Mother's hip fx in nrsg home

  1. I would like some advice from LTC staff and others including any LNC's regarding an incident which happened to my mother.
    In January at change of shift from days to evenings a CNA put her on the toliet and left her there alone. She was told to ring the call light when she was finished and the CNA shut the door and left.

    Last June, my mother had two CVA's at the right basal ganglion. She is now hemi-plegic on the left. She can move her lt leg a little and can transfer with mod-max, mostly max assist by one-two persons. With max assist she can take a few steps in PT with hemi-cane and two staff members. Before the hip fx she was able to walk 25-35 ft with hemicane and 2 person assists.

    The day of her fall she was found by her regular CNA- the one who toileted her was not her regular caregiver. She was laying on the floor with her body halfway out of the bathroom doorway. She called the RN to her room. The nurses notes state that my mother said she was trying to get herself back into her wheelchair which my mother vehemently denies that she said. It also states that the RN did ROM and the RN charted that there were no bruises or marks- however- my mom c/o a lot of pain when they STOOD her to get her back into her w/c and then a few minutes later when they STOOD her to put her in bed. They called the doc and based on the info the nurse gave him he ordered a FEMUR X-ray. The portable service came and did the film. The results weren't ready until approx 9 pm that evening. In the meantime they again STOOD her to go to dinner and yes they had her sit up in her w/c even though she was complaining of pain. Then after they had the results of the x ray the CNA was instructed to again STAND her to get into bed. Prior to then she was assisted by two CNA's to stand but nonetheless she had to stand. Mother screamed bloody murder and collapsed onto the bed.

    The RN in charge that night is one that absolutely hated me. She was haughty when she told us mom's x-ray was neg. so "there shouldn't be any reason she is c/o so much." When the CNA put her to bed for the night I looked at my mom's thigh and hip. There was a very large bulge close to her groin and she was complaining a lot of groin pain. She could not straighten her leg or have any tension on it. I had to inform the RN and LPN of my findings because they certainly knew nothing about it.

    The next day her regular day CNA told me that she had repeatedly told the LPN in charge that mom was in a great deal of pain. She said the LPN told her that my mom HAD to get up for breakfast and lunch and reminded her that the previous night's xray was neg. Approx 1PM, the CNA insisted that the LPN come to the room because my mom was in agony and the pain meds were not holding her. She finally decided to call the doc and send her to the hospital because she was crying and crying. She called us and told us tomeet our mom at the ER.

    Yes, she did fx the head of the femur. I also found out she hit her head- no notes about neuro checks or that it had happened. At the hospital they also discovered huge swelling and bruising on her left elbow which was NOT noted in the nurses notes and her elbow was Xrayed. The staff at the home did not know about the elbow bruising and swelling. I called the charge nurse on my mom's division at the home and informed her that my mom's hip was fx. I also asked her approx how many times she was stood on her leg before it dawned on anyone that something was wrong. She said she couldn't possibly answer that question. Mom had surgery and was in the hospital for 5 days. The nursing home charged us $700.00 for a five day Medicaid bed hold!

    She returned to the nrsg home. On the day of the return the staff was very hostile to my sister and I. We talked to the nursing staff about making sure mom was comfortable, etc. But the *****y RN was in rare form, almost manic. She was so hyper and psyched up and was yelling at us when her tone should have been normal conversation. My sister and I then went to see the administrator. Sis asked very politely asked that my mom NOT be left alone on the toilet again. The administrator started yelling at my sister and told her she couldn't promise anyone would be with her when she was placed on the toilet because "we don't do private duty here"! My mom is unable to "right" herself if she starts falling to the left side because of the paralysis.The ***** is no longer employed at the home. She was asked to give her resignation for some questionable illegal behavior on the premises of the facility according to the CNAs.The home denies it and says it is a personnel matter that they can't discuss but that they assure us it wasn't because of drugs. Right!!!

    They have since admitted to us that she should NEVER have been left alone on the toilet. BUT... my mom suffers each and every day with hip pain. She is barely able to assist herself and doesn't walk more than 2-3 ft with MAX assist. My sister and I both have numerous health and pain problems and are unable to lift her or her wheelchair. So, now we just take her out for rides but we end up coming back in about 45 minutes because she can't stand to sit on her butt due to pain. Of course, since she is Medicaid they "plateaued" her in skilled PT a little less than 2 and 1/2 weeks after surgery and returned her status to restorative therapy. Previously we had requested 5 days of restorative therapy and they complied. This time I was told by the PT that the front office will NOT approve any more than 3 days of restorative therapy for MEDICAID patients.

    She is now doing "restorative" therapy but I had to take her to the ortho surgeon a few weeks ago because she c/o pain when her leg was internally or externally rotated. It turns out that her lt knee had become contracted. Even though their PT notes indicated that they were doing all sorts of things such as ROM during her restorative sessions. The ortho doc said "B_ _ _ S_ _ t! They are putting her in a w/c at 6am and keeping her there for several hours or this wouldn't be happening". They had the asst. administrator call me and tell me that the PT said her knee is NOT contracted. I told her that she could take that up with the ORTHOPEDIC SURGEON whom my mom had seen 4 days prior to her call. I then told her what he said about leaving her in the w/c for so long and she shut up like a clam. I offered to call him and tell him that they disputed his medical diagnosis and needed him to call them so they could tell him he was wrong but she declined.

    She has recently developed a pressure area on her lt hip- reddened but skin not broken - 2nd time but they don't straighten her out when she is listing to the left side. They just walk past her and ignore it. We have asked that she be put to bed after meals but that's just a wish also. They hung a q2hr turn schedule above her bed but that is an absolute joke.

    What they keep forgetting is my mom is almost completely aware and not DEAF and CONFUSED like some of them think she is. She repeats everything they say about her and other patients to us. She just laughs at us when we ask if they turn her on nights.

    Moving her to a different facility is out of the question. This is the only Medicaid bed available around here and believe it or not this is the best facility we could find! It is impossible for us to care for her at home and neither one of us has the room for her.

    In May her PCP ordered a voice amplification system for her since she is aphasic and dysphonic from the CVA. It was ordered on May 17, 2002. She still doesn't have it. The speech therapist called me and said they had some systems but they were broken and that her supervisor said she had no intention of getting them repaired. She said the family would have ot buy her a system. Told us it only cost about $25.00. WRONG- $200.00+ !
    Administrator said she would look into it. Told her that when I called the 800 # for Medicaid they said the home should provide it. Told her to call them herself- " I said you know the number for providers to call- I used the 80 number for patients. That was on June 15 and I still haven't heard back from her.

    How long can they wait before implementing an order that was written on MAY 17?

    My sister and I have had a meeting with a lawyer for the purposes of filing a negligence suit against the nursing home and it's staff.

    I forgot to tell you. When I took her to the ortho surgeon just recently I had called the portable xray service and told them that he wanted to see the film from the day of injury. He really didn't but I did. Guess what? The film was of the DISTAL 2/3 of the FEMUR! I asked the ortho if the head of the femur was supposed to have been included and of course he said yes. BUT THEN he said " sure is a nice xray of your mom's left KNEE!!!
    Makes sense to me now. About a week ago one of the RN's was joking that they had taken the wrong xray by the time they had figured out it was her hip that was fx! They found out when I called them from the ER. The ER staff was livid that she hadn't been sent to the hospital the day before when it happened.

    What's the first thing you think of being injured when an elderly patient falls? Duh, the HIP!!!

    Mother was moved to this facility last November because in the previous home (same owner) she developed bacteremia from MRSA - no one knew she was sick with a 103 temp and low bp and tachycardia. My sister and I figured it out when we kissed her hello. ER staff said it was a good thing we brought her in when we did because she would have died if we didn't.

    ALSO, another time she c/o chest and arm pain for over 8 hrs. Nurse kept telling us over the phone that it was abd pain and that it was just indigestion and that she looked ok to her. I got to the home in the afternoon and called 911. She had an MI and went on to have 4 balloon angioplasties and 3 stents during the next 3 critical weeks. I called the state on them for that and they were cited for not informing the doc of the seriousness of the situation and for not sending her to the hospital sooner. The state surveyor nurse from the dept of aging also cited them for the lack of any infection control practices. I made 37 allegations against them and they were cited for 3!!! The nurse from the state called them and told them that a complaint had been filed against them!!! So
    much for the element of surprise!!! I had 4 rolls of color pictures for evidence of filth and feces and urine everywhere. WHAT DOES IT TAKE? A DEATH???

    Now, the lawyer says IF they decide to take our case we have to call the division of aging again and make a hotline complaint for her hip fracture. He said they would not be able to take our case unless we were willing to do that.

    I can not do this much longer and neither can my sister. Why can't I just be my mom's daughter and not have to be her nurse? Neither my sister nor I are well enough for all of these preventable problems. We are not asking for her to be treated like a queen just like they would want their own mom treated.

    They hadn't brushed her teeth from Dec 22, 2001 to Feb 27, 2002 and when we confronted them at a family mtg they said they would take care of the problem. I replaced her toothpaste tube on Feb 27, 2002 and just removed it from her room on June 24, 2002. There is barely any squeeze marks on the tube! It's alost cause.

    There are NO nurses notes from March 15, 2002 to April 22, 2002. Then only one entry and none again until May 8, 2002. Is that LEGAL???

    Please help me with your opinion.
    Thank you,
    PappyRN

    Any opinions??
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  2. 42 Comments

  3. by   jevans
    Pappy RN

    I don't know if I can help cos I'm from the UK with a very different system BUT I am a Stroke Nurse.
    I was totally appalled to read your post and feel cross and angry that your mother has been subject to this type of treatment.

    I printed your post so I could go throughit point by point

    1] No pt of mine who is mod/max dependent should be left unattended without support.
    Question you could ask- do the facility have a standing hoist? if so why are they not using it. It is the only way that a stroke pt with no balance can be left.

    2]Stroke pt's do have problems with swallow and when she was told she needed to sit out it was probably to prevent aspiration.

    3] I cannot understand why no effective analgesia had been given nor why neuro obs not done its standard practice

    4] Nursing homes in the UK differ from residential homes due to the level of nursing care needs. Is it the same?
    But in any case as qualified nurses we have a code of conduct that informs us we have a duty to maintain dignity and treat our patients as individuals. this was clearly not done

    5] Limb contractures are extremely common with stroke pt particularly after an incident like this cos mum must have tried to find a comfortable position for her hip. What are they doing about it. Not the PT but nursing staff?

    6] Pressure areas- does she have a special airflow mattress? if not why not? she should also have a pressure relieving cushion for her chair and position must be changed atleast 2hrly

    7] Positioning in chair- corect position can be maintained with very little intervention a] ensure affected arm is placed on a pillow
    b] a rolled up towel on her affected side placed between her thigh and the chair.

    8] Stroke pts are not stupid and she should not be treated as confused EVER. Communication is vital

    9] the catelogue of other events are so appaling that you can not let these matters rest

    Please write your complaints and forward them on a circulation to The State, Your Congress, Insurance, Nursing Board and anyone who is involved with this facility.

    As for the nursing home I personally would like a copy of her careplan and if every aspect of life is not on it I would ask for it. Then you have them!

    I understand you do not want her to be treated like a queen but lets be fair she deserves quality care whoever she may be. I think both you and your sister need to continue to be the best advocates you obiviously are and look out for her best interests

    Good luck and give them hell They deserve it
    j
  4. by   santhony44
    I know that laws and regs vary from state to state but definitely lots of negligence here. I don't see that you have any choice but to file a complaint with the state. I'd also consider talking to the state Medicaid folks too. Has her PCP been involved in much of this? He needs to stay on them about things too, including the order from May. Good luck to you- and I'd keep looking for alternative placements!
  5. by   ERNurse752
    Get her outta there, and sue their a$$es off!
  6. by   pappyRN
    Thank you for your responses. I appreciate your taking the time to comment on my post. The things I have listed are just a FEW of the things that go on.

    My mom is a silent aspirator and is supposed to have her liquids thickened to nectar consistency. The staff evidently has some problem with the correct amount of Thik- It to use in the size glasses they use in the dining room. My mom got to the point where she was refusing to drink anything at meals because they used so much of the powder in her drinks that you could turn the glass upside down and NOTHING would fall out! That is how they expected her to drink and that is also how they brought a cup of water to her for her meds!

    My mom is currently exercising her right to refuse to use the Thik-It. She says she just doesn't care if she aspirates. My sister and I have tried to convince her of the need to use it but she won't listen to us. I even conducted "home experiments" in my kitchen with attempting to discover how much Thik-It to use in their size serving glasses and how to cut down the amount so as to allow the thickening that occurs upon standing. Next, I called the manufacturer and asked them to mail me some guides that could be hung on the wall or just be placed in the dining room. The home refused to hang them and told me they already have them hanging but to this day I have still never found them.

    Then, I asked them why it was so impossible to get the staff to comply with nectar thick or honey thick liquids for pts. The DON said " we've tried but they just won't listen". I told her that I would be glad to do an inservice "free" for them but she refused. I believe the refusal to comply with the correct use of the thickening agent borders on blatant insubordination.

    Emotionally, this has been very hard on my sister and I. Just recently, one of the CNAs told me that the staff calls me the "boisterous" sister- I guess because I am more apt to speak up about medical/nursing issues. Then I was told that they also warned them to look out for me because I am the "mean" sister. It is not unusual for us to greet the staff when we enter the building and my mom's division only to be met with silence and heads turned the other way.

    When my mom asks to lay down for a while it has to be at the convenience of the staff. She doesn't like to take long naps and once she's in bed they refuse to get her up until she's been in bed for at least 2 hrs. Of course, she is usually NOT positioned off her reddened lt side.

    The 2nd to last time that she had a UTI she had a fever and c/o HA. Her CNA put her to bed with 2 sweaters, 2 blankets, a quilt, a sheet,and a throw over her! When she had bacteremia the ER staff had told us that they should be taking rectal temps on her as they are more accurate in the debilitated elderly for knowing their core
    temperature. So, I asked them to get a rectal
    thermometer and check mom's temp. This was shortly after we arrived and were told that she had a 99.1 and a HA. They searched the entire 165+ bed facility and could not even find one. The RN admitted that my mom felt way hotter than 99.1 and that they have been having trouble with their thermometers and that they needed to be calibrated. I asked them if they had a good old fashioned glass thermometer but of course they didn't. So, I stormed off to Walgreen's and bought a digital thermometer and returned totake mom's rectal temp. It was 102.6, not 99.1 ! I stripped all the blankets and sweaters from her and dressed her in her nightshirt. The staff got mad because they said she had to go to the dining room for supper. They don't allow residents to eat in their rooms unless a family member is present.
    *** Did I forget to tell you that this was the DAY BEFORE they left her unattended on the toilet when she fell off and broke her hip ???

    My mom's version is that she asked the CNA not to leave her alone in the bathroom because she only needed to void and she is lightening quick at it- besides she had a UTI and was only voiding in small amts. The CNA told her just to ring the beel when she was done. My mom would have had to LEAN FORWARD to even reach the bell and she doesn't have the ability to then straighten herself out. The CNA had also closed the door and my mom was afraid that no one would come and answer the bell due to past experience and also to mom's problem with conception of elapsed time. She told us when they didn't answer the bell she just tried to lean forward to push the door open enough for her roomate to ring the bell or yell for help.

    In the past we had informed the staff that my mom was impulsive- one of the many reasons she couldn't have that shiny new motorized w/c that she wanted. But they didn't believe us because they said they can joke around with her and she doesn't seem impulsive to them.

    jevans- I have never seen a standing hoist in the facility and they have never used any type of lift on my mom.

    They also NEVER use gait belts! I bought one for her roomfor my sister and I to use in the event that we don't have a choice but to lift her.

    The nursing staff is not using any intervention in regards to her knee contracture. In fact, the asst administrator called me back and told me the PT said the contracture was no longer an issue about one week after I first talked to her.

    She has an ultraform mattress. The positioning every 2 hrs is a non entity. Will probably never happen.

    I purchased a few small pillows to use between her thigh and the side of the chair. They never put them in the chair with her. I find them on the floor or in her closet.

    Please pray for her that her situation improves.
    Personally, I'm just appalled at what goes on and hope to God that I die before I ever have to be incarcerated in a nursing home!

    To it's credit this home is immaculately clean with NO urine and/or fecal odors but I guess that's a moot point when you factor in the neglect.

    It truly is like a palace compared to the other 11 nursing homes we looked at. The list of deficiencies cited by the state was minimal. Almost every other facility had at least 20 pages worth of text from the state!

    By the way, the administrator had a fourth of July party on the third open to the entire community. There were free hot dogs, soda, popcorn, and beer for the 5-7 thousand + guests. This included a magnificent fireworks display.
    BUT... they can't afford the voice amplification system so she can communicate because (adm)" if I had to do those kinds of things for all the Medicaid pts I couldn't afford to. Medicaid doesn't pay us enough and we lose money on those pts every day. That's why we only have a few Medicaid beds. We'd lose too much money"!

    What more can I say?

    Warm personal regards,
    PappyRN
  7. by   night owl
    It's a shame that we work hard our entire lives then have to be subjected to this kind of treatment. You place your loved one in a nursing home thinking that they will be well taken care of when in reality they all become neglected to a certain point. Pappy, you will find this in every NH across America... incidents occur and the cover ups begin. Had the care giver who helped her to the BR stayed with her until she was finished, NONE of this would have happened. Why did she leave her alone in the first place? Did she have other residents to take care of or did she not know she needed to stay there until she was finished? I could ask you hundreds of questions, but I'll leave that up to your attorney. I only pray that I don't ever have to be placed in a "home". There are some very caring people in NHs, but there's not enough of them. They're over worked with too many residents to take care of, too much paper work to do and too much bull from administration which leaves too little time for giving the care the elders really need. In any case, I hope you sue the crap out of them. You know the saying, "Be nice to your kids...they'll pick out your nursing home!" It's a joke b/c the "best" nursing home in the world will have the same old problems the worst one has...unless nurse to patient ratios improve.
  8. by   BernieO
    I don't even know how to begin. As I read your post, I got angrier and angrier. I manage a 45 resident wing in a LTC. Any fall requires a detailed account sent to the state. A fall resulting in a fracture requires a phoned report within 48 hours to the state. This is the state mandate in IL. I'm sure your state also has similar regulations. This written report must include assessment, care plan with intervention, and prevention implementations. This is a very important state report. A facility could be heavily fined if this is not done. Your mother was assessed incorrectly and the cardinal rule of not listening to your resident was broken.<p>From what I read, your mother is not receiving proper care determined by her needs. I would love to see her care plan. I would love to have your mother in my facility. <p> All residents who require an assist of 1 or 2 persons, must have someone stay with them in the bathroom. One of my CNA's left such a person for 1 minute to get a change of clothes. This CNA received a written warning and 1 day suspension. Resident safety is the most important factor in caring for the elderly.p>Unfortunately, a law suit might not be possible or profitable. Often judgements are based on the person's future contributions to family and society. But this case screams IMPROPER CARE. Good Luck to you.
  9. by   jevans
    Pappy RN
    sorry it's taken so long to get bak- been working the afternoon shift

    I realise you have problems with moving mum BUT for her safety and welfare please consider it
    SILENT ASPIRATION OMG her fluids can be regulated using thickener in water, which is, as directed mixed using a whisk
    You do not need rocket science.
    These people do not understand or comprehend her needs.

    PLEASE PLEASE know that you can be supported here and listen to the advice given REPORT THEM

    lots of love prayers and support
    j
  10. by   pappyRN
    Thanks for the support. I'm waiting to hear from the law firm about whether or not they will take our case.

    The CNA who left mom alone in the bathroom did so because it was change of shift and she was a DAY person so she was leaving. I guess she was in a hurry to get out of there. Her mistake has virtually cost my mom her health. She has just not had very much stamina since the fracture. She was anemic with a Hgb of 7.5 after her surgery and it just seems like she has never really bounced back.

    Am I as one of her POA's, allowed to see the report that was sent to the state? (Missouri). I have copies of almost all of her records. I usually make it a practice to get copies of mine so I also get my mom's. She signs for me to receive the copies. She is still competent and I still have her sign for things whenever possible. We secured the powers of attorney for the times when she can't sign for herself. It's ok with her that I get the records. I discuss them with her after I've read them. I've NEVER seen anything charted about a call to the state. Are those records available to my mom and I?

    As far as her fall assessment- get this- I can't remember the name of the fall assessment scale but they only rated her risk as a 10! Wasn't even close to recognizing her potential for falls.

    If I had to grade their charting they would get an F - for failing to CYA. There are so many things left out and so many questionable things charted that I almost feel sorry for them if it goes to court. I think the lawyer will be able to rip them a new butt.

    I am unable to drive any farther than I do to see her. I feel it necessary to go almost every day. For some details of my health just go to the topic "drug seeking patients" and look at my replies in that thread.

    My brother is of absolutely NO help to my sister and I. I'm barely holding up as it is. They know I am watching their every move now. They don't know about the attorney yet. I even take pictures when I feel it will be helpful. I am not optimistic that things will work out in our favor because if the state couldn't do any more than they did in the previous facility than I don't know what will. Have you ever heard of the state calling and telling them that a complaint had been filed?
    This particular nursing home chain has facilities in 5 states!

    My mom simply no longer cares about the silent aspiration. She is so depressed about her situation and hates it there so much that she could care less if she aspirates. She was even shown the video barium swallow that was done at the hospital. She doesn't even cough that much anymore which is scary.

    I'm just furious that they could give such a big party on 3rd of July and refuse to get the voice amplification system. Speaking of the 3rd of July, my mom's daytime CNA accidentally parked her car in the wrong parking lot that day so they made her move it. She told the day charge RN ( a lazy a$$ who can't seem to leave the chair at his nurses station), that if her pts needed anything to ask her two helpers (?training CNAs?) to get what her pts needed. My mom told John that she had to use the bathroom and he told her that she would have to wait for the CNA to return. Well, she returned but by the time she got to my mom's room she couldn't hold it and was incontinent of urine and feces. My mom cried with humiliation.

    Can you imagine if all this goes on with us visiting everyday- what about those poor souls who don't have anyone to advocate for them.

    There was an incident last year in an unrelated NH where 3 or 4 residents died because the a/c wasn't working and the temp of the 3rd floor got to 95+ degrees. The grand jury refused to indicte the NH owners. Can you believe it? Well, the county prosecutor's mom is a resident in the same facility as my mom. Think anything will happen to them? I don't.

    We buy her nice soaps and shampoos because their stuff isn't all that great. The CNAs leave her toiletries in the shower/tub room and use them on everyone else and then bring back the empty bottles to my mom's room.

    I am almost to the point of praying for my mom's passing so she can be at peace.

    I thought they weren't supposed to discriminate against Medicaid pts.

    Warm regards,
    PappyRN
  11. by   adrienurse
    :angryfire :angryfire :angryfire

    I am an LTC nurse and I found that your thread was almost too painful to read! It sounds like my worst nightmare. It is my guess that what you have experienced in your mother's care and deterioration is only the tip if the iceburg -- concerning how dysfinctional that place is. Get your mother out of that place! Believe me, there are better nursing homes. Please do not allow yourself to blame long term care in general for this. Your story should read when very bad care practices supported by very bad management happen to good people.

    I hope your mother is feeling better.
  12. by   ktwlpn
    It is paramount that you move your mother out of that home-she will never get good care there.Have you looked at state and county run homes? Not pretty-but in this area they are well staffed and run well and very strictly regulated...I believe that the state overlooks a great deal when they visit the pretty private (for profit) places....That's why the hell holes continue to exist-they welcome the inspectors with coffee and danish and then trot out the therapy dog...and then pass out the rose colored glasses to them....You may have to drive 3 or 4 hours to find a suitable place for your mom-she will die if left there with the incompetent and uncaring staff....
  13. by   BernieO
    Pappy---Get in contact with the Ombudsman for your area. I'm sure your state has that program. The best way to find them is to call the Elder Abuse Hotline. They will investigate & protect your mother's rights. There is no charge. Medicaid or Private Pay should make no difference in a resident's care. Most of the caregivers at my facility do not know who is private pay vs Medicaid. They all get treated the same. If we need something special for a resident without funds, we have donation money to use. Payment is never an excuse for poor nursing care.<p>Can you get the speech pathologist or primary care doc to intercede with the thickening liquid issue? The resident dietician should also be involved in monitoing the feedings. Her care plan and MDS should dictate the proper feeding of your mother.<p>Regarding the state reports, I doubt the POA or resident can have access to them since they are not part of the chart. Good Luck
  14. by   night owl
    Pappy,
    I was appalled why this CNA left your mom alone in the BR...just because she had to go home...People who think like that should not be working in a place where they are supposed to be taking care of people. I hope she was fired! Or at least had some kind of disciplinary actions against her. If that happened in my facility, she would have been at least suspeneded. If this place looked like a palace and had the least amount of citations against them, I'd hate to see the other places! Good luck in finding a better place, but you do need to get her out of there. Alot of places look good, but it's the staff ratios you need to look into and of course the # of deficiencies. I will keep you, your sister and most of all your mom in my prayers. Keep us informed of your journey and most of all, we will continue to be here to lend you support and encouragement.

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