (Baillie et. al. 2013). This concept
can be related from physicians to the rest of the resident’s care team. Bioethical principles to be
considered are resident autonomy, beneficence, and nonmaleficence. Respect for patient

CARE 27
autonomy is allowing the resident to make decisions for himself (Bratianu 2015). The nursing
staff should remember that the resident has not lost all his freedom, and dignify the resident’s
(reasonable and safe) choices. Beneficence is the principle of the health professional doing the
most good, and benefiting the largest number of people (McTeigue and Lee 2015). The goal of
medicine is to aid patients (and residents) in healing.
Nonmaleficence is the principle to do the least harm McTeigue and Lee 2015). Even
though the nursing staff must provide care that is sometimes uncomfortable, or even painful, for
residents, it must be balanced by beneficence (Bratianu 2015). The ethical consideration would
be to ensure that the end justifies the means. An example of this might be a CNA performing
range of motion with a semi-immobile resident. The discomfort the resident may feel for that
short period is justified to keep her joints flexible and muscles moving. Care givers have an
obligation to prevent and remove harms, balance the benefits against possible risks of an action,
and protect and defend the rights of their patients (Pantilat 2008).
Quality Assurance and Performance Improvement (QAPI) teams should be assembled to
aid the resident in having a say for her care plan, which will also resonate with respect for patient
autonomy (Brush and Calkins 2016). When the resident is an active participant at care planning
sessions, the resident will be more likely to comply (Brush and Calkins 2016). An example of
this would be a resident who wants to renew her license so she can drive a car again, but her
glaucoma and delayed reflexes prevent her from doing so safely. The care team will hear the
resident’s wishes and concerns, teach her why this is not a safe plan, and give her options for
safe traveling.
Quality improvement programs for the nursing home can prove challenging because
staffing levels are difficult to fulfill and facilities are operating with small and limited budgets

CARE 28
(Abrahamson 2016). Duke University researchers (2013) conducted a pilot study for reducing
falls in the nursing home, and findings suggest that the interventions used can heighten resident
outcomes by improving and educating on staff connections, information exchange, use of
cognitive diversity, and sense-making (Colon-Emeric et al. 2013). Specifically training nursing
staff about all possible risk factors of the nursing home’s population will greatly reduce multiple
instances of falls, infections, and bedsores, especially with residents suffering from dementia
who (at times) cannot clearly express their needs and/or symptoms (Van Gaal 2014). Continued
education, frequent training of staff, and administrators examining if current methods are
effective is a must for delivering quality care.
Finally, a nursing home who is accredited by the Joint Commission will perform better
on multiple levels than a non-accredited facility (Williams, Morton, Braun, Longo, and Baker
2016). In a study conducted by Joint Commission employees (2016), accredited nursing homes
performed better in areas of having less CMS deficiency citations, medication use, complaints,
confirmed abuse allegations, use of restraints, and contractures (Williams et al. 2016). To the
public, choosing a facility for a loved one who is accredited by the Joint Commission will be a
better choice than a non-accredited facility. Specific to quality of care standards, an accredited
nursing home will focus on resident-centered needs and guidelines (Williams et al. 2016).

CARE 29
Nursing Home Laws
This section of the literature review will be informative about various laws pertaining to
nursing homes, teaching the reader what legislation will be important to the facilities and their
residents. Congress passed the Older Americans Act of 1965 to increase social services, research
projects, and education regarding geriatrics and aging (ACL 2016). While the Older Americans
Act (OAA) was originally intended to help older adults stay in their homes (Jeszeck 2015), the
OAA Reauthorization Act of 2016 has amended that the state’s Long-Term Care Ombudsman
Program be advocates for residents in nursing homes (Yao 2016).
One of the most influential laws for long-term care, within the Omnibus Budget
Reconciliation Act (OBRA) (Zhao and Haley 2011), is the Nursing Home Reform Act of 1987,
which deems that a nursing home must be state-licensed, providing care that establishes the
highest possible quality of life for the residents (LII 2016). This Nursing Home Reform Act
states that a resident’s assessment of physical and mental capabilities must be conducted by a
registered nurse and completed by the appropriate health professionals, with each participating
professional signing their portion of the assessment (LII 2016). This assessment must be done
within two weeks of the resident’s admission to the facility, and must be repeated every three
months thereafter, with any falsification of records resulting in fines and employment actions
(LII 2016). The reasoning for this is to ensure that the residents have been accurately evaluated
to be prescribed and provided the best possible care. Further clarifications and mandates within
this law require that nursing assistants must be certified professionals or uncompensated,
voluntary workers (LII 2016). The totality of this law renders the legal certification of the health
professionals working within the nursing home, the rights that are due to the residents, and the
assurance that these rights are recognized and brought to fruition. The Nursing Home Reform

CARE 30
Act has garnered positive results. Largely in part of the 24-hour RN staffing regulation, there
was a decrease in numbers of residents with pressure ulcers, physical restraints, and urinary
catheters decreased (Harrington et al. 2016).
The specific list of nursing home resident rights can be found a various organizations’
fact sheets, on the Medicare.gov Web site, within the Nursing Home Reform Act legislation, and
should be given to residents upon arrival in the nursing home. Residents have the right to be
fully informed, to participate in their own care, which includes participation in their care plan as
well as the refusal of medications and treatments (NCC for NHR 1999). Residents have the right
to privacy, confidentiality, and to make independent choices (NCC for NHR 1999). If this does
not contraindicate the health and safety of others, residents have the right to visitors and to keep
their belongings (CMS 2016d). Residents have the right to stay in the nursing home unless
medically indicated (NCC for NHR 1999), and to have their room feel comfortable and like
home (CMS 2016d). Residents have the right to complain; this could be with their state’s long-
term care ombudsman or the nursing home’s staff, free of repercussions (NCC for NHR 1999).
The most important in any healthcare setting, residents have the right to dignity, respect, and
freedom, including being free from elder abuse (NCC for NHR 1999).
Medical malpractice is a hot topic within healthcare, but little research has been centered
around malpractice within nursing homes (Konetzka, Park, Ellis, and Abbo 2013). In a 2004
study conducted by Troyer and Thompson, their findings indicate that when a nursing home
produces a lower quality of care, that nursing home has a greater likelihood of malpractice
accusations (Konetzka et al. 2013). In 1997, the Government Accountability Office (GAO)
reported over 20 serious offenses of quality care levels that were not attended to as set forth by
the Nursing Home Reform Act (Wells and Harrington 2013). The GAO was interested in this

CARE 31
matter because the Nursing Home Reform Act is funded by government (taxpayers’) dollars.
The Affordable Care Act (ACA) has new provisions regarding stricter reporting on the
companies (real estate, banks, accountants) involved with the nursing homes, which has been
said to be helpful in tracking malpractice claims (Zhao and Haley 2011).
One of the most notable changes to the ACA regarding long-term care is called the
Nursing Home Transparency and Program Improvement Act of 2009 (Subtitle B), which
basically stipulates that nursing homes must be held more accountable for reporting facts such as
staffing levels, ownership status, and having more readily available information on the
Medicare.gov Nursing Home Compare Web site (Wells and Harrington 2013). Stricter
guidelines for background checks for any nursing home employees who provide direct patient
care and tighter regulations for facilities participating in Medicare and Medicaid also now exist
(Wells and Harrington 2013).
Regarding the population of Iowans, what is interesting about Subtitle B is that the
Nursing Home Transparency and Improvement Act was introduced by Senators Chuck Grassley
of Iowa and Herb Kohl of Wisconsin (Siegel and Nied 2010). Senators Grassley and Kohl felt
strongly that certain information should be more scrupulously reported to the Department of
Health and Human Services (DHHS) and the state’s long-term care ombudsman, more
specifically the owners, operators, and accountants, with the goal of being held more accountable
for their actions or inactions (Siegel and Nied 2010). This provision will result in an increase of
their liability and possible litigation if accusations are merited.
Title XX of the Social Security Act of 1974 is what stimulated the creation of Adult
Protective Services, which set the path for further legislation for the older population (NAPSA
2016). A branch of the U.S. Administration on Aging, the National Center on Elder Abuse

CARE 32
(NCEA) has a mission to ensure that older adults are free of elder mistreatment (Chen, Twomey,
and Whittier Elias 2012). As part of the ACA, the Elder Justice Act was passed in 2010, which
fights elder abuse, appropriating approximately 75% of its budget to Adult Protective Services
(APS) (Falk, Baigis, and Kopac 2012). It is noted that this act is not only for elder mistreatment,
but rather justice for elders, focusing more on the issue of human rights (Falk et al. 2012). The
Elder Justice Act and the work of organizations such as the NCEA and APS can only be
successfully achieved if the community, significantly the long-term care health workers, are
educated in detecting elder mistreatment and how to report such instances (Chen et al. 2012).
Another type of abuse comes in the form of Medicare and Medicaid fraud. In the year
2011, almost $98 billion of Medicare and Medicaid spending went toward fraudulent causes,
such as billing for services not rendered, or incorrect billing (Goldman 2012). The Medicare-
Medicaid Anti-Fraud and Abuse Amendments of 1977 set forth “fraud control units”, consisting
of independent accountants, attorneys, and investigators, to find and punish any fraud (Goldman
2012). An example of this in the nursing home setting is the case of United States vs. Lorenzo.
Dr. Lorenzo was a dentist who billed Medicare for “consultations” of nursing home residents,
which were not ordered nor medically indicated by a physician (Showalter 2015). Dr. Lorenzo
received payments of $130,719.20 from 3,683 fraudulent billing cases, in which the court
assessed to the defendant $19 million in damages (Showalter 2015).
The Health Insurance Portability and Accountability Act (HIPPA) was passed in 1996,
and within this legislation was the federal Health Care Fraud and Abuse Control Program
(Goldman 2012). This is another amendment dealing with antifraud cases. It is like the
Medicare and Medicaid Anti-Fraud and Abuse Amendment which penalizes offenders with
fines, however different because penalties now include a ten-year prison time (Goldman 2012).

CARE 33
Nursing Home Staffing Levels
This section of the literature review will focus on staffing levels in nursing homes.
Typical staff found in a nursing home will be registered nurses (RNs), licensed practical nurses
(LPNs), and certified nursing assistants (CNAs) (Leland et al. 2012). It has been reported that
many nursing homes have severe inadequacies of quality measures, largely due to staffing issues
(Harrington et al. 2016). The Nursing Home Reform Act, discussed more at length in the
“Nursing Home Laws” section, explains that the facility must provide continuous services by
licensed nursing staff that is adequate to administer the level of care its residents require (LII
2016). No scholarly articles regarding a set number for nurse-to-patient ratio have been found.
This may be due to all residents needing a varying level of care. The Centers for Medicare and
Medicaid state that there is no federal mandate for staffing levels, and report nurse-to-resident
contact in the form of minutes per day (CMS 2016b). The Nursing Home Reform Act does list
that a nursing home is required to employ a registered nurse every day, with eight successive
hours of working (LII 2016). Also noted is that some individual states have adopted their own
legislation of standards regarding minimum staffing levels and/or staff-to-resident ratios (Chen
and Grabowski 2015).
As a provision within the ACA on behalf of the Nursing Home Reform Act, nursing
homes must report their staffing data to DHHS (based on payroll) (Siegel and Nied 2010), and it
is reported from a two-week period immediately prior to the yearly inspection from the nursing
home’s state surveyors (CMS 2016e). It is still unclear exactly how to interpret this data. The
Centers for Medicare and Medicaid provide a disclaimer statement saying that when reporting
the nursing staff-to-resident ratio, it is the total number of minutes worked by the particular

CARE 34
nursing category divided by the number of residents (CMS 2016e). The information does not
totally reflect the actual number of minutes spent with each individual resident.
The Nursing Home Compare Web site lists the national and state average of nursing
staff-to-resident ratio in minutes per day, but only provides this information for nursing homes
who are Medicare and Medicaid certified (CMS 2016e). It lists that the national average of RN-
to-patient contact is 50 minutes per day, with the Iowa average being 48 minutes per day (CMS
2016b). The national average of LPN-to-patient contact is 51 minutes per day, with the Iowa
average being 37 minutes per day (CMS 2016b). The national average of CNA-to-patient
contact is 2 hours and 28 minutes, with the Iowa average being 2 hours and 27 minutes per day
(CMS 2016b). The higher these minutes per day accumulate is the measure of nursing care the
residents receive, therefore the higher the minutes, the better.
Gathering information from over 150 staffing studies, it is noted that the level of nursing
home quality increases with RN hours (Harrington et al. 2016). A study conducted by Zhao and
Haley (2011) emphasizes the information listed above, and that a nursing home will have lower
numbers of deficiencies, falls, UTIs, and bedsores when the RN staffing levels are higher. The
researchers even suggest to increase the nursing home’s number of working RNs because of the
positive correlation with fewer malpractice claims (Zhao and Haley 2011). One could think of
the adage “spend money to make money”, suggesting that spending increased funds on paying
RN wages will prove more lucrative in the future because of fewer lawsuits and less pay-outs.
It is imperative that nursing homes have sufficient numbers of staff in which to rely
because turnover rates are negatively correlated with the delivery of quality care (Zhang, Unruh,
and Wan 2013). With low numbers, staff may be called upon to work double shifts or overtime,
causing burnout and work overload (Zhang et al. 2013). CNAs are especially likely to feel the

CARE 35
burnout providing the majority of hours of direct resident care, often tolerating less-than-
desirable behaviors from some residents, or emotional feelings when a resident has died (Castle
and Ferguson-Rome 2015). Nursing home administrators have a difficult task of making the
staff expectations reasonable while still adhering to federal and state regulations to provide the
highest quality of care. Administrators may have to redistribute funds away from departments
such as housekeeping, maintenance, or dietary to be able to increase the numbers of nursing staff
(Chen and Grabowski 2015). Reallocation is suggested so the facility does not go in the red.
Researchers also suggest that administrators evaluate the specific needs of current residents and
base staffing upon this, such as having more LPNs if medication needs are high, and more CNAs
if repositioning and ADL needs are high (Zhang et al. 2013). Dawson (2016) also suggests
continued education, training, and stricter certification and licensing requirements to enhance the
quality of the entire existing staff.
Although studies suggest higher RN staffing levels are correlated with positive resident
outcomes, the bulk of resident care is performed by non-licensed caregivers (Freeman-Jobson et
al. 2016), estimating that CNAs provide about 80% of direct care in the nursing home (Castle
and Ferguson-Rome 2015). Because of the increase of the older population, direct care workers
such as CNAs will outnumber grade school teachers, fast food workers, RNs, and policemen by
the year 2022 (Dawson 2016). While CNAs are not licensed like LPNs or RNs, the state of Iowa
has mandated regulations. If the nursing assistant has not completed the 75-hour CNA state-
approved program, that NA shall complete 20 hours of in-house training before any resident
contact (Iowa Code 2009). Subsequently, the 75-hour program to become a certified NA must
be fulfilled within six months of hire, and all legal documentation will be kept in the employee’s
file (Iowa Code 2009).

CARE 36
Oftentimes nursing homes employ the use of agency staff due to their regular staff having
time off or employment vacancies. While the facility is meeting their nursing staff quota for the
shift or day, agency staff has been correlated with a lower overall quality of care (Castle and
Engberg 2007).
Nursing homes with higher CNA staffing levels have a lower rate of resident falls
(Leland et al. 2012). Providing adequate, quality care in the form of frequent positioning to
residents with immobility or limited mobility will reduce the instance of bedsores (Van Gaal et
al. 2014). This can only be achieved when there is a sufficient staff.

CARE 37
Method
The following section of this capstone will include information about the research
method of collecting information from the Centers for Medicare and Medicaid Nursing Home
Compare Web site regarding the quality of care delivered to the residents of each of the nine
nursing homes that were studied. The accessible population to be discussed is the residents of
nursing homes in Davenport and Bettendorf, Iowa. The sampling frame for this research
includes nine nursing homes in Davenport and Bettendorf, Iowa. The collected data of the cost
per day of the facilities and the information from the CMS Nursing Home Compare Web site
will be analyzed and correlated to the hypotheses.
ResearchMethod and Design Appropriateness
The goal of any research project is to gain knowledge and insight into answering the
given research question, and the research method is a systematic way of gathering information to
be studied for validating the hypotheses (Mahmood 2010). Qualitative research methodology is
acquiring descriptive data, while quantitative data includes information that is measurable with
numbers (NCHEC 2015). This Capstone is predominantly qualitative and descriptive in nature,
with qualitative data collected from the Centers for Medicare and Medicaid
NursingHomeCompare.gov Web site and the average cost per day for long-term care of each
facility, collected through phone conversations with nursing home representatives. The quality
of care in seven Davenport and two Bettendorf nursing homes will be rated using a scale
designed by the researcher to measure a level of care.

CARE 38
Population
A population is a group of things or people about which data is being collected, and
Mosby’s Medical Dictionary (2009) defines it in terms of statistics, with the population being the
subjects of which to study. The target population for the general purpose statement of the cost of
long term care being staggering in the United States (Mullen 2013) would be all residents of
nursing homes in the country. The accessible population is a smaller sample size of the target
population for which the researcher has access (Mack 2016). The accessible population for this
Capstone includes residents of nursing homes in Davenport and Bettendorf, Iowa. A resident in
a nursing home is generally a person who is over the age of 65 who can no longer adequately
care for himself, living in a facility that provides 24-hour a day, long-term custodial- and skilled
care (MedlinePlus 2016). With the average cost to live in an Iowa nursing home being $175 a
day (Iowa Nursing Homes 2016), or $63,875 per year, it will be determined if the residents in
Davenport and Bettendorf, within Scott County, nursing homes are receiving quality care for this
cost.
As of 1 July 2015, Scott County, Iowa had a population of 172,126, with 14.8% of this
number being people aged 65 or older (US Census Bureau 2015). This equates to 25,475 adults
aged 65 and older in Scott County, Iowa. In a University of Iowa report by the Center for Aging
(2012), people aged 60 and above are considered “older adults”; the census has projected that by
the year 2025, Scott County will have a 25% population total of older adults, and a 50%
population total of older adults in the year 2040. With Scott County’s inevitable increase in its
older adult population, nursing home care, and an acceptable level of quality, will always be
necessary.

CARE 39
Sampling Frame
Only nursing homes offering skilled care are being evaluated. Davenport houses seven-
and Bettendorf houses two skilled care nursing facilities. These nine facilities include:
1. Bettendorf Health Care Center. 2730 Crow Creek Rd. Bettendorf, IA 52722. This
facility is represented as BHC in data tables.
2. Davenport Lutheran Home. 1130 W. 53rd St. Davenport, IA 52806. This facility is
represented as Lutheran in data tables.
3. Good Samaritan Society. 700 Waverly Rd. Davenport, IA 52804. This facility is
represented as GoodSam in data tables.
4. Iowa Masonic Health Facilities. 2500 Grant St. Bettendorf, IA 52722. This facility is
represented as Masonic in data tables.
5. Kahl Home for the Aged and Infirmed. 6701 Jersey Ridge Rd. Davenport, IA 52807.
This facility is represented as Kahl in data tables.
6. ManorCare Health Services. 815 E. Locust St. Davenport, IA 52803. This facility is
represented as MC Dav in data tables.
7. ManorCare Health Services – Utica Ridge. 3800 Commerce Blvd. Davenport, IA
52807. This facility is represented as MC Utica in data tables.
8. Ridgecrest Village. 4130 Northwest Blvd. Davenport, IA 52806. This facility is
represented as Ridgecrest in data tables.
9. St. Mary Healthcare and Rehabilitation Center. 800 E. Rusholme St. Davenport, IA
52803. This facility is represented as St. Mary in data tables.

CARE 40
Data Collection
Initial data was collected for the literature review chapter which included scholarly
research articles regarding quality measures in the nursing home regarding staffing levels, ethical
considerations, Joint Commission accreditation, and instances of resident infections, falls and
injuries, bedsores, pain levels, mobility, and incontinence. The collection of this data was
predominantly qualitative, with some quantitative data presented with national statistics of
prevalence rates.
Qualitative data to be analyzed will be collected from the Centers for Medicare and
Medicaid Nursing Home Compare Web site regarding publicly reported data for each nursing
home. General information about the nursing home that was collected is the overall rating,
health inspection, staffing quality measures, automatic sprinklers, health deficiencies, number of
complaints, number of reported incidents, and number of fire deficiencies (see Table 1). Staffing
information about the nursing staff was collected regarding the number of hours RNs,
LPNs/LVNs, CNAs, and physical therapists spent per day with each resident (see Table 2).
Instances of federal fines or the denial of federal payments were collected on each nursing home
(see Table 3). A list of quality measures for each nursing home was collected, including
instances of resident falls, UTIs, pain levels, bedsores, incontinence, indwelling catheter,
physical restraints, worsened mobility, ADL assistance increases, losing too much weight,
depressive symptoms, vaccines, and the use of antihypnotic-, antipsychotic-, and antianxiety
medications (see Table 4). The price per day for long-term care of the Davenport and Bettendorf
nursing homes of both a private- and semi-private room was obtained each nursing home
representatives.

CARE 41
Data Analysis
Each nursing home representative provided their cost per day for both a private- and
semi-private room. These two costs were averaged to serve as one cost per day average per
nursing home. One nursing home only offered private rooms, and this was used as its average
cost per day. To measure quality of care levels, all information gathered from the CMS Nursing
Home Compare Web site was comprised into tables using four categories: General Information,
Staffing, Penalties, and Quality Measures. This data was composed into a numerical scoring
system developed by the researcher. Each, individual measure of care was compared to the
national average for that sub-category, and given points in order to compute an overall quality of
care score for the nursing home (see Table 5).
Within the General Information category, the measures of Overall Rating, Health
Inspection, Staffing, and Quality Measures each had a possible 5-point score, as they are rated on
the CMS Nursing Home Compare Web site in terms of 5 stars, with 5 being the best rating. The
presence of automatic sprinkler systems was given 1 point. The average number of health
deficiencies in the United States is 7.2 (CMS 2016b). If the nursing home had deficiencies
above 7.2, this is a negative outcome. 7.2 was subtracted from the nursing home’s (higher)
number of reported deficiencies, and represented as a negative number (rating) to indicate the
negative outcome. For instance, a nursing home with 10.3 health deficiencies would have a
score of -2.1. If the nursing home had below 7.2 deficiencies, this number is subtracted from 7.2
and represented as a positive number to indicate the positive outcome. For instance, a nursing
home with 3 health deficiencies would have score of 4.2. Each reported complaint, incident, and
fire deficiency was given a negative number as its score. For example, a nursing home with one
reported complaint would have a score of -1. A rating of zero for these three measures is ideal.

CARE 42
Staffing information is represented with five sub-categories. The points are awarded
here by comparing the national average of each sub-category to the given nursing home. If the
given nursing home is at or above the national average for staffing covered, it has been awarded
1 point. If the nursing home is below the national average for staffing covered, it has been given
zero points. The data being analyzed is the hours per day spent with each resident by RNs,
LPNs/LVNs, CNAs, Physical Therapists, and the overall time spent with each resident by all
staff.
In the Penalties category, if a nursing home received any federal fines or was denied
federal payment, each instance was given a rating of -1 to indicate the negative outcome.
The Quality Measures category is the most detailed. In some instances, a higher
percentage is considered the desired score, while in others a lower percentage is ideal. A rating
of -1 was appointed if the measure was more than twice the national average in negative terms.
A rating of 0 (zero) was appointed if the measure was between 1-49% below the national average
in negative terms. A rating of 1 was appointed if the measure was between 1-49% above the
national average in positive terms. A rating of 2 was appointed if the measure was more than
twice the national average in positive terms. A score of 2 was given for 0% physical restraints
used. A score of 2 was given for 100% compliance with administering vaccines.
All results are listed in the Tables chapter. The scores for measuring the level of quality
care are as follows: St. Mary Healthcare and Rehabilitation Center scored a -13.8 for quality of
care, with an average daily rate of $225 (phone communication, Carla Hall, December 13, 2016).
It is also important to note that St. Mary is under investigation by CMS due to its severely low
performance (2016b), which supports the low quality score. Bettendorf Health Care Center
scored 1.2 for quality of care, with an average daily rate of $208 (phone communication, Chrissy

CARE 43
Mikles, November 29, 2016). The Kahl Home for the Aged and Infirmed scored a 4.2 for
quality of care, with an average daily rate of $295 (phone communication, Anonymous Kahl
Home representative, November 28, 2016). ManorCare Health Services Davenport scored a 17.2
for quality of care, with an average daily rate of $241 (phone communication, Anne Sieprawski,
November 29, 2016). Good Samaritan Society Davenport scored 23.2 for quality of care, with
no daily rate available. Iowa Masonic Health Facilities scored 27.2 for quality of care, with an
average daily rate at $218 (phone communication, Marsha Alexander, November 29, 2016). The
Davenport Lutheran Home scored 28.2 for quality of care, with no daily rate available.
ManorCare Health Services Utica Ridge scored 34.2 for quality of care, with an average daily
rate of $267 (phone communication, Hope Greenwood, November 29, 2016). Ridgecrest Village
scored 37.2 for quality of care, with no daily rate available.
Of the nursing homes with the average daily rate for long-term care available,
St. Mary cored the lowest rating for quality of care at -13.8, with an average daily cost of living
at $225. Bettendorf Health Care Center scored the second lowest rating for quality of care at 1.2,
and has the lowest daily cost of living at $208. Pertaining to H1A, there no direct correlation
between the cost and level of quality of care in Davenport and Bettendorf, Iowa nursing homes,
seeing as St. Mary has a much lower quality of care score, yet is more costly than Bettendorf
Health Care Center. Iowa Masonic Health Facilities scored 27.2, which is 26 points greater than
Bettendorf Health Care Center, and with an average daily rate at $218, costs just $10 more per
day. The cost of daily living at St. Mary is still higher (at $225) than at Iowa Masonic, with St.
Mary having a quality of care score 41 points lower than Iowa Masonic. When viewing the data
for the Kahl Home for the Aged and Infirmed, the facility rated with a 4.2 quality of care score
with an average daily rate at $295. When comparing all the data of quality of care ratings and

CARE 44
daily costs of living, H1A would be refuted. These findings support the H10 null hypothesis that
there is no correlation between the cost and level of quality of care in Davenport and Bettendorf,
Iowa nursing homes.

CARE 45
Findings
The following section of this capstone will discuss limitations to the research, use and
applications of findings, and recommendations of the research.
Limitations
The following is a discussion about the limitations of this research. One limitation was
the time constraint, as this capstone was conducted in just 10 weeks. One aspect that limited
research was the lack of primary data. A collection of interviews of staff, residents, and
residents’ families would have been enlightening to have first-hand opinions of conditions and
quality measures. The residents are the customers of the nursing home, relying on the nursing
staff for assistance with many ADLs, transfers, medications, or even as simple as a fresh glass of
ice water. Having the residents’ opinions on the quality of care provided, the wait time after
pushing a call light, and how often they actually receive a bath would be invaluable information.
If it were possible to measure friendliness, warmth, and hospitality, it would be. It would also be
beneficial to be able to measure a “fun factor” for the residents. For the residents who are
capable, it would be interesting to know if they are offered engaging and thoughtful activities
that would be enjoyable and doable, like crafts, card games, or visiting performers. That is the
kind of insight that could be gathered by conducting resident interviews.
The CMS Nursing Home Compare Web site gives data as to the findings from the CMS
review of a facility. Deficiencies and complaints are listed in number form, such as 11
deficiencies for that reporting period. It is possible to open a hyperlink within the “Health
Inspection” details to view the complaints as documented by CMS. Furthermore, it would be

CARE 46
informational to know what the nursing staff and/or facility did to rectify the inimical situation,
and what follow-up occurred.
A limitation to analyzing the data is that only 6 of the 9 nursing home administrators
contacted were available or willing to disclose the average price per day of skilled care. It would
also have been beneficial to know the nursing home’s status with the Joint Commission, and
whether it is accredited.
Use and Application of Findings
Despite the limitations, this research indicates that there is not a correlation between the
cost and level of quality of care in nursing homes in Davenport and Bettendorf, Iowa. The use
and application of these findings may contribute to the betterment of quality procedures and
guidelines through administrative guidance and nursing staff continued education, and
compliance with Medicare and Medicaid mandated regulations for a high level of achievement
on the nursing home’s behalf. The following will explain recommendations for Davenport and
Bettendorf nursing homes.
Recommendation: Increase career skills for nursing staff in an effort to improve quality of
care. Eight of the nine nursing homes studied had an overall Staffing rating of 4 out of 5 stars.
Regardless, the level of quality provided is inconsistent. Following a study of interventions
specifically aimed at changing staff behaviors of care for improved resident outcomes (2015),
Low et al. suggests that bettering these practices for heightened resident outcomes is complex,
but possible. Findings also showed that not only did resident outcomes improve, but the staff
now enjoyed their duties and felt more autonomous (Low et al. 2015). This could also aid in the
deficiencies of retention.

CARE 47
Only five of the nine studied nursing homes had acceptable ratings for residents with one
or more falls in the reporting period. The four nursing homes with deficient scores for number of
residents with more than one fall all had a staffing score of 4 out of 5 stars. There is no reason
why this many residents should have falls when staffing numbers are above average. Many falls
that occur in the nursing home are preventable (Nursing Home Abuse Guide 2016), especially
with adequate staffing. Reasons for a resident fall can include weakness, immobility issues,
negligence, hazardous entities such as wet floors or improper bed heights (Nursing Home Abuse
Guide 2016), improper transfer techniques, and inadequate resident care plans (Rich 2015). One
of the most reoccurring reasons for falls in the nursing home is the resident needing assistance to
use the toilet, and call lights not being answered quickly enough (Angel 2013). This is
understandable on behalf of the resident; regardless of being a resident in a nursing home, these
people wish to retain their dignity and continence, which could be a reason the residents often go
to the toilet unassisted. It is sometimes difficult for the CNAs when they are assigned eight to
ten residents on their watch, have three scheduled baths, are often assisting fellow CNAs with
transfers, must dress residents and get them to the dining hall, make beds, and multiple call lights
are beeping. Adequate staffing numbers should ease this predicament. Also worth noting is that
CNAs have the most physically demanding responsibilities and are paid the least (Angel 2013).
In Davenport and Bettendorf, Iowa the (typical) starting wage for a CNA is $9 per hour, which
can increase with shift differentials and years on the job, but is a lesser wage than most
McDonalds jobs in Davenport (Glassdoor 2016). It is unfortunate that CNAs are entrusted with
the care of people’s loved ones, yet get paid less than flipping frozen burgers and taking drive-
thru orders. This subject could become another entire research paper, but perhaps if CNAs were
paid more for their responsibilities and strenuous work, they might take more pride in their job

CARE 48
and move at a more efficient pace, such as answering the call lights faster for toileting purposes,
thus reducing resident falls.
Training staff members, and ensuring the implementation, of fall prevention guidelines
and procedures should be a high priority for nursing home administration. Instilling the use of
resident motion-detector alarms (such as a mat on the seat of the wheelchair that beeps if the
resident raises off the seat) and remembering to lower beds after linen changes will positively
affect the number of resident falls and injuries (Angel 2013). If a CNA is called into a room for
toileting assistance, the aide will turn off the chair alarm before transferring the resident. If the
resident attempts to transfer himself, the alarm will sound, notifying staff of an unassisted
transfer, thus speeding them along to the resident location. A strong and influential Director of
Nursing or Nursing Home Administrator must stay involved and actively lead the staff toward
these success-proven methods (Fleming and Kayser-Jones 2008). A nursing home administrator
who is impassioned for this change and willing to take the necessary steps to further train and
educate her staff would be recommended for all nine nursing homes studied in this capstone.
Recommendation: Indwelling catheters should only be used when prescribed by a
physician. Only four of the nine nursing homes studied had at- or above the national standard
for the use of indwelling catheters. UDHHS instilled a plan in 2013 to reduce the instance of
indwelling catheter infections for nursing home residents, funded by the Agency for Healthcare
Research and Quality (AHRQ) (Mody et al. 2015). The prevalence of UTIs are greater in
residents with an indwelling catheter than without (Mody et al. 2015) due to the colonization of
bacteria in the device (Mody, Maheshwari, Galecki, Kauffman, and Bradley 2007), which is why
it is imperative for the proper use of indwelling catheters. This is an important resident-safety
factor to consider (Mody et al. 2007). UTIs can become much worse and more widespread

CARE 49
infections if not treated properly, even leading to death in some cases (Freeman-Jobson, Rogers,
and Ward-Smith, 2016).
Educational aspects presented by the AHRQ to reduce infection by indwelling catheters
are to teach staff necessary handwashing techniques for before and after contact with residents,
proper use of PPE, removal of counterindicated catheters, and proper maintenance of indwelling
catheters (Mody et al. 2015). Nursing staff frequently does not complete the recommended
evaluation of whether the indwelling catheter should be removed (Chen, Chi, Chen, Yu-Chih,
and Wang, 2013). Catheters should not remain indwelling for the purposes of care for an
incontinent resident or collecting urine specimens, or if the resident can voluntarily void (Chen et
al. 2013). Recommended by the Healthcare Infection Control Practices Advisory Committee,
putting together a system of reminders for the staff to maintain the proper upkeep and evaluation
of residents with indwelling catheters will help decrease the instance of UTI (Chen et al. 2013).
These reminders and resident evaluations did receive resistance from physicians and nursing
staff when being implemented in the study conducted by Chen et al. (2013), however the data
ultimately showed a reduction in the prevalence of indwelling catheter infections. This would be
a very useful tool for the five Davenport and Bettendorf nursing homes who were below the
national standard for this quality measure.
Recommendation: Be aware of what constitutes the CMS delegation of federal fines and
payment denials. Upon the evaluation of the “Penalties” category, 6 of the 9 nursing homes
studied have been issued federal fines, and 2 of the 9 nursing homes have received payment
denials from Medicare and Medicaid in the past three years. Of the 2 nursing homes denied
payment from Medicare and Medicaid, St. Mary of Davenport was denied payment on two
occasions. The Centers for Medicare and Medicaid report that fines will be issued until the

CARE 50
nursing home corrects the deficiency, and the Federal government will cease Medicare and
Medicaid payment to a nursing home until the identified insufficiency has been rectified (CMS
2016d).
A limitation to this research is that the CMS Nursing Home Compare Web site does not
issue detailed information for why a nursing home received a fine or was denied payment.
According to the GPO’s detailed report (2011) of 42 CFR §488.406, the most severe penalty
issued is a termination of provider agreement between CMS and the nursing home. Dependent
upon the facility’s history of said deficiency and the relationship of the infraction to another,
penalties issued could include the transferring of residents out of the nursing home, directed plan
of correction or training, denial of payment for new resident admissions, and total closure of the
facility (GPO 2011). The nature of penalties can include the nursing home’s noncompliance
with the set forth Federal standards for more than three months, and three consecutive survey
reports showing a substandard quality of care (Levinson 2008). This report does not give
instances of what constitutes the offenses. More information is needed to properly evaluate the
penalties and payment denials.

CARE 51
Conclusion
People will continue to need long-term care, and nursing homes will continue the battle
between difficult reimbursement policies, costs of operations, and the fact that the two may not
balance (Abrahamson 2016). This manuscript highlighted the general problem that long-term
care is costly in the United States, with the specific problem being that long-term care is costly in
Davenport and Bettendorf, Iowa. The average price in the state of Iowa to live in a nursing home
is $175 per day (Iowa Nursing Homes 2016), or $63,875 per year. Of the collected data, the
average cost per day to live in a Davenport or Bettendorf nursing home is $242 per day, or
$88,330 per year. This is almost a 40% increase over the Iowa average for cost per day of living
in a nursing home.
As the background of long-term care was discussed, Bojazi and Tacchino (2016)
reported that approximately 70% of the aging population will someday need long-term care. The
actual numbers of this 70% will continue to increase, as by the year 2050, it is projected that 88
million people will be aged 65+, with 19 million of that number being aged 85+ (Freundlich
2014). The purpose of this research was to determine whether a relationship exists between the
cost of residency and level of quality of care in nursing homes located in Davenport and
Bettendorf. Since people will continue to need long term care, the cost of that care will
constantly be reviewed, with the research question being: how does the cost of residency in
nursing homes in Davenport and Bettendorf, Iowa relate to the level of quality of care? The
null hypothesis was that there is no correlation between the cost and level of quality of care in
Davenport and Bettendorf nursing homes. With hopes that the (high) cost of living in a nursing
home is therefore matched with a high level of quality of care, the supporting hypothesis was

CARE 52
that there is a correlation between the cost and level of quality of care in Davenport and
Bettendorf, Iowa nursing homes.
In the Literature Review section, nursing home quality of care was explained using
several indicators of quality, and were used because this is the information found on the CMS
Nursing Home Compare Web site. Of the 3 million serious infections that occur each year in
residents of long-term care facilities, the only type of infection for which this Web site offers
information is a UTI. Having available data about the instances of the five most common
infections for people aged 65+ would be ideal. These additional ailments would include skin
infections such as shingles or MRSA, bacterial pneumonia, influenza, and gastrointestinal
infections such as C-diff or H. Pylori (Stevenson 2015). It would also be extremely helpful if the
CMS Nursing Home Compare Web site would list whether each nursing home is accredited by
the Joint Commission, as currently this information is not available and has proven difficult to
find.
Also within the Literature Review was explanations of several laws and a list of resident
rights. Legislators hold high regard for older Americans as corresponding laws are consistently
created or updated. It is unfortunate that the Nursing Home Reform Act’s explanation that the
facility must provide continuous services by licensed nursing staff that is adequate to administer
the level of care its residents require (LII 2016) could not be more specific. The Iowa
Department of Education deems that there must be 1 adult for 4 every children under the age of
24 months, 1 adult for every 6 children aged 24-35 months, and 1 adult for every 8 children aged
4 years and above for preschool (Iowa DOE 2016). As Iowa has standards for specific adult-to-
child ratio, some sort of nurse-to-resident ratio system like this should be instilled for nursing
home residents as well. This could be another area for improvement and further research.

CARE 53
This Capstone’s research method was predominantly qualitative and descriptive in
nature, with qualitative data collected from the Centers for Medicare and Medicaid
NursingHomeCompare.gov Web site and the average cost per day for long-term care of each
facility, collected through phone conversations with nursing home representatives. No definitive
way of measuring the level of the quality of care was available, which is why the researcher
created a scale and scoring method. This allowed the researcher to rate each of the nine
Davenport and Bettendorf nursing homes’ level of quality of care received by their residents.
Following the initial examination of information within the literature review, the
collection of data for quality of care from the CMS Nursing Home Compare Web site was
gathered, and the price per day for long-term care of the Davenport and Bettendorf nursing
homes was obtained from the nursing home representatives. This was analyzed by the researcher
by creating tables to display given data, each entry given points, both positive and negative in
value, to measure the level of quality of care provided by each nursing home. A total score of
overall quality of care was appointed for each of the nine facilities and compared to their costs
per day. An increase of level of quality of care was not consistently seen with higher costs per
day. Therefore, the null hypothesis was validated, and there is no correlation of the level of
quality of care and cost per day apparent with nursing homes in Davenport and Bettendorf.
This research could very well be continued and expanded. The time constraint of ten
weeks for research, data collection, and analysis was limiting. The most glaring improvement
that should happen is that eight of the nine nursing homes studied had an overall Staffing rating
of 4 out of 5 stars, but regardless, the level of quality provided is inconsistent. Each nursing
home could benefit from continued staff training, education, and evaluating the level of pay,
especially for CNAs. Another disappointment when having at or above-average nursing

CARE 54
coverage was that 5 of the 9 nursing homes having unacceptable statistics for indwelling catheter
use, and is another justification for the progression of the nursing staff’s education. From more
of an administrative standpoint, since 6 of the 9 nursing homes studied have been issued federal
fines and 2 of the 9 nursing homes have received payment denials from Medicare and Medicaid
in the past three years, it would be advantageous to have a better understanding and adherence to
the Federal nursing home guidelines and regulations set forth by Medicare and Medicaid.
The level of quality of care provided to nursing home residents cannot be measured using
just one variable. Several factors will weigh into the overall perception and actuality of the level
of quality of care. Because no correlation was found between quality of care and cost per day of
the Davenport and Bettendorf nursing homes, people and loved ones embarking on the
possibility of living and obtaining care in one of these facilities should visit, conduct personal
assessments and interviews with administration, and stay abreast of any changes on the CMS
Nursing Home Compare Web site.

CARE 55
References
Abrahamson, Kathleen. (1 September 2016). Is There a Business Case for Nursing Home
Quality Improvement? Nursing Economic$, 34(5), p. 225-235. ISSN: 0746-1739
Administration for Community Living (ACL). (7 June 2016). (U.S. Department of Health and
Human Services). Administration on Aging (AoA): Older Americans Act. Retrieved
from http://www.aoa.gov/AOA_programs/OAA/
Alexander, Gregory; Madsen, Richard W.; Miller, Erin; and Wise, Keely. (July/September
2016). A National Report of Nursing Home Information Technology and Quality
Measures. Journal of Nursing Care Quality. Volume 31(3), p. 201-206. DOI:
10.1097/NCQ.0000000000000187.
Alexander, Marsha, phone communication, 29 November 2016
Angel, Karen. (1 August 2013). (Huffington Post). Nursing-Home Falls a Common and
Preventable Cause of Death and Serious Injury. Retrieved from
http://www.huffingtonpost.com/karen-angel/nursinghome-falls-a-
commo_b_3684980.html
Anonymous Kahl Home for the Aged and Infirmed Representative, phone communication,
28 November 2016
Baillie, Harold W., Garrett, Rosellen M., Garrett, Thomas M., and McGheehan, John. 2013.
HEALTH CARE ETHICS: Sixth Edition. Pearson Education, Inc. Upper Saddle River,
New Jersey.
Bojazi, Gianna and Tacchino, Ken Beam. (June 2016). Strategies for Overcoming the Risks

CARE 56
Associated with Aging. Journal of Financial Service Professionals. 70(4), 7-12.
Retrieved from http://eds.a.ebscohost.com.lib.kaplan.edu
Bratianu, Patricia. (2015). (Nursing Explorer). Nursing Ethics – Ethical Dilemmas Faced By
Retrieved from http://www.nursingexplorer.com/blog/nursing-ethics-ethical-dilemmas
faced-by-nurses-everyday-47
Brush, Jennifer and Calkins, Margaret. (1 January 2016). Person-centered Care and Resident.
Long-Term Living: For the Continuing Care Professional, 65(1), p. 24-27.
Castle, Nicholas G. and Engberg, John. (1 October 2007). The Influence of Staffing
Characteristics on Quality of Care in Nursing Homes. HSR: Health Services Research,
42(5), p. 1822-1847. DOI: 10.1111/j.1475-6773.2007.00704.x
Castle, Nicholas and Ferguson-Rome, Jamie C. (1 August 2015). Influence of Nurse Aide
Absenteeism on Nursing Home Quality. The Gerontologist, 55(4), p. 605-615.
DOI:10.1093/geront/gnt167
Cellucci, Leigh W.; Wiggins, Carla; and Farnsworth, Tracy J. 2014. Healthcare Marketing: A
Case Study Approach. AUPHA Health Administration Press. Chicago, IL.
Center on Aging, University of Iowa. (October 2012). (UIOWA). Directions for Serving
Seniors in Scott Co., Iowa. Retrieved from http://www.casiseniors.org/docs/U_of_I.pdf.
Centers for Disease Control and Prevention. (15 September 2015). Nursing Homes and Assisted
Living (Long-term Care Facilities [LTCFs]). Retrieved from
http://www.cdc.gov/longtermcare/index.html
Centers for Medicare and Medicaid Services. (2016a). How Can I pay for Nursing Home Care?
Retrieved from https://www.medicare.gov/what-medicare-covers/part-a/paying-for-
nursing-home-care.html

CARE 57
Centers for Medicare and Medicaid Services. (2016b). Nursing Home Compare. Retrieved
from https://www.medicare.gov/nursinghomecompare/
Centers for Medicare and Medicaid Services. (2016c). Resident Rights. Retrieved from
https://www.medicare.gov/nursinghomecompare/resources/resident-rights.html
Centers for Medicare and Medicaid Services. (2016d). What Information Can I Get About
Penalties? Retrieved from
https://www.medicare.gov/nursinghomecompare/about/penalties-info.html
Centers for Medicare and Medicaid Services. (2016e). Why Quality Measures are Important to
You (Long-stay Resident). Retrieved from
https://www.medicare.gov/NursingHomeCompare/About/Long-Stay-Residents.html
Centers for Medicare and Medicaid Services. (5 November 2013). Certification Process.
Retrieved from https://www.cms.gov/surveycertificationgeninfo/
Chen, Elaine A.; Twomey, Mary S.; and Whittier Eliason, Stephanie. (1 October 2012). The
National Center on Elder Abuse: Helping America’s Elders to Live with Safety, Dignity,
and Independence. GENERATIONS – Journal of the American Society on Aging, 36(3),
p. 103-105. ISSN: 0738-7806
Chen, M.M. and Grabowski, D.C. (1 July 2015). Intended and Unintended Consequences of
Minimum Staffing Standards for Nursing Homes. Health Economics, 24, p. 822-839.
DOI: 10.1002/hec.3063
Chen, Yin-Tin; Chi, Mai-Man; Chen, Yu-Chih; Chou, Shin-Shang; and Wang, Fu-Der. (1
March 2013). Using a Criteria-Based Reminder to Reduce Use of Indwelling Uninary
Catheters and Decrease Urinary Tract Infections. American Journal of Critical Care,
22(2), p. 105-114. DOI: http://dx.doi.org.lib.kaplan.edu/10.4037/ajcc2013464

CARE 58
Colon-Emeric, Cathleen S.; McConnell, Eleanor; Pinheiro, Sandro O.; Corazzini, Kirsten; Porter,
Kristie; Earp, Kelly M.; Landerman, Lawrence; Beales, Julie; Lipscomb, Jeffrey;
Hancock, Kathryn; and Anderson, Ruth A. (1 December 2013). CONNECT for Better
Fall Prevention in Nursing Homes: Results from a Pilot Intervention Study. Journal of
the American Geriatrics Society, 61(12), p. 2150-2159. DOI:
http://dx.doi.org.lib.kaplan.edu/10.1111/jgs.12550
Davis, Nadinia and LaCour, Melissa. 2014. Health Information Technology: 3rd
Edition. Elsevier. St. Louis, Missouri.
Dawson, Steven L. (1 March 2016). The Direct Care Workforce — Raising the Floor of Job
Quality. GENERATIONS – Journal of the American Society on Aging, 40(1), p. 38-46.
ISSN: 0738-7806
Dickey, Elizabeth. (2016). (NOLO). When Will Medicaid Pay for a Nursing Home or Assisted
Living? Retrieved from http://www.nolo.com/legal-encyclopedia/when-will-medicaid-
pay-nursing-home-assisted-living.html
Falk, Nancy L.; Baigis, Judith; and Kopac, Catharine. (September 2012). Elder Mistreatment
and the Elder Justice Act. Online Journal of Issues in Nursing, 17(3), p. 1-1. DOI:
http://dx.doi.org.lib.kaplan.edu/10.3912/OJIN.Vol17No03PPT01
Family Caregiver Alliance. (31 January 2015). Selected Long-Term Care Statistics.
Retrieved from https://www.caregiver.org/selected-long-term-care-statistics
Fleming, Mary Louise and Kayser-Jones, Jeanie. (1 November 2008). Assuming the
Mantle of Leadership: Issues and Challenges for Directors of Nursing. Journal of
Gerontological Nursing, 34(11), p. 18-25. ISSN: 0098-9134
Freeman-Jobson, Jennifer H.; Rogers, Jamie L.; and Ward-Smith, Peggy. (1 March 2016).

CARE 59
Effect of an Education Presentation on the Knowledge and Awareness of Urinary Tract
Infection Among Non-Licensed and Licensed Health Care Workers in Long-Term Care
Facilities. Urologic Nursing, 36(2), p. 67-71. DOI:
http://dx.doi.org.lib.kaplan.edu/10.7257/1053-816X.2016.36.2.67
Freundlich, N. (February 2014). (Robert Wood Johnson Foundation). Long-term care: What
are the Issues? Retrieved from http://www.rwjf.org/en/library/research/2014/02/long-
term-care--what-are-the-issues-.html
Glassdoor. (2016). CNA Salaries: Davenport, Iowa. Retrieved from
https://www.glassdoor.com/Salaries/cna-salary-SRCH_KO0,3.htm
Goldman, T.R. (31 July 2012). Health Policy Brief: Eliminating Fraud and Abuse. Health
Affairs. Retrieved from
http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=72
Greenwood, Hope, phone communication, 29 November 2016
Hall, Carla, phone communication, 13 December 2016
Harrington, Charlene; Schnelle, John F.; McGregor, Margaret; and Simmons, Sandra F. (12
April 2016). The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes.
Health Service Insights (9), p. 13-19. doi: 10.4137/HSI.S38994
Hassan, Mohammed Adam. (2016). (Academia). Research Populations. Retrieved from
https://www.academia.edu/5563491/Research_Population
Hunter, Jennifer C.; Mu, Yi; Dumyati, Ghinwa K.; Farley, Monica M.; Winston, Lisa G.;
Johnston, Helen L.; Meek, James I.; Perlmutter, Rebecca; Holzbauer, Stacy H.; Beldavs,
Zintars G.; Phipps, Erin C.; Dunn, John R.; Cohen, Jessica A.; Avillan, Johannetsy;
Stone, Nimalie D.; Gerding, Dale N.; McDonald, L. Clifford; and Lessa, Fernanda C. (18

SharonStone1HA599_Final_Capstone_Unit9FinalSubmission

SharonStone1HA599_Final_Capstone_Unit9FinalSubmission

Recommended

Recommended

More Related Content

What's hot

What's hot (8)

Viewers also liked

Viewers also liked (17)

Similar to SharonStone1HA599_Final_Capstone_Unit9FinalSubmission

Similar to SharonStone1HA599_Final_Capstone_Unit9FinalSubmission (20)

SharonStone1HA599_Final_Capstone_Unit9FinalSubmission