Legal Solutions for Your Lifetime

Most of the people I have represented tell me they have never had a lawyer before.  They are not sure what to expect.  What you can expect from my office is someone who cares what you want; someone who cares about delivering cost effective legal services to assist you at any stage of your life.

My practice is dedicated to helping people with: starting a family; starting a business; protecting their family and their business; dealing with business issues; planning their estate; dealing with incapacity, and; planning ahead so that you know you and your family will be safe and secure even if you do lose the capacity to make decisions on your own.

Please feel free to look around and read the articles.  If you find something that speaks to your needs, make an appointment.  The first half hour is free of charge.  I look forward to meeting with you.

VA Benefits

It’s complicated is the title to a movie starring Meryl Streep and that guy that imitates Donald Trump.  It is also an apt description of VA benefits.  There are two main types of VA benefits to look at when considering income for purposes of paying for assisted living: Service Connected Disability and Improved Pension Plan a/k/a Aid and Attendance.

Service Connected Disability applies to service persons who were injured during the course of their service in the US military and certain survivors.  To be eligible for this benefit, the service person must have been injured while on active duty, or exposed to something like Agent Orange that affected them adversely in ways that may not show up until long after discharge.

Service connected disability is calculated in percentages of disability.  The higher the percentage, the greater the income.  Income is also set by the rank the veteran had while in service.  Neither is income affected by the assets of the veteran, or family survivor.

The other type of VA benefit is through the Improved Pension Plan, commonly known as Aid and Attendance Benefits.  Actually, Aid and Attendance is the highest level of benefits paid through the Improved Pension Plan.  Basic Pension benefits apply to qualifying veterans and some survivors who can still get in and out of the home themselves.  Homebound benefits apply to qualified veterans and some survivors who, obviously enough, are homebound.  Aid and Attendance benefits apply to qualified veterans and some survivors who need help to get through their daily lives.  Typically, this applies at assisted living facilities, although it can apply at independent living centers and even at home under certain circumstances.

Pension Plan benefits require several factors to be met.  First, the veteran must have had at least 90 days of active duty, at least one of which was during a time of war, at least up until the Gulf wars.  Gulf War veterans must have at least two years of active duty to qualify for the benefit.

Second, the veteran has to have limited income.  The maximum benefit amount for one veteran is $25,525, as of December 1, 2016.  Every Dollar the veteran and household family earn counts against that amount and reduces the benefit Dollar for Dollar.  However, if the expenses are qualified expenses, like the cost of assisted living, the qualified expenses reduce the income that is counted against the benefit Dollar for Dollar.  Because this is remarkably unclear; if a veteran had income of $25,525 a year and no qualified expenses, the veteran might qualify in terms of service and resources, but get no benefit because the veteran’s income matched the benefit.  If the same veteran had $30,000 in assisted living expenses, the veteran would get the entire benefit of $25,525.

Resources are the final category of eligibility.  The current limit on resources is unknown.  The VA regulation states that resources should be reasonable under the circumstances.  There is a proposed regulation that would limit resources to $119,220.  That regulation has been in circulation for a while and rumor is it will go into effect sometime early in 2017.  President Elect Trump has proposed rather sweeping changes to VA benefits.  It may well be that if the proposed regulation goes into effect, it will be effective for only a limited period of time.

Should you, the attorney, decide to assist a client in obtaining VA benefits you should be aware of several other important things.  First, you should be accredited by the VA to practice before the VA.  That requires specific education in several areas and an update of your education every two years.  Second, you may not be paid to help with the application for benefits unless it is already been denied at the first level.  Lawyers typically provide other legal services and throw in assistance with the application “for free” to get around this requirement.

Finally, many attorneys put in an informal application to achieve an early start point for benefits if they are approved.  Given that the review process for these informal applications averages seven to nine months I believe an informal application is a bad idea.  I prefer to put in the effort to get all information necessary and put in a formal application where processing times are much shorter.  Be careful.  If an application is rejected, there is a one year waiting period for a new application.

The Programs and How They Work

MEDICARE:  Medicare comes with two different coverage categories.  Part A is hospitalization insurance.  You pay the premiums every time you pay taxes.  Part B is Doctor and Home Healthcare.  You must pay the Part B premium when you start getting Medicare.  Medicare pays for the same things health insurance pays for when you are working.  Additionally, it can pay for skilled care in a nursing home when needed – after a three day admission to a hospital.  It pays for up to the first 20 days at no deductible and no co-pay.  After that, it can pay for up to the next 80 days of skilled care with a daily co-pay for which the insured is responsible.  Medicare does not pay for stays at nursing homes beyond the 100 days.  It will pay for home health and doctor visits while in a nursing home, but not for the stay.

If you are on Medicare you should strongly consider having a Medicare supplement policy.

MEDICARE SUPPLEMENT:  Medicare Supplement policies are private insurance policies that cover most, if not all, of Medicare co-pays and deductibles.  Additionally, Medicare supplement policies can pay for coverage beyond the scope of traditional Medicare; depending on the policy and what coverages are selected.

One kind of Medicare supplement policy that many people get is called a Part D Policy, or a Drug Policy.  This policy can pay for a part of most drug costs.  Drug costs are generally not covered by Medicare or normal Medicare Supplement policies.

MEDICARE ADVANTAGE:  Medicare Advantage policies (also known as Part C policies, or Medicare Replacement policies) are private insurance policies that replace regular Medicare policies and generally have all the features of Medicare Supplement and Part D policies as well.  Medicare Advantage carriers have an agreement with Medicare where monies representing Medicare Part A coverage is paid by Medicare to the Medicare Advantage company allowing purchase of a Medicare Advantage policy for about the same price as a regular Medicare policy with Part B, Supplement and Part D coverages added to it.  Most Medicare Advantage policies are built upon a Health Maintenance Organization (HMO) platform, with checkups and reduced or free membership in local YMCA’s as a part of the coverage.

Where a Medicare Advantage plan falls short of need is when the insured has deteriorated health that calls for measures like skilled care at a nursing home, or dialysis.  Typical Medicare Advantage plans have high co-pays and deductibles as well as significant limitations on how long a skilled care stay can be.  This is possibly because Medicare Advantage companies are paid monies by Medicare on a capitation basis (a fixed amount per insured) versus by the service provided basis.

SWITCHING FROM MEDICARE ADVANTAGE TO MEDICARE:  In an ideal world people would be able to sign up for a Medicare Advantage plan when they are younger and in generally better health so that they can prolong that good health and then switch to regular Medicare when their needs start becoming more acute.  We do not live in an ideal world.  If an insured desires to switch from Medicare to Medicare Advantage, or vise versa, the insurance companies will look to current health to see if they will provide coverage and at what cost.  Once the health of the insured is an issue, getting a policy is also an issue.  Persons newly eligible for Medicare coverage and persons just coming off of employer plan health insurance do not have to undergo underwriting and can get a Medicare or Medicare Advantage policy no matter what their health situation may be.

MEDICAID:  Medicaid is the medical benefit (not insurance) program for impoverished persons.  SSI eligibility, or less than $2,000 in countable assets are the gateways for acceptance into Medicaid coverage.  Additionally, there are income limits depending on family size.  Medicaid pays for hospital, doctor office, rehab and drugs.  It is not divided in coverage as is Medicare.

TENNCARE/MEDICAID:   Medicaid is not an insurance program.  It is assistance to the needy and strict income and asset guidelines apply.  Additionally, any benefits are subject to estate collection.

Asset Eligibility is:

$2,000 for the institutional spouse

In order to prevent giving money away to become eligible there is a five year look back period during which transfers create a penalty.  The penalty is calculated by dividing the full amount given away in the last five years by the current penalty divisor.  This year the penalty divisor is $5,472.00.  So, if an applicant has given away $43,824.00 four years and eleven months before applying for Medicaid the State will not pay for care until 9.54 months have passed.  The penalty period begins when the applicant is otherwise qualified, meaning in the long term care facility and down to $2,000 in countable assets.  In case someone is tempted to incur the penalty to be able to disburse assets, the cost of private care is usually at least $2,500 more a month than the penalty divisor.

Just because the IRS allows you to give away certain monies every year without incurring a gift tax does not mean those gifts are exempt from creating a penalty.




A Medicaid spend down is all about what is a countable asset and what is not a countable asset.  Some examples below:


Liquid assets

Institutional Spouse IRA, 401k, etc.

Cumulative cash value of life insurance exceeding $1,500

Equity in a business exceeding $6,000

Second house

Second vehicle

Equity in house over $543,000

Primary residence if held in revocable living trust

Primary residence if it is rented out

Non contiguous land to principal residence

Non-Qualifying annuities



Primary residence if equity under $543,000

Community Spouse tax deferred savings

Vehicle of any value as long as it is used to transport to and from medical care

Vehicle (1) under $4,600 equity

Qualified annuities

Equity in a business for support of $6,000 or less

Qualifying Special Needs Trust

Assets that cannot be liquidated

Most itemized pre paid funeral plans and gravesites

Once qualified the patient pays their income directly to the facility and TennCare pays the rest of the state authorized pay rate for the facility.  The patient actually gets to keep $50.00 a month for personal expenses like clothes, shoes, hair cutting or styling, etc.  Usually the facility keeps the money for the resident and doles it out as necessary.

VA PENSION:  A benefit paid to a veteran or surviving spouse who needs care and qualifies on income and assets.  There are three basic levels:

Basic Pension              Home Bound              Aid & Attendance

The amount of the benefit depends on marital status and whether or not the applicant is a veteran, or a surviving spouse.  The full A&A amounts are:

$1,759 single veteran

$2,085 married veteran

$1,130 surviving spouse

NOTE: spouses of living veterans are not entitled to benefits.  So, for instance, if the veteran is fine and the non-veteran spouse needs assistance the VA will not provide assistance until the veteran dies.

The benefits are not taxable and are not subject to estate collection.

In order to qualify the veteran must have had a minimum of 90 days of active duty, at least one of which was during a defined term of combat.  The length of duty for Gulf War veterans is longer, generally 24 months.

Income qualification is the benefit amount.  In other words, if your income matches or exceeds the benefit amount, you are not eligible.  Income is calculated as net of qualified expenses.  Qualified expenses are costs of care in a facility, health insurance, supplies, etc., which exceed the benefit by 5%.

Asset eligibility is an area filled with myths.  The actual limit is the amount of your qualified, but un-reimbursed, expenses over your expected lifetime as calculated by VA life expectance tables.  The application has to go to a committee if assets are $80,000 or over.  Generally, a successful application should have countable assets of roughly one year’s worth of expenses.

You may give away all of your money in the morning and apply for benefits in the afternoon.

The VA does not count trust assets where the veteran loses all control over the money.  So, the typical VA trust makes sure the grantor has no control.  The trustee is supposed to give the facility the difference between income and facility cost.

Annuities can convert countable assets into income, or into a non countable asset.  In order to do this the annuity must be:




The annuity need not be actuarially sound.



TennCare/Medicaid, Medicare and VA benefits can help to pay for nursing home care.  Medicare will only pay for a limited period of time and only if the person needs Skilled Care (IV drugs, physical therapy, or occupational therapy.)  VA benefits can pay towards long term nursing home care.  However, VA benefits cap out at substantially less than the private pay cost of nursing home care.  Only TennCare benefits can pay for nursing home care for longer periods of time.

Aside from citizenship and residency, there are three categories of qualification for TennCare:  Financial, Income and Physical Need.

If your client is single, the financial picture is somewhat straightforward.  The client can qualify as long as the client has less than $2,000.00 in countable assets.  Their house is not countable.  A vehicle that is used to go to medical care is not countable.  Most burial arrangements are not countable.  Special needs trusts are not countable.  Most everything else is countable.

Couples are more complicated.  The community spouse is the one staying home.  The institutional spouse is in the nursing home.  The institutional spouse must have less than $2,000.00.  With a couple there is one more uncounted asset, community spouse tax deferred savings (IRA, Keogh, 401K.)

Everything countable is added together before dividing the whole into two equal parts.  It does not matter who has title to the asset.  Pre-nuptial agreements are not considered by TennCare in counting assets.  Once the assets are divided each spouse has to spend their half down to acceptable levels.  The institutional spouse has to spend down to less than $2,000.00.  The community spouse can keep a minimum of $23,844.00 (assuming there is that much.)  The community spouse may keep no more than $119,220.00.

When your client applies for TennCare your client must divulge any gifts during the last five years.  This is called the lookback period.  Normal birthday and holiday presents generally do not count.  Gifts beyond that do even if the gift is not a taxable gift under the annual IRS gift exclusion ($14,000.00 this year.)  That’s right, Medicaid and the IRS do not talk with each other.  Gifts to qualified special needs trusts do not count, nor do gifts of the house to disabled children, or to children who have stayed in the house and cared for the institutional spouse for at least two years.

All of the countable gifts are added up and then divided by the average state reimbursement rate for nursing home care through TennCare.  This years that amount is $5,472.00 per month.  As many times as $5,472.00 goes into all the countable gifts made in the last five years is how long TennCare will not pay for the nursing home stay.  Partial months count.

To illustrate, if I gave away $54,720.00 four years and eleven months before going into the nursing home, TennCare would not pay for the first 10 months of my stay.  Private pay rates at nursing homes are generally a good deal more than $5,472.00 per month.

Income for the person seeking benefits is limited to $2,199.00 per month, or three times the federal poverty level.   If the client has income beyond that you will need to draft a qualified income trust (QIT.)  Simply putting income beyond $2,199.00 into the QIT makes the client eligible.  In practice all of the client’s income should go into the QIT for ease of bookkeeping.  Money from the QIT can only be used for nursing home care, hearing aids, dental work and eyeglasses.

Income from the institutional spouse can potentially be assigned to the community spouse if the community spouse gets below $2,003.00 per month.  Income may also be paid to the community spouse up to a maximum of $2,981.00 per month as long as the community spouse “needs” the income according to housing cost estimates that may have last been accurate when the Beaver was being raised by June and Ward.

The final qualification standard for TennCare is medical need.  In brief, you really have to be in bad shape to qualify for long term care benefits in a nursing home.  There is a test, called the PAE (Pre Admission Evaluation) that determines whether or not the applicant qualifies.  The PAE score must be at least a 9 to qualify.  Private institutions like hospitals and nursing homes may do PAE tests.  Those test results are reviewed and it is common for a nursing home 10 or 11 to be reduced to a 7 or 8 by the TennCare PAE reviewers.

Once the person qualifies for TennCare, that person pays all of their income, less $50.00 per month, to the nursing home.   This is known as the Patient Liability.  The State makes up the difference between the patient liability and the reimbursement rate for that institution.  The $50 usually also goes to the institution to pay for things like hair and laundry.

Practicing Elder Law

Helping qualify clients for benefits is a sometimes tricky, and often frustrating, area of practice.  Good lawyers are left feeling befuddled by the maze of laws, regulations, guidelines and rules that govern benefits for their clients in need.  They have every right to feel lost.  The rules are complicated and filled with hidden traps that can adversely affect vulnerable clients.

For example, the Social Security Administration says that trusts which can be collapsed when they get too small to be cost effective are countable assets that disqualify individuals who must have less than $2,000 to receive SSI and Medicaid.   Prenuptial Agreements mean nothing to TennCare caseworkers who require couples to spend down their life savings in order to qualify one of them for nursing home benefits.  And, oh yes, giving the house to the kids will make your client run afoul of the five year look back period for Medicaid/TennCare and the imminent ten year look back period of  the Veterans Administration.

Over the years I have seen people create absolute messes when they thought that they could outsmart the system.   The problem with trying to outsmart the system is that the usual efforts at outsmarting the system come with a significant downside; a penalty period.  Currently, every Dollar improperly transferred away from the applicant or spouse within five years of the application for benefits creates a penalty period.  The length of the penalty period is all of the money improperly transferred during the last five years divided by $5,472.00, the average State reimbursement to nursing homes for long term care.  The penalty period begins when the applicant is otherwise qualified; meaning they are down to less than $2,000 in countable assets and in the nursing home receiving care.  At that point the person needing help has usually spent all their money and the adult children are worried about how they are going to be able to afford an attorney, much less the $7,000 plus a month of nursing home costs in private pay rates.  The way to avoid those emergencies is planning.

In the case of TennCare and VA benefits, the sooner the planning the better.  When the mental capacity of the client is gone so is their chance of making arrangements outside of court proceedings.  Assets transferred to a trust four years and eight months ago incur the same penalty period TennCare requires from an asset transfer made four months before an application for benefits.

With good planning a couple may well be able to afford for one to live in a facility while the other spouse remains home and can still afford groceries.  With more planning a court will not have to appoint someone to make life and death medical decisions for a person they never met before they were in the hospital.  Clients can even use their power of attorney to appoint the person they want to be their conservator should they ever need one.

Be careful when you do decide to practice elder law.  Be sure you are willing to wrap your head around the twenty five pages of Rule 1240-03-03, the 25 pages of 42 U.S.C. §1396p, and the Program Operations Manual System of the Social Security Administration.   Knowledge of these important documents will allow you to work out strategies for families who need help qualifying for benefits while simultaneously making sure there are enough resources to keep the at home spouse safe.

Benefit law and regulation are only a part of providing for clients in need of benefits.  A working knowledge of the tax implications of trusts as well as how trusts report income paid out to beneficiaries is crucial.  It is also important to make sure that there is somebody who knows how to run any trusts involved in planning.  The best drafted trust in the world is useless if it is not run according to its internal rules.

You will also need to become familiar with annuities.  Annuities have been a major vehicle for converting assets which prevent people from obtaining benefits into assets that allow people to get benefits from both TennCare and the VA.  The system has, however, been abused, the rules have changed, and older couples have purchased what they thought was security in an annuity only to find that the annuity not only disqualifies them, they cannot get their money back intact.

I like my practice.  I get to help families in need.  We navigate through tough problems together and make sure loved ones have the care they need.  That’s a good thing.  You might enjoy it as well.

Powers of Attorney



Everybody knows that powers of attorney are loss leaders.  They are forms where you just fill in the blanks, smile big, get a little money for a little work, and try to sell more services.  No big deal.  Wrong.  Powers of attorney give the attorney in fact the ability to clean out bank accounts, hide resources, withhold needed treatment and  extend suffering where permission to case treatment and bring on comfort measures is refused.

In other words, you the attorney should be as careful about explaining and qualifying clients and family for powers of attorney as you are when planning an estate.  This means making sure that you remove as much opportunity for undue influence as you can from the process.  It means making sure the client is genuinely comfortable with the proposed attorney in fact.  It also means exploring various tools to ensure that the attorney in fact is going to have every reason to behave in a fiduciary fashion.  As you might expect, it is also critical to establish capacity.

The court dockets in Middle Tennessee testify to the fact that powers of attorney are abused.  Complaints cite monies that have disappeared in small and great quantities.  I am the plaintiff’s attorney on one that involved the disappearance of over $800,000.00 through abuse of a power of attorney.  Oftentimes the money that is stolen will never be paid back.  It is just gone.

Removing undue influence means a certain amount of planning mixed with a certain amount of common sense.  Who is the person pushing for the power of attorney?  Is it the person who is going to sign it?  Is it a child?  Is it an old acquaintance, or someone new to the scene?  How is the client getting to your office?  Yes, you can and should have a private conference with the person who is signing the documents.  That is probably not enough.  Do you really think that the ride home is not going to include the question: “So what did you tell the attorney?”, or “What did the attorney tell you?”   Trust your intuition.  If it seems fishy it probably is fishy.  If you think there might be undue influence try to find a way to find a way to speak to the client in a way that provides some assurance.

Not everyone is qualified to act as an attorney in fact.  If they struggle with their finances and write a lot of rubber checks with their own money there is reason to believe they might do the same with the client’s money.  If they have obtained a series of “loans” from mom and dad without ever bothering to pay those loans back handing them the keys to the accounts with a power of attorney is probably a truly bad idea.  If it comes right down to it is probably better to decline the work than to explain your lack of diligence in the witness stand in a later proceeding to recover lost savings.

A popular tool to ensure no funny business is requiring one or more doctors to certify lack of capacity before the power of attorney comes into effect.  The tool does nothing to prevent problems after the principal is declared to lack capacity.  It also ignores the problems that will arise when the principal probably lacks capacity, but believes they are just fine.  Have you tried to persuade a doctor that nothing bad will happen if they declare their patient lacks capacity?

It seems a better idea to use surety bonds, private accountings, and trust protectors who can remove the attorney in fact and bring bad conduct to the attention of the court and the police.   A person who knows that even a quickly repaid “loan”  will cause everyone in the family to know what happened is not likely to think that “loan” is a good idea.  Making sure more family members are involved also tends to alert the family to what is happening and prevent potential fraud and conversion.

Checking to ensure there is adequate capacity is a keystone to a successful power of attorney.  A person who has capacity is less susceptible to undue influence and is more likely to spot an attempted financial grab than someone who is foggy.  An optimal way to ensure capacity is to have the physician certify capacity within a few days of the signing of the documents.  Witnesses who know the principal, have no stake in the outcome and are trusted by a majority of the family are a good idea where capacity is in question.  You might try administering a test to detect dementia.  The problems with such tests include what happens if the client fails the test and making the attorney and staff witnesses.  Remember also that with rare exception attorneys are not trained psychiatrists or psychologists.


Powers of attorney are wonderful tools for clients and family.  They can ensure that a trusted family member is handling business as well as, or better than, the client.  They can lift a burden from clients who worry what might happen if they can’t make decisions for themselves.  They can prevent the guilt stricken child from keeping the client in a coma by insisting that the hospital do everything to keep the client alive.

A power of attorney can help prevent conservatorships and their high costs.  In the event a conservatorship becomes necessary the preferred conservator can even be named in the power of attorney.   The judge is required to pay attention to the nomination and probably appreciates it.

Even the best, most artfully crafted, power of attorney is useless unless people know about it and can see it.  I strongly urge clients to take copies of their healthcare powers of attorney to all of their doctors and the hospitals near them to put the documents in the electronic medical records.  I also urge clients to take their general powers of attorney to their banks and financial institutions.  While such a thought beggars the imagination banks have been known to refuse to recognize powers of attorney for reasons that defy reason and logic.  Best to know that and fix the issue before it is too late.

Nursing Homes

People live longer into infirmity now more than ever before.  According to the US Census Bureau only the dependency ratio for older adults was 11 percent in 1940.  In 2010 that ratio was 21 percent.  By 2020 the dependency ratio is expected to reach 28 percent and 37 percent in 2040.  Someone has to take care of this dependent population.

Families are not able to accommodate all of the older persons who are dependent.  This is where nursing homes, assisted living centers and independent living centers come in.  Nursing homes are the place where people who need the most help live.

There are two different kinds of residents in most nursing homes:  people needing long term care, and persons needing skilled care.  People needing long term care are unable to take care of their activities of daily living: eating, bathing, dressing, toileting, transferring and continence.  This population may be paying for their care entirely out of pocket, have some assistance from the Veterans Administration, or be receiving long term care benefits from TennCare.  By law, each resident is required to receive the same level of care, no matter what the payment source might be.

People needing skilled care are generally getting physical therapy, occupational therapy, or IV therapy.  Medicare, or other types of insurance, generally pay for rehabilitative care.  This kind of care pays the most per bed per day in a nursing home.

According to a 2015 Genworth survey of private pay costs for long term care the average across Tennessee was $192 per day, or $70,080 per year.  In Nashville and surrounding are that rate is an average $200 per day, or $73,000 per year.  The average TennCare reimbursement rate for long term care in Tennessee is $182.42 per day, or $66,583.30 per year.

The average length of stay in a nursing home for long term are is somewhere around 835 days.  Around Nashville that means an average of $167,000 in nursing home cost per person.  So, clients either have to have enough money to pay for the cost on their own, or must have few enough countable assets to qualify for TennCare benefits.  What does this mean for an attorney trying to help clients qualify for the potential of nursing home care for their clients?   It means is it a good idea to help your clients prepare.  In the case of nursing home care, the sooner the better.  Keep in mind that most transfers of assets that occur within five years of an attempt to qualify for TennCare assistance create significant problems.

Revocable living trusts are not the answer.  Because they can be revoked the entirety of the assets of a revocable living trust can be counted.  Annuities may be part of the answer, but could easily be dangerous.  Long term care insurance products, especially partnership plan qualifying products, are a good idea in many circumstances.   Irrevocable trusts are a good option, but you had better know what you are doing when you draft one.  Tax issues, trustee issues, allowable distribution issues, and allowing for change as the clients have varying needs should all be considered when drafting the trust. What might seem to be a minor issue can create major problems when your client applies for benefits.

Selection of the right nursing home is important.  Good management at a facility can make the difference between a decent experience and a horrible experience.  Proximity is also important.  It is easier for family to visit a close facility.  The more family visits, the better the care.  If staff believe a family member may show up at any time, the resident is more likely to be in good shape at all times.

There are a number of companies which help families find appropriate placement in all levels of eldercare facilities.  Walking around the facility a day or more before the meeting with the marketing person is a must.  If the hallways smell in more than one or two places, care is lacking.  If the afternoon “entertainment” for the residents is lining up in front of the nursing desk, care is lacking.  Look in at the therapy area.  If one therapist is attending too many people at once, it is likely no one is getting adequate care.  It doesn’t matter if the hallways are festooned with fresh carpet and lovely paintings when care of the human residents is lacking.