“I was so obsessed that one day I made myself a Wonder Woman crown out of construction paper and my mom says the glue was dripping all down my forehead when I came out wearing it,” Finck-Boyle recalls.

More than 30 years later, Finck-Boyle still sports the look on occasion, though she’s upgraded to a scarf emblazoned with a Wonder Woman emblem that she received from former colleague and close friend Gail Jernigan, MBA/HCA, the senior administrator of Transitional Care Center Capital City. Jernigan presented her with the scarf as Finck-Boyle was preparing to close the long-established and beloved Washington, DC, nursing home and hospice center The Washington Home. 

Finck-Boyle had been the facility’s administrator/executive director for six years before the board of directors sold the property to Sidwell Friends, the prestigious private school that sat next door.

“Gail gave me the scarf and said, ‘I think you’re going to need this,’” says Finck-Boyle, now 48. 

“As we prepared to close, there were days that were good and days that were not good, so sometimes I would walk through the building with the scarf on just for fun, to try to make people smile.”

The 2016 closure of The Washington Home took its toll on Finck-Boyle and her husband of 18 years, Pete, their son Finn, now 13, and daughter Katie, now 10. 

“My children grew up in The Washington Home, coming to visit in costume for Halloween or just to spend time with the residents when they were off school,” Finck-Boyle recalls. She shut down the facility with the same care and concern she showed throughout her time as its leader — treating residents like family and ensuring each one was smoothly transported and transitioned to a new facility, says Jernigan.

“Janine closed The Washington Home with grace and integrity and singularity of purpose, always with the residents’ comfort and care in mind,” she says. “I’m proud to be in the same business with her.”

In her current role as vice president of regulatory affairs for LeadingAge, Finck-Boyle says her biggest asset is that she understands the ins and outs of running a long-term care facility and what’s it’s like to “fight fires all day when you’re just trying to get your budget done.”

Outside of work, she can often be caught watching Finn play baseball or Katie play soccer, or taking in a Washington Nationals baseball game. Or in many instance, she might be exploring art at one of the district’s many galleries or just reading a book at one of her favorite summertime spots — with her extended family at the Jersey Shore or with her husband’s family on Cape Cod.

“It’s so important for me to be around a body of water, just relaxing and reading a book,” she says. 

A self-proclaimed “foodie,” Finck-Boyle is always up for trying new restaurants — of which there are plenty in DC. She loves sushi  — “the rarer the better.” 

Through it all, she always has an eye out for a potential run-in with Carter, a childhood icon she’s still trying to emulate.

“She lives right near here, in Maryland, you know,” she says with a hopeful rise to her voice.

Resume: 1993, earns B.S. in biology with a minor in healthcare administration, from Stonehill College; 1993, becomes an HCIS Consultant at Meditech; 1998, completes MBA in healthcare administration with a certificate in gerontology from Cleveland State University; earns nursing home administrator license; 1999, hired as Director of IT at Hadley Memorial Hospital and Skilled Nursing Facility in Washington, DC; 2000, named Administrator at Hadley; 2002, rises to CEO, Hadley Memorial Hospital and Skilled Nursing Facility; 2010, becomes Administrator/Executive Director of The Washington Home and Community Hospices in Washington, DC; 2017, named Director of Health Regulations and Policy at LeadingAge; 2018, promoted to Vice President of Regulatory Affairs at LeadingAge.

Jody DePriest, regional vice president of Pathway South, recently was given the first ever “Hometown Hero Award” by the Louisiana Nursing Home Association. 

The distinction honors long-term care professionals who “exhibited on-the-job courage, strength, selflessness and compassion during an emergency or disaster.” DePriest received plaudits during the LNHA convention and trade show in September in this, the award’s first year.

DePriest leads his company’s emergency preparedness program. His skills were put to the test during a devastating 2016 flood that threatened the Flannery Oaks Guest House, a 130-bed skilled nursing facility in Baton Rouge. 

Officials noted that he worked closely with nursing facility staff, administrators, local authorities and state authorities during the flood, and also ensured communication between the groups remained up-to-date. In addition, he was the last to evacuate the facility after helping each resident and staff member to safety.

DePriest’s “dedication and sacrifice to keep residents safe and comfortable at all times is inspiring and commendable,” praised Pathway South President Earl Thibodaux. 

“Pressure ulcers have significant potential for both morbidity and mortality, as well as being a high risk for litigation,” says Japa Volchok, DO, Vice President of Operations at Vohra Wound Physicians.

But what about the challenges of treating non-pressure wounds such as arterial, venous and diabetic ulcers, skin tears or abrasions, puncture wounds and scrapes? 

These types of conditions account for about 60% of wounds in long-term care, and they can have a significant impact on residents’ quality of life, says Mark Ross Hopkins, LVN, WCC, Wound and Product Specialist at Gentell.

“Pressure ulcers may be the ‘star of the show’ in long-term care, but arterial and venous ulcers, skin tears and abrasions and diabetic ulcers are certainly ‘best supporting actors,’” Hopkins says. “If they’re not diagnosed properly, they can be very debilitating to a resident.”

Thorough skin assessments, precise documentation, ongoing staff education, the right equipment and a positive relationship with local acute-care facilities can all help in a facility’s ability to provide excellent wound care for its residents, experts say.

“To help ensure all wounds receive the care and attention they deserve, facilities need innovative and effective ways to care for today’s complex skilled nursing patient,” says Dawn Fortna, MSEd, CDE, CWOCN, Clinical Nurse Educator with Medline.

Why so much pressure?

Pressure ulcers have been given a magnitude of attention in long-term care over the last decade, having been the focus of regulatory, education and dressing innovation efforts, while non-pressure wounds have not received the same amount of attention. For example, facilities must report worsening pressure ulcers in their facilities though the Minimum Data Set (MDS), as well as other mitigating factors that aggravate pressure ulcers, such as urinary incontinence and mobility.

“Non-pressure wounds are less understood across all levels of long-term care and often receive less concern and inquiries from families,” says Volchok, who is also a vascular surgeon. 

Fortna agrees, noting that many resources from a facility’s already shrinking budget go toward implementing protocols and education for pressure injuries. 

Non-pressure wounds, however, are often more complex and require higher levels of training and skill to properly diagnose and treat — a challenge for time-strapped long-term care nurses who have to be knowledgeable in multiple areas of care, Fortna says.

“Wound care is a specialty of its own and there is a lot to learn,” she says. “Education and evaluation needs to be ongoing as best practice continues to evolve.”

In addition, the MDS often requires wounds to be miscategorized for its purpose, leading to clinical confusion about just what etiology the wound is and how it should be treated, says Dea J. Kent, DNP, RN, NP-C, CWOCN, president-elect of the Wound, Ostomy and Continence Nurses (WOCN) Society.

“Because documentation supports the MDS, nurses must chart to support the MDS category, which is problematic because everything is a pressure ulcer and not all wounds on the leg are vascular in nature,” she says.

Patients take their cue from the nursing staff, and if the nursing staff is confused due to the convolution of the information, then the patients ultimately will be confused as well. 

Another reason non-pressure wounds may not always be managed as carefully as they should be is because they require special expertise to manage well, and can require a multidisciplinary approach involving physicians from multiple specialties, says Volchok.

Take, for example, venous ulcers, which account for about 6% of wounds in long-term care. Proper treatment for venous ulcers often calls for bandages that provide gentle compression of the leg. 

An improper diagnosis, examination or application of a compression dressing can have drastic consequences and can result in the loss of a limb. 

“Having a physician available who can properly diagnose a venous ulcer, examine and confirm adequate arterial blood flow, and then having a nurse trained in the application of compression dressings can pose a challenge for long-term care facilities,” Volchok observes.

Improved clinical outcomes start with knowledge and education and it is important that these exist at all levels from physician staff to nurse assistants. 

“When knowledge is lacking, the prevention, diagnosis and proper treatment of these types of wounds will suffer,” he says.

Ensuring proper assessment

In an effort to thwart any type of skin wound before it becomes a problem, clinicians need to complete a thorough skin assessment daily during patient rounds, says Amy Grey, clinical leader of wound care for Essity.

“Precise documentation of a wound is imperative to monitoring changes and adapting treatments,” she says.

Once a wound is discovered, facilities should perform diagnostic studies to determine the root cause, as this is critical to a resident’s treatment plan, says Hopkins.

“Oftentimes, wounds to the lower extremities are diagnosed as pressure wounds but are found not to be after diagnostic studies and clinical review,” he says. “Identifying the root cause allows for successful treatment and also affects quality measures, pressure rating percentage and overall patient and family satisfaction with the long-term care facility.”

Equipment also can play a big part in skin integrity issues, says Kelly Sullivan, Senior Product Consultant of Rehabilitation for Direct Supply. 

“Imagine sitting on a vinyl sling seat of a wheelchair without a cushion,” she says. “The hammock effect would lead to adduction, forcing your legs to slide against each other and causing friction between the knee joints. Continuous pressure against your hips from the frame and sling seat could lead to bruising or skin tears.”

To avoid this, she recommends adding a cushion with a rounded bottom to residents’ wheelchair seats, as a way to help fill in the sling gap and offload pressure from the ischial tuberosity and coccyx region.

Proper treatment depends on the wound type itself, Hopkins notes. 

Some of the most common wounds seen in long-term care are skin tears and abrasions, as thinning of the skin is an unfortunate side effect of advanced age and certain medications. Most of the time, skin tears are of surface depth, but the risk of infection is still present, he says.

“Each nurse has his or her own method for healing a skin tear, but the most important factor is infection control and reducing contributing risk factors,” he says. “Once a skin tear has been discovered, cleansing the wound properly is essential.” He also recommends that facilities take a proactive approach to preventing skin tears — and that doesn’t have to mean spending a significant amount of money on prevention sleeves.

“Often a simple long-sleeved shirt will suffice,” he says.

When it comes to treating diabetic ulcers, patient education and management of the resident’s fasting blood glucose levels takes center stage, Hopkins says. 

Wound healing slows when glucose levels are consistently elevated. 

Therefore, staff and residents must be taught about how glucose levels affect healing. 

“Like treatment and plans of care for pressure ulcers, care of non-pressure wounds should be individualized,” Hopkins says. “As the long-term care setting presents a plethora of opportunities for a wound nurse, it also presents a lifetime of learning opportunities.”

Special oversight needed

Speaking of a lifetime of learning, when it comes to wound care, long-term care staff simply need more training, experts say.

“Basic skin care and knowledge of the importance of skin breakdown prevention is a key component to improved outcomes, and caregivers need to understand that any break in the skin may allow bacterial entrance and lead to septicemia and a potentially fatal situation,” Fortna says.

Kent agrees, noting that education for staff — from CNAs to nurses to dieticians — on the basics of pressure and non-pressure wound and skin injury prevention must be provided.

“Everyone in the facility is a caregiver, and everyone can help with the prevention effort,” she says.

Long-term care nurses should also be training in wound etiology and treatment, accurate wound assessment and how to relay reports and ask questions when a good report isn’t given, she adds. Designating one or two nurses specifically as “wound care nurses” and sending them for education through, for example, the Wound Treatment Associate program through the WOCN Society is also ideal, Kent says.

Finally, she says, don’t take an “us versus them” attitude when it comes to wound care. 

“Neither acute-care nor long-term care facilities want to be ‘at fault’ for the development or worsening of any type of wounds,” she says.

Instead, Kent recommends that directors of nursing and skilled nursing administrators make a point to initiate and cultivate relationships with acute-care facilities, wound experts and wound care clinics in their community and encourage mentorship for their nurses from these experts.

 “These are the aspects of care that require thoughtful attention and action, but it can do wonders for the sake of the patient,” she says. 

Occupancy decreased to 87.8% in the second quarter of 2019, from 87.9% a year ago — the lowest level in eight years, as reported by the National Investment Center for Seniors Housing & Care (NIC).

An analyst attributed it to isolated economic factors in some areas and in a larger context, zoning, regulations and shifting demographics. But the issue may have legs, according to Beth Burnham Mace, NIC’s chief economist. She pointed to “a clear downward trend” occurring in construction starts nationwide for new senior housing units. 

Mace urged industry leaders to “keep an eye on this data going forward to make informed decisions on new developments and other potential investments.”

The number of independent SNFs has been declining, according to a report in the National Real Estate Investor. Twenty-one new facilities opened in 2018, compared to 51 in 2013. 

Hardest hit have been rural areas, where at least 440 facilities have closed in the past 10 years, a New York Times report notes.

Observers agree that nursing home beds are currently being added more via replacement properties than new construction.

Meanwhile, demographics alone seem to defy any long-term doubts about the need for considerably more beds across every senior living setting over the next 10 years — statistics tempered by a recent Health Affairs report that most middle income seniors won’t be able to afford to sleep in them. 

Such trends may help explain the impetus behind the Ensuring Medicaid Provides Opportunities for Widespread Equity, Resources and Care Act (EMPOWER), which created the “Money Follows the Person” (MFP) program. 

The bill provides states with enhanced reimbursement for Medicaid services that promote the use of home- and community-based health care services in place of institutional, long-term care services.

According to the federal Medicaid program, since 2016, more than 75,000 people with chronic conditions and disabilities have transitioned from institutions like skilled nursing back into the community through MFP programs. 

Some are finding success with asset repurposing. Others are resurrecting with an age-old real estate strategy: mixed use.

“Stand-alone nursing homes are falling out of favor. Investors and consumers want property that has several tiers of senior living, including memory care, assisted living and nursing homes,” explained NIC Senior Principal Bill Kauffman in the National Real Estate Investor.

Earlier this year, Health Dimensions Group issued a report that supports Kauffman’s point. The firm said it believes that “more SNFs will convert to senior housing alternatives, such as low-income or market rental apartments, specialized units like traumatic brain injury or mental health units, assisted living, or memory care assisted living, all of which have experienced increasing consumer demand.” Cantata Health reported similar coming trends in its late 2018 industry forecast, stating it expects many nursing home companies to explore more profitable specialty ventures in areas such as diabetes, obesity, mental health and opioid addiction.

Michael Davis, senior vice president at Walker & Dunlop, believes diversification is the future. 

“The SNF industry continues to face headwinds with shorter lengths of stays, lower reimbursed managed care contracts, and increased alternatives to SNF care,” he says. “So these additional services should help attract additional residents and income.”

Spreading the wealth

Owners are looking for ways to expand their capabilities and thereby diversify revenues and maintain strong quality of payors, says Matt Huber, market manager, healthcare for People’s United Bank. 

“If the SNF is able to do this, then it will capture those higher reimbursements and ultimately, greater net operating income,” he adds.

That said, those owners who endeavor to bring their facilities into a mixed-use environment should choose neighbors wisely.

Kevin Giusti, managing director at Walker & Dunlop, says he has seen more SNFs with a component of memory care or assisted living “lease up well.” While teaming with a standalone dialysis provider may be a recipe for success, Giusti and others caution that combining some services might send a mixed message. 

That is why some financial experts say mixed-use developments should provide a very visible delineation, and if at all possible, be in separate, stand-alone buildings, particularly with drug rehab and substance abuse units.

“Given the uncertain reimbursement climate, adding private pay memory care as an option with high-acuity residents should be successful,” says Cindy Hazzard, a broker with JCH Senior Housing Investment Brokerage. “Is it wise or even possible to mix drug rehab or mental health with conventional skilled nursing or memory care without distinct barriers separating residents? The physical plant issues as well as staffing and fingerprinting, would be considerable. If these can be managed, it could be quite profitable.”

Mixed blessings

Not all owners are jumping into the mixed-use pool. After all, it is a quantum leap outside many of their comfort zones of conventional long-term care. 

“Incorporating higher-acuity facilities into mixed-used developments can be a challenge for developers for several reasons,” Conner Girdley, vice president of Lancaster Pollard, noted in a Lancaster Pollard blog. “SNF residents don’t consume the same retail services that residents of a market-rate development would. Moreover, the higher costs associated with constructing and operating senior living facilities can be an obstacle for senior living developers competing with market rate developers.” 

Giusti asserts that rehab residents don’t stay long enough. That fact and the acuity of longer-stay residents make both poor candidates for certain mixed-use developments. 

“If a developer can find a good site and still make the construction numbers work for a project of this nature, I think that could be a positive,” he says. “If the location was very desirable, however, that could drive up costs and this approach is not as viable.”

Girdley believes pairing skilled nursing care with other forms of care, especially memory and behavioral, has had mixed results.

“The challenge is that each product offering necessitates specialized care and staffing needs,” he says. “Most successes in these pairings have come in the form of building natural referral networks and improved visibility, while running each product offering as an independent unit, even if services are provided next door or within the same facility.”

“Obvious winners are facilities that partner with universities, hospitals and faith-based organizations,” Girdley tells McKnight’s. “Close alignment with hospitals provides a consistent referral network, while universities and faith-based organizations provide commonality and a supportive culture.”

But mixed use projects anchored by a skilled nursing facility can and do work.

“Many skilled nursing facilities have utilized intergenerational strategies, such as a pre-school on site, to both enhance the quality of life for their residents who enjoy looking out at the playgrounds, as well as drive additional foot traffic through their facilities,” observes Dan Revie, managing director at Ziegler.

Winning strategies

Among the biggest success factors for SNFs: locating near large hospitals, outpatient centers, emergency care and other mainstream medical care services.

“In general, we have seen good success with a specialized program that brings hospital level care to the SNFs,” says Imran Javaid, managing director at BMO Harris Bank. “This includes advanced cardiology care or strategic relationships with orthopedics and even some cancer care specialities. Transportation offices and proximity to physician offices are also important.”

There are several ways developers can make a proposed SNF project as attractive as possible to lenders, investors and others.

“Diversity in core and ancillary services and proximity to feeder sources such as assisted living and hospitals,” says Hazzard. “An important component in assessing risk is presenting a well-structured business plan that includes evaluation of potential market share and what unique factors would potentially influence competitive positioning.”

Come prepared to the lending table with choices, says Neal Raburn, managing director, seniors housing lending for Greystone.

“Instead of a one-size-fits-all approach, developers could offer two to three different brands under one corporate umbrella, each targeting a different price point, similar to what is common in the hospitality industry,” Raburn notes. 

Several experts strongly advise owners and developers to build replacement facilities rather than completely, “from the ground up” new ones. 

“This reduces the fill-up risk as a large percentage of residents at the older, existing SNF will be moved to the newly built SNF,” observes Giusti. Alternatively, he suggests building in a CON state or an area that will have limited new supply, something that would “provide comfort for lenders and investors.”

Girdley cautions owners to understand that it can be difficult to secure available land and obtaining zoning approvals in any commercial development. 

“Enlist mixed-use master developers that have already secured land and obtained zoning approvals for development,” Girdley notes.

While the inclusion of a senior housing component can help in obtaining approvals for most mixed-use projects, restrictions and regulatory obstacles for senior living facilities “make it more difficult for developers to expand in cities,” he adds. “Combining multiple uses into a vertical mixed-use building helps to overcome this obstacle.”

Javaid says his experience at BMO working exclusively on new SNF construction demonstrates there is no substitute for a proven track record of operating facilities that have a higher Medicare census and shorter-stay residents.At the end of the day, lenders are looking for experienced operators focused on quality.

“There is always a temptation for developers to chase higher yields that can be found in senior housing relative to other real estate types. However, the importance of a quality operator cannot be overemphasized,” notes Revie. “Having an experienced operator that can successfully navigate the current and future operational challenges, including a changing reimbursement environment, staffing pressures, and advances in technology, is critical to success.”

Adds Jeff Binder, managing director at Senior Living Investment Brokerage, “Without question, the first thing you should be prepared to discuss with lenders and/or investors is the depth, and strength, of your operator.”

“The labor market has never been as tight as it is today and organizations are having to get much more creative to attract and retain staff,” points out Anthony Perry, president of Executive Search Solutions, a recruitment firm for the senior living sector.

The longest bull market in United States history has turned up the pressure for employees up and down the long-term care chain — from CNAs to the C-suite — according to experts who commented on compensation data in the 2019–20 “Nursing Home Salary & Benefits Report,” the largest annual survey of long-term care professionals. It was published by LeadingAge and supported by the American Health Care Association. 

The 42nd annual industry analysis from Hospital & Healthcare Compensation Service gathered input from 1,611 U.S. nursing homes, encompassing 166,000 employees. 

At first glimpse, those at the top of the compensation pyramid had a less than stellar year. Administrators’ national average wage expanded by 1.67% to $111,842, while directors of nursing experienced a 1.81% salary increase to $96,720. 

But a closer look conveys a slightly different picture. Among facilities that also participated in the survey last year, administrators’ salaries increased by a robust 4.35% to $127,967 in 2019. Directors of nursing saw a slightly more modest 3% salary increase to $103,343 using the same comparison method, which analysts typically use as a better method of comparison.

Feeling bullish

Other high-level positions saw strong wage growth. Salaries of executive directors jumped to $207,848 in 2019, a whopping 5.45% increase. Retirements, in part, are driving this demand, notes Matt Leach, senior consultant with Total Compensation Solutions based in Armonk, NY. A total of 60% of CEOs or executive directors are said to be retiring in the next few years, he says. This has resulted in increased turnover and the need for long-term care to pay bigger bucks for its CEOs.

Among his firm’s clients, for example, three have new CEOs. These three were: promoted from within, snatched from another area of healthcare, and lured from a continuing care retirement community across the country. 

“They [facilities] have to pay key executives more money, or recruit and retain the ones they have,” Leach explains.

Thanks to a booming economy, positions at both ends of the spectrum fared well over the past year. Consider the following: 

Wages for housekeepers expanded by 2.97%, while those for wait staff rose by 3.06%. 

It’s a question of supply and demand, compensation experts point out. When supply cannot meet demand, it creates a labor shortage and wage pressures. The hospitality field, including hotels and restaurants, is among the industries competing with long-term care, Leach notes.

“I can’t remember a time when it [the labor market] was tighter,” Perry says. “Where last year it was tight, the ancillary or support positions, like housekeeping, maintenance, cooks, were still very easy to fill. This year, those positions are becoming harder and harder to fill.”

As a sure sign of the unique long-term care labor market, Perry offers this example: Cooks are now receiving sign-on bonuses. 

“I had never seen that before in my three and a half decades in the business,” Perry notes about the $2,000 sign-on bonus recently paid to a cook in the Phoenix area. “Now I’ve seen it.”

Perhaps underscoring facilities’ labor challenges, some of the biggest salary increases took place among positions related to recruitment and retention. Examples: Compensation for the director of human resources rose by 4.01%, while pay for the director of staff development increased 3.21% and the salary of the scheduling coordinator expanded 3.56%. 

Regarding the last position, Leach notes: “If you have a good scheduler, you’ll have a good organization. A good scheduler means everyone is happy and you retain talent. They [facilities] see a competitive advantage and they are willing to pay higher wages for a job like the scheduler.”

Turnover tale

As in years past, the strong economy continues to drive demand in one key category: nurses. 

“For CNA and nursing positions, supply is not meeting the demand and it will continue to become more competitive as we have growth in the industry,” says Mark Heston, president of Heston and Associates, a consulting firm that works in the areas of leadership development and coaching, compensation and strategic planning. 

Turnover rates reflect that nurses — LPNs, CNAs and RNs — are still a hot commodity. The national average in turnover was 36% among RNs, 32% among LPNs and 46% among CNAs.

Moreover, there is an increasing number of retiring nurses in the acute-care sector, which affects openings in the long-term care space, Perry says. 

Other factors

The strong economy also may be creating resident demand. 

“The two are not unrelated because there is a lot of retirement going on, and a lot of people moving into CCRCs,” says Paul Gavejian, managing director of Total Compensation Solutions. 

But the economy is not the only factor affecting compensation. Staffing ratios, such as those in California, are compounding staffing challenges. There is also significant movement involving mergers and acquisitions of nursing home chains. Because of easy access to capital, for instance, many small chains have cropped up in the field. 

“This has become more prevalent because of cheap money … which is creating the opportunity for people to start their own businesses,” Perry says. 

Mission: Recruit and retain 

In the current labor environment, facilities that are able to recruit and retain their employees will be the real winners, compensation experts point out. 

“One of the biggest problems we have in the industry is wage pressure, and if you don’t give people a reason to stay, they’ll leave,” points out Heston, who earlier in his career served as chief of human resources for Life Care Resources, which manages rental senior living communities.

One way that facilities increasingly are luring employees is through robust incentive plans, according to Leach. Under these bonus plans, an employee’s pay will vary from year to year based on a facility hitting an organizationwide goal. 

Bonus data provided in the survey suggests that facilities are succeeding financially. The percentage of bonus to salary was 16.3% for executive director, 15.4% for chief financial officer, 14.4% for director of human resources and 13.7% for nursing home administrator.   

“At the end of the day, the top organizations are performing quite well and the pay reflects that,” Leach says. 

Getting ahead

Attracting and keeping qualified talent does not have to be complicated. It begins for The Clare, a continuing care retirement community in Chicago, at the interview process, explains Kyle Exline, its executive director.

Since the facility is near Northwestern Hospital, there is not a shortage of capable registered nurses and CNAs in the area. The challenge is finding the right employees for the environment, Exline notes.

“We do a really good job of taking the interview process seriously and vetting candidates appropriately and making the best decisions we can,” he comments. “Retaining them and keeping them motivated are then what we strive for.”

As opposed to trying to “fill holes,” the community focuses on finding the right candidate from the get-go, he explains. While a person’s experience and capability for the role are key, the facility prioritizes the candidate’s personality, including their mannerisms and how they interact, over their professional experience and training. The rationale? While it feels confident it can teach and train candidates in cases where technical skills are lacking, it cannot necessarily help someone fit into the culture of the organization.

 “Those more ‘soft skills’ are what we are looking for,” Exline says, adding, “the soft skills are much harder to teach.”

Exline notes that the first 90 days are especially important for a new hire, and the organization does not hesitate to execute a termination if the employee is not passing muster. 

In terms of retaining employees, the facility provides additional training to workers, offers tuition assistance to encourage staff to receive additional schooling, and promotes from within. It regularly recognizes successful staff members, including a “kudos program” in which residents and family members submit cards touting employees’ accomplishments. 

Those little touches make “people feel like they are part of this community, part of this family … we are looking for ways to make them feel appreciated,” Exline says.

The facility’s efforts apparently have paid off: Turnover is less than 22% for the 10-year-old facility. 

I love opera, so getting to listen to it all the time as therapy would take at least a little bit of the sting out of losing my mental faculties. Truth be told, what happens on the stage makes a lot more sense to me than what happens off it these days, so living permanently in that world might be a relief.

Many people would choose to let their dementia run wild rather than listen to opera music. If nursing homes start playing it regularly, lawsuits will undoubtedly follow, alleging harm from the overuse of psychomusical meds. 

Opera also can cause debilitating vision problems. According to an unreliable source — me — eye rolls caused by a description of opera plots can result in permanent damage to the optic nerve and eye socket musculature. 

Regardless, in the 12-week study, playing traditional Chinese opera music to older dementia patients helped reduce the behavioral and psychiatric symptoms of the disease. But why did it seem to soothe and calm? 

Here’s a theory. Perhaps the heartrending arc of opera characters, as evidenced in the tragic choices they seem hopelessly predestined to make, parallels the feelings of inevitability and powerlessness felt by those with dementia. Even in a foreign language without translation, you can hear the pain, fear and loss. 

In Puccini’s “Madama Butterfly,” Cio-Cio-San watches the harbor day after day, naively hoping for her beloved’s return. When he does, the outcome is anything but happily ever after. 

Maybe that’s why opera resonates with those suffering from dementia. They’re living a heartbreaking story they’re powerless to change.

As of Nov. 28, there will be trauma focused F-tags that surveyors will assess as part of Phase 3 implementation.

Traumas are sensitive emotional wounds and I’m concerned that in their well-meaning efforts to comply with the new F-tag directives, staff and surveyors will be poking these emotional wounds with a big stick.

There are many aspects of the situation that contribute to my uneasiness. An in-service training or two won’t make up for the general lack of psychological training of the staff, for example. And teams are still having difficulty identifying major triggers for psychological evaluation. 

There are also privacy concerns, including how and where to hold interviews, and how to safeguard information in records.

In addition to all of this, I operate from a belief that virtually every resident coming into long-term care has been traumatized to at least some extent by the health event that precipitated their admission, the medical procedures they’ve undergone, being away from home and other losses. While not every resident has post-traumatic stress disorder (PTSD), for most people, this experience brings up past times when aspects of their lives were out of control.

The good intention of increasing awareness of mental health issues would be better served by evaluating every resident for psychological services upon admission, the way each resident is assessed by rehab, recreation and other departments, while simultaneously improving the training of staff to refer residents after certain life or personal events. 

Better yet, as the field moves away from the fee-for-service model, funding could be directed toward staff positions for psychologists so we can focus not only on individual residents, but on psychoeducational groups for family and staff needs.

Meanwhile, since trauma-informed care regulations are coming, I hope that staff and surveyor training emphasizes the importance of personal information in as private and sensitive a manner as possible. 

They were distinctly there earlier this year when we celebrated our first McKnight’s Women of Distinction class. Oh, sure, it would have been natural for many unchosen to wonder, “What about me? With hundreds of nominations, however, there was just no way for the judges to fit every deserving person on the boat, so to speak. 

But there was also another notable “What about me?” vibe we occasionally received. It came in the form of sullen comments from men, as in why aren’t you also having a recognition program honoring male achievements? If you need a black-and-white answer for that one, I’ll let you ponder it a little longer on your own. 

But I will also point out that men were, and have been, central to so much of this program. For anyone — man, woman or child — to overlook this, or quickly gloss over it, would be incredibly short-sighted. Setting aside the original spark at our company for getting the program off to a flying start, there are other poignant male influences to consider.

Numerous honorees, for example, thanked male colleagues, mentors, loved ones and friends. A great example comes from a video interview with “Rising Star” honoree Erin Donaldson, a Life Care vice president. Right off the bat, she chooses to credit long-ago coworker Jim Biggs for helping her become established and rise in the profession. (See the video and others online at www.mcknights.com.)

A “village” of women and men, in other words, raising leaders and working together toward the greater good.

For anyone thinking it’s just a he-said-he-said or she-said-she-said world, they need to think again. 

Support and celebrations deserve to be spread around. We are stronger together than we are apart. Not a terribly complicated concept, when posed in other settings. No pouting or effigy burnings welcomed.

And instead of worrying “What about me?” think about making a positive impact on someone else. Then say it while taking credit pridefully, with an exclamation point: “What about me!” 

That counts too.

Genesis Healthcare grabbed the early lead in the pink slip parade. The firm let go of about 600, or more than 5%, of its rehab workers. Many other operators have been considering similar moves. That is, if they haven’t done so already.

For this sudden talent purge, we can thank Medicare’s shiny new Patient Driven Payment Model, or PDPM. This revised patient classification system was designed to remove therapy minutes as a payment driver. And if the early returns are any indication, it is more than doing its job.

Some would argue that without the infusion of therapy services we have seen in long-term care, many thousands of residents would be recovering from hospital stays far more slowly, if at all.

What many unfortunate therapists are now experiencing reminds me of a scene from the film “Casino.” Mob chieftains at a table are considering whether one of their own, Andy Stone, could become an informant. Three bosses jump to his defense. Then a fourth asks: “Look, why take a chance?” You can probably guess what happens next. 

To be clear, it’s still early into PDPM. And there are many people far smarter than me who believe things will more or less stabilize with time.

I’m not dismissing that view. But let’s not forget that long-term care has a proven history of following the money. Or to be more exact, one of chasing new service options that enhance payments.

A quarter century ago, therapy was pretty much a non-factor in skilled care. What ushered it in? For the most part, an opportunity to tap into Medicare dollars by delivering covered services. Almost overnight, many facilities were transitioning from $100 to $150 daily Medicaid payments to the $400 to $600 Medicare could deliver.

The Medicare shift turned out to be good for business. Will therapist reductions have a similar legacy? I’d say it’s too early to tell.

But it’s becoming clear that a growing number of operators don’t want to take any chances.