Continuing Care Retirement Community Research Articles

Horticultural therapy impact on people with dementia

BackgroundDementia is a progressive disease, and as the disease progresses, many families seek help through activities and therapies. In contrast to some other therapies, horticultural therapy (HT) is widely accepted by most people with dementia (PWD) because it invites them to the natural world.ObjectivesTo explore whether HT emotional and communication measures (i.e. appropriate expression of emotions, ability to communicate with others) are higher than in other activities offered to PWD in adult day care centers (ADCC) and continuing care retirement community (CCRC), and whether there is a difference between the impact of HT on the number of “positive actions” (communication actions and actions that fit the guided activity) vs. the other activities.Research design and methodsFifty-one PWD attending ADCCs and living in one CCRC were recruited to a structured HT activity and other activities that took place in the ADCCs and CCRC. The activity took place over 10 weeks. The effects were assessed using Dementia Care Mapping (DCM) and questionnaires.ResultsPaired t-tests found that higher levels of mood and behavior were observed during HT activities compared to the other activities. Also, communication and function actions were higher in the HT activities as compared to the other activities.Discussion and implicationsThis study adds to the growing evidence of the benefits of HT for PWD regardless of past experience in gardening/agriculture. HT seems to provide high therapeutic benefits and should be more prevalent in centers caring for PWD.

Older Adults in CCRCs: Their Social Engagement, Processes and Solutions

ABSTRACT As the older adult population continues to grow, the demand for Continuing Care Retirement Communities (CCRCs) is increasing in the United States. Older adults living in CCRCs may, however, experience social isolation and loneliness if they lack meaningful and sustained social engagement – seen as the quintessence of fulfilled human living. To date, the social engagement preferences and priorities of older adults who live in CCRCs remain under researched. We therefore utilized participatory action research to explore the social engagement goals, processes and solutions of older adults living in CCRCs. An Interpretive Phenomenological Analysis (IPA) approach was adopted to explore the perspectives of 25 older adults living in a CCRC (females = 75%; mean age = 85; mean length of stay = 4.3 years). Thematic analysis of interview data identified three main themes, in addition to subthemes, critical to maintaining social wellbeing in a CCRC: 1) meaningful engagement with CCRC committees and clubs, and contributions to community led by those who live there; 2) opportunities and challenges associated with resilient living, as well as end-of life concerns; and 3) a sense of belonging and connectedness contributing to social community and health wellness. The findings suggest that the social engagement of older adults who live in a CCRC can be enhanced by introducing and promoting initiatives that bring joy, a sense of purpose, belonging, and fulfillment. This engagement needs to align with individuals’ preferences and priorities to ensure satisfying lives and a sense of community.

Associations Between Components of Self-Management Theory and Falls Among Older Adults.

To examine the relationship of key individual and family self-management theory (IFSMT) components, including self-management process variables on proximal (self-management behaviors) and distal (falls) outcomes in older adults. A secondary data analysis was conducted using data of 99 older adults living in continuing care retirement communities in the U.S. Midwest. Descriptive statistics, multiple regression, and logistic regression were performed to analyze the data. The multiple regression model demonstrated a positive association between self-efficacy for physical activity and steps per day. The logistic regression model showed that high expectations regarding aging are associated with reduced likelihood of meeting daily protein intake. Key components of the IFSMT, such as self-efficacy, steps per day, and expectations regarding aging, are important when designing self-management interventions to prevent falls. [Journal of Gerontological Nursing, 50(8), 19-28.].

Participation in a social cluster program among persons in residential living at a continuing care retirement community during COVID

A Continuing Care Retirement Community (CCRC) initiated a voluntary cohort or “social cluster” (SC) program during the pre-vaccination phase of COVID. SCs are self-selected small groups of persons who decide about types of social interactions. The program began in April 2020, and a cross-sectional survey of residents was conducted in November 2020 to assess perceptions of COVID (e.g., worry and prevention) and of program participation. A secondary goal was to explore if program involvement was associated with perceptions of social isolation. Participants (n = 85) were “somewhat” (49 %) or “very” (11 %) worried about COVID, and 34 % participated in a SC. 89 % of the SC participants indicated that “Dining within 6ft” was most preferred. Improvement in boredom, social isolation, activity level, mental health, hope, and fear was noted among some SC participants (55 %, 52 %, 41 %, 38 %, and 14 %, respectively). Findings contribute to understanding social engagement needs amidst COVID.

COVID-19 Pandemic and Posttraumatic Growth in Residents of a Continuing Care Retirement Community: A Mixed Methods Study.

The coronavirus disease 2019 (COVID-19) pandemic impacted life for older adults living in residential settings, affecting their psychosocial well-being. Risk for COVID-19 is associated with increasing age and pre-existing health conditions. The current study aimed to describe the challenges of COVID-19 and post-traumatic growth (PTG) for residents of a continuing care retirement community (CCRC) in South Florida. A parallel mixed methods approach was used to explore the experience of older adults with PTG. Quantitative data were analyzed using descriptive statistics. Qualitative data were analyzed using content analysis to identify emergent themes. Ninety-eight older adults living in a single CCRC completed a survey. Age ranged from 67 to 99 years (mean age = 86 years), with >90% identifying as non-Hispanic White and female (78%). Using the PTG theoretical framework, experiences were categorized into five dimensions: new possibilities, relating to others, personal strength, spiritual growth, and appreciation for life. The current study focused on the challenges and growth experienced by older adults, as framed by PTG theory. Findings shed light on the capacity of this demographic, with an average age of 86 years, to overcome obstacles and achieve PTG. [Journal of Gerontological Nursing, 50(6), 25-33.].

Social Disability as Disaster: Case Studies of the COVID-19 Pandemic on People Living with Disabilities

Social disability is a process or event that significantly disrupts, paralyzes, or prevents the formation and/or sustaining of interpersonal social relations required for meeting human needs. When prolonged, the ‘disabling’ of essential human interrelationships can have a destructive impact. This is especially true in communities where people are highly interdependent and where individuals living with disabilities rely upon social relationships to prevent isolation and decline in overall wellbeing. Meanwhile, disaster response systems have developed to first rescue or protect individuals’ ‘bare life’ and immediate, bodily needs. We argue that these systems, intended to mitigate disaster, can exacerbate social disability as a kind of collateral damage. We explore this problem as it unfolded amidst the COVID-19 pandemic in two research sites: one located in rural, northern Scotland and another located in rural, Midwestern United States. The Scottish research focuses on experiences, causes and risks of social disability for adults living with disabilities within a small rural community, while the U.S. research focuses on emergence of and resistance to social disability among residents of a continuing care retirement community for 55+ aged adults. We conclude with implications and recommendations for disaster intervention and future research.

Investigating the Influencing Factors of the Purchase Intention of the Continuing Care Retirement Community: A Case Study of Shenzhen

China officially entered the aging society in 2000, witnessing a rapid surge in demand for senior care services. In response, the real estate industry introduced the concept of Continuing Care Retirement Communities (CCRCs). The relationship between this model and complex risks in urban security resilience encompasses various factors, including filial care, demand for senior care, and urban sustainable development. The strategic layout and planning of CCRC enhance the security resilience of urban operational systems in the face of intricate senior care risks. However, the development and operation of CCRCs have encountered the challenge of sluggish project progress, primarily due to a lack of robust purchase intention. This study investigates the factors influencing the purchase intention of CCRCs in mainland China, using the Theory of Planned Behavior (TPB) as the foundational theoretical model. Additionally, three contextual constructs (economic cost, product performance, and external stimuli) were introduced to form the initial model. Based on the initial model, six factors were identified and nine hypotheses were proposed. A questionnaire survey was conducted to collect data, and Structural Equation Modeling (SEM) analysis was employed to test the proposed hypotheses. The results indicate that consumers’ purchase intention of CCRCs is primarily influenced by product performance and subjective norms, followed by economic cost. At the same time, external stimuli have a significant indirect effect on it.

Fear of Falling in Older Adults Living in a Community-Dwelling Facility: Prevalence and Its Impact on Activity Behavior and Physical Function.

This study examined the prevalence and the impact of fear of falling (FOF) on physical activity (PA), sedentary behavior (PA), and physical function in older adults living in a continuing care retirement community (CCRC). Ninety-three older adults were included and self-reported assessed on PA and SB. Further, participants' physical function was assessed using a collection of measures of valid objective tests. Independent t test was used to compare the dependent variables between FOF groups, and analysis of covariance (ANCOVA) was used to control for assistive device usage. FOF was prevalent in 47.3% of the sample and PA and SB did not differ between FOF groups (p > .05). ANCOVA revealed that performance on several physical function tests remained significantly better (p < .05) for the no FOF group compared to the yes group. Our findings demonstrated similar levels of PA and SB between FOF groups, but worse physical function for older adults reporting FOF.

Exacerbation of Pre-Existing Chronic Pain in Older Adults After SARS-CoV-2 Infection: A Single-Center, Cross-Sectional, Observational Study.

To identify the prevalence of exacerbation of pre-existing chronic pain after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and investigate the impact of exacerbated previous chronic pain on quality of life, sleep quality, anxiety and depression levels and risk factors associated with exacerbated chronic pain among elderly coronavirus disease of 2019 (COVID-19) survivors. In this cross-sectional study, elderly COVID-19 survivors with chronic pain residing in Continuing Care Retirement Community (CCRC) were recruited from April 2023 to June 2023. Eligible individuals were divided into exacerbation and non-exacerbation groups based on the patient-reported worsening symptoms of previous chronic pain after SARS-CoV-2 infection. Baseline information, COVID-19 symptoms, laboratory parameters, characteristics of exacerbated chronic pain, quality of life, anxiety and depression levels were systematically collected. Ninety-five (95/441, 21.5%) older adults suffered from exacerbated chronic pain with a median numerical rating scale (NRS) score of 6 (4-7) on a median duration of 4.9 (4.3-5.6) months after SARS-CoV-2 infection. More participants were not vaccinated against COVID-19 (46.5%, 40/86 vs 26.1%, 86/330, P < 0.001) in exacerbation group. Exacerbation group exhibited poor quality of life (EQ5D index: 0.734 [0.536-0.862] vs 0.837 [0.716-0.942], P < 0.001), more severe anxiety (GAD-7: 2 [0-5] vs 0 [0-3], P < 0.001) and depression (PHQ-9: 4 [2-7] vs 2.5 [0-5], P < 0.001) than non-exacerbation group. Risk factors significantly associated with exacerbation of pre-existing chronic pain were neuropathic pain (aOR 4.81, 95% CI 1.73-13.32, P = 0.003), lymphocyte count (aOR 0.31, 95% CI 0.12-0.78, P = 0.013) and D-dimer levels (aOR 6.46, 95% CI 1.92-21.74, P = 0.003). Our study observed a prevalence of 21.5% exacerbation of pre-existing chronic pain after SARS-CoV-2 infection, with a consequence of poor quality of life, more severe anxiety and depression. Previous chronic neuropathic pain, lower lymphocyte count and higher D-dimer levels were risk factors associated with the development of exacerbated previous chronic pain.

Understanding the well-being of residents in Chinese Continuing Care Retirement Communities-a case of Shanghai.

China is one of the world's fastest-aging countries. Continuing Care Retirement Communities (CCRCs) have emerged as a viable option for accommodating and serving older adults. However, Chinese CCRCs are still in the early stages, and comprehensive research on resident well-being is still deficient. The study aims to assess how well residents in CCRCs are faring in terms of their psychological and physical health, considering China's aging population and changing societal structures. After a thorough literature review to pinpoint relevant well-being measures in psychological and physical health, the study implemented a survey to capture residents' experiences and perceptions, and subsequently analyzed how well-being correlates with demographic characteristics. The results show that while Chinese CCRCs can enhance residents' well-being through personalized care and social activities, challenges such as psychological distress and declining physical health remain. Demographic factors, including living situation and length of stay, also affect residents' well-being. The study emphasizes the importance of ongoing research and evaluation to guide evidence-based practices and improve CCRCs continuously. Overall, it offers a comprehensive analysis of the wellbeing of Chinese CCRCs residents, shedding light on both psychological and physical health aspects and providing valuable insights for enhancing CCRCs design, implementation, and evaluation in China and elsewhere.

“DO IT ANYWAY”—RESIDENT-DRIVEN ENGAGEMENT TO MAINTAIN MEANINGFUL LIFE IN CONTINUING-CARE RETIREMENT COMMUNITIES

Abstract As the aging population continues to grow, the demand for Continuing Care Retirement Communities (CCRCs) is increasing. However, residents in CCRCs often face social isolation and loneliness, which can negatively impact their health and well-being. To combat these issues, activities and engagement have been proposed as potential solutions. However, the voices of those vulnerable to social isolation are seldom heard. This study aimed to explore the perspective of residents on how resident-driven engagement in CCRCs may maintain a meaningful life. A qualitative research approach was used, consisting of semi-structured interviews with 26 residents in CCRC. Thematic analysis identified five key themes related to resident-driven engagement: a sense of community, turning lemons into lemonade, doing it anyway, pink letters, and committees and clubs. The “do it anyway” attitude emerged as a prevalent theme, emphasizing the importance of pushing past challenges and limitations to pursue activities that bring joy and meaning to residents’ lives. The findings suggest that resident-driven engagement can lead to a sense of purpose, belonging, and fulfillment in CCRCs. The research provides insights into how communities can foster an environment that supports such engagement. By prioritizing resident-driven activities and empowering residents to take control of their lives, CCRCs can promote the well-being and quality of life of their residents.

MUSICAL THEATER AND MEANING MAKING IN A RETIREMENT COMMUNITY

Abstract “I think I’ve had it up to here with pickleball…” Thus begins the first song in “Movin”, an original musical written, produced, and performed by members of a continuing care retirement community (CCRC), which addresses themes ranging from dementia, death and widowhood to finding community, purpose, and late-life love. The idea began in informal conversation between two former university colleagues, Philip Sloane (a geriatrician, GSA member, and former CCRC board member) and Hugh Tilson (a CCRC resident, aged 82) about describing the aging experience through song. Hugh gathered a group of fellow CCRC residents, none of whom had professional songwriting or theater experience but several of whom had musical backgrounds or an interest in theater. Meeting regularly over nearly two years, they envisioned, created, and then produced an original musical around the theme of “freshman year in a retirement community.” The final production included 9 cast members, 12 original songs developed by five lyricists and two composers, many production-related volunteers, and a narration to link the songs together. This symposium will describe the process, present and illustrate aging-related themes from the production, place the musical in the context of existing research about meaning-making and the arts in later life, and conclude with a discussion by a senior leader in a major senior housing organization. Presentation about development and production of the musical will include videos of rehearsals, songs from the production, and interviews with performers. Sponsored by the Humanities, Arts, and Cultural Gerontology Advisory Panel

SYMPTOM BURDEN, POSITIVE AFFECT AND RESILIENCY IN OLDER ADULTS EXPERIENCING NORMAL AGING

Abstract Older adults (age≥65) with multimorbid disease burden may be at chronic risk for bothersome symptoms, which can consequently reduce positive affect (e.g., feelings of excitement and enthusiasm). However, we hypothesized that individuals with more resiliency (the ability to “bounce back” from distress) may experience positive affect despite symptom burden. We conducted secondary analysis of baseline self-report survey data (collected between 8/2023-10/2023) from a prospective study of resiliency in older adults residing in nine continuing care retirement communities (CCRCs) across the U.S. Eligible participants lived independently in CCRCs and scored &amp;gt;11/15 on the five-minute Montreal Cognitive Assessment. Surveys assessed symptom burden (Condensed Memorial Symptom Assessment Scale), resiliency (Current Experience Scale), and positive affect (Positive and Negative Affect Schedule-Positive Affect). Bivariate correlations and multiple linear regression evaluated associations of symptom burden and resiliency with positive affect. Participants (M age =81, SD=5.6) were predominantly White (96%) and female (75%). Greater symptom burden correlated with lower positive affect (r=-.295, p&amp;lt;.001) and lower resiliency (r=-2.56, p&amp;lt;.001). In a multiple regression model, lower symptom burden (β = -.136, p=.003) and more resiliency (β=.626, p&amp;lt;.001) were independently associated with greater positive affect. The overall model accounted for 45.4% of variance in positive affect (F(2, 284) =117.198, p&amp;lt;.001). Lower symptom burden and more resiliency contributed to more positive affect among older adults in senior living communities. Because resiliency and positive affect are both potentially modifiable targets for intervention, longitudinal study and psychosocial interventions should explore the effects of increased resiliency on positive affect and general well-being over time.

AGING WELL, AGING DIFFERENTLY: A COMPARISON BETWEEN LIFE PLAN COMMUNITY RESIDENTS AND THE COMMUNITY AT LARGE

Abstract Residing in Life Plan Communities (or Continuing Care Retirement Communities) may have benefits to well-being due to greater access to wellness programs and services. The purpose of this research was to examine changes in health and wellness between Life Plan Community residents and older adults residing in the community at large over five years. Data included 1,729 residents (69% female, mean baseline age = 81.64) who participated in Years 1 and 5 of the Age Well Study, and 427 older adults (50% female, mean baseline age = 80.78) residing in the community at large who participated in multiple waves of the Health and Retirement Study. The community-at-large group was proportionally sampled to be similar to the residents on age, income, and race/ethnicity, and both groups completed the same measures of health and wellness at each time point. Data were analyzed using multilevel models controlling for age, gender, income, education, and marital status. Compared to the community-at-large older adults, residents tended to exhibit better physical, emotional, social, intellectual, and vocational wellness in Years 1 and 5, but lower spiritual wellness in Year 5. When comparing Year 1 and Year 5, both groups reported similar changes over time on physical and vocational wellness measures. Community-at-large older adults tended to report more favorable changes in emotional and spiritual wellness, and residents showed more favorable changes in social and intellectual wellness. Although effects of the pandemic should be explored further, these findings have implications for supporting aging well in different types of residential settings.

Differential Gene Expression in Pain-Related Genes are not Affected by the Presence of Dementia

BackgroundPrior work has demonstrated differences in the transcriptome between those with and without chronic musculoskeletal pain. AimsThe aim of this study was to explore whether pain-related gene expression is similar between individuals with and without dementia. DesignThis was a descriptive study using a one-time assessment. Settings: Participants/SubjectsA total of 20 older adults living in a continuing care retirement community, 50% of whom had dementia were inlcuded in this study. All were female and the mean age of participants was 89 (SD = 6). MethodsPain was evaluated based on the PROMIS Pain Intensity Short Form 3a. Whole blood was collected by venipuncture into Tempus vacutainer tubes (3 ml) and the RNA was extracted at the Translational Genomics Laboratory at the University of Maryland Baltimore. Analyses included a differential expression analysis, a weighted gene co-expression network analysis, and a pathway enrichment analysis. ResultsEighty-three genes were differentially expressed between individuals with and without pain (p <.05). After normalizing gene counts and removing the low expressed genes, 18,028 genes were left in the final analysis. There was no clustering of the samples related to study variables of pain or dementia. ConclusionThe findings from this study provided some preliminary support that pain-related gene expression is similar between individuals with and without dementia.

ADMISSIONS AND DISCHARGE PRACTICES IN ASSISTED LIVING: THE ROLE OF REGULATORY AND ORGANIZATIONAL CHARACTERISTICS

Abstract This study examined how state regulations and AL organizational characteristics relate to admissions and discharge practices. Using data from a representative sample of 250 AL communities in 7 states and a database of AL regulations, we employed bivariate analysis and multilevel linear probability models to examine regulatory and organizational correlates of AL community admissions and discharge practices for three activities of daily living (ADLs [bathing, getting out of bed, and eating]). There was a pattern between admissions regulation and admissions practices in AL; for example, 38% of communities with license types that had the most flexible admissions regulations allowed residents with feeding limitations to be admitted; conversely, 18% with the least flexible regulations allowed them to be admitted. However, the relationships were not statistically significant in bivariate or multivariate analysis. A higher percent of residents with Medicaid as a primary payer source was associated with a decrease in the probability of admitting (𝛽 = -0.01, p&amp;lt;.001, 95% confidence intervals [CI]: -0.01, 0.00) and discharging (𝛽 = 0.01, p=.013, 95% CI: 0.00, 0.01) residents with bathing limitations. Being operated in association with a continuing care retirement community or nursing home was associated with a higher probability of discharging residents who needed assistance with bathing (𝛽 = 0.14, p=.013, 95% CI: 0.03, 0.26) and more so with feeding (𝛽 = 0.26, p &amp;lt;.001, 95% CI: 0.15, 0.36). Findings suggest a need to consider whether models of AL and AL practices could better align with the residents’ needs.

SENSOR-ENHANCED CARE COORDINATION TO ADDRESS OLDER ADULT HEALTH: LESSONS FROM AN INTERDISCIPLINARY RESEARCH TEAM

Abstract Researchers at the University of Missouri have a history of developing and testing aging in place (AIP) care coordination models for clinical translation. Vital to this work are in-home, residentially installed sensors to detect early illness and functional decline over time. While much smart home research is focused on older adults living in continuing care retirement communities, our team developed a novel sensor-enhanced care coordination approach for community-dwelling and disabled older adults as part of two ongoing, federally funded projects. For this symposium, we will highlight the Age-friendly Sustainable Smart and Equitable Technologies for Aging in Place (ASSETs for AIP) demonstration program, funded by the Department of Health and Human Services. Our first presentation will overview our interdisciplinary approach to creating this novel care coordination model, with specifics about research team composition, population focus, and methods. Our second presentation will highlight recruitment strategies and share lessons learned from reaching and enrolling this population that often experience residential transitions. Our third presentation will overview the open-source smart home and consumer-grade technologies deployed in this work, and practical considerations for technology installation, support, and sustainability and clinical team training. Our symposium will close with a presentation of selected client case studies that illustrate how clinical care coordinators use sensor data to remotely monitor and empower older adults for behavior change via telehealth consultations. This symposium will help inform other care coordination research, particularly that which uses sensor technologies and telehealth to facilitate aging in place.

Gauging the stress of long-term care nursing assistants using ecological momentary assessment, wearable sensors and end of day reconstruction.

Nursing assistants working in long-term care (LTC) often report that their job is stressful. To reduce their work stress, a better understanding of their stress profile is needed. We aimed to pilot test methods to identify and understand stressors that LTC nursing assistants experience. We asked each participant to provide wearable sensor/watch data, ecological momentary assessment (EMA) surveys and end of day review data over two eight-hour working shifts. Eight nursing assistants participated. All participants worked in a common continuing care retirement community in Maryland, United States of America. Our stress assessment method revealed 83 stressful events that were classified under 10 categories. Most of the reported events were rated as having a mild to low-moderate intensity. The three most common causes of stress were work demands and pressure (28.35%), heavy workload and staffing (19.69%), and safety issues and COVID-19 concerns (17.32%). We also explored the difference between stress events and intensity among different shifts. Disrespect from residents (22.73%) was the most commonly reported stressor during day shifts. Feeling rushed was the most commonly reported stressor during the evening (22.47%) and the night (38.46%) shifts. We found stress was commonly reported. Stress intensity conflicted with prior literature, and we explored possible explanations. We discuss potential implications for these findings, modification of our methods to increase feasibility, the utility of these data collection methods for future work and suggest next steps.

Organizational and market characteristics associated with nursing homes’ affiliation with a continuing care retirement community

Organizational and market characteristics associated with nursing homes’ affiliation with a continuing care retirement community

Special Focus Facilities vs Special Focus Facility Candidates: What is the Difference?

ObjectivesThis study compares Special Focus Facilities (SFFs) and Special Focus Facility Candidate Facilities (SFFcs) on organizational traits and quality outcomes to evaluate the effectiveness of the SFF program as a quality improvement intervention and inform potential areas for program reform. DesignThis is a retrospective analysis. Settings and ParticipantsUsing data from the Centers for Medicare and Medicaid Services archives for 2020, this retrospective study analyzed 247 nursing facilities (50 SFFs and 197 SFFcs). MethodsVariables of interest were staffing, profit status, facility size, certification status, number of residents, and complaint citations: t tests, χ2, Fisher's Exact test, and multivariate analysis of variance were used to compare the 2 groups. ResultsFrom an organizational perspective, SFFs and SFFcs are minimally different. Both groups had similar facility size, profit status, hospital affiliation, continuing care retirement community status, and Medicare/Medicaid certification. Large and for-profit facilities were overrepresented in both groups. SFFs and SFFcs exhibited statistical differences in the number of complaint deficiencies. The groups had no significant difference in staffing levels, category, severity of complaints, or incident reports. Conclusions and ImplicationThe study's findings suggest that the SFF program, while resource-intensive, is minimally impactful. The similarities between SFFs and SFFcs raise questions about the program's effectiveness in improving nursing facility care. Previous adjustments to the program may not have successfully achieved the desired quality improvements. This research highlights the need to further evaluate the SFF program's effectiveness as a quality improvement intervention. It also underscores the importance of addressing biases and subjectivity in state survey agency processes, which affect the enrollment of nursing facilities. The study underscores the flaws within the nursing home monitoring system and the 5-star quality rating system, especially when comparing small samples between states.