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Theft of Controlled Substances in Long-Term Care Homes: An Exploratory Study

January 2023

The theft of controlled substances has been studied in the community and healthcare settings including hospitals, pharmacies, hospice, and pain clinics. However, research on these thefts in long-term care homes has yet to be published. This exploratory study makes first steps toward bridging this gap. Using 107 Minnesota Department of Health's investigation reports substantiated as "drug diversion" between 2013 and 2021 in assisted living residences and nursing homes, we found that 11,328.5 tablets were stolen from 368 residents (97.5% were controlled substances), with over 30 tablets stolen per resident. We also identified the types of medications stolen, duration of theft, extent to which nurses stole the medications or were those initially suspecting thefts, and the role of surveillance cameras in confirming allegations. The findings could raise awareness to this form of elder mistreatment in long-term care homes and call for action to address it.

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Elder Mistreatment Investigations Buried No More: 50 Reasons Why Elder Care IQ is Needed

January 2023

The public’s ability to access completed mistreatment investigation reports on the website of the Minnesota Department of Health (MDH) Office of Health Facility Complaints (OHFC) has been limited for many years. Elder Care IQ (launched on November 29, 2022), a free service established by Elder Voice Advocates, contributes to addressing this major gap by making these investigation reports more easily accessible at the care provider level. The web-based search tool allows anyone to learn about the regulatory history of assisted living residences, nursing homes, and home health care agencies across Minnesota. In doing so, Elder Care IQ serves as one among several means people can use to identify problematic and unsafe care providers. 

The following is a list of 50 reasons why Elder Care IQ is needed:

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Long Term Care Ombudsman Program (LTCOP) in United States: Time to Establish the Program in Israel

November 2022

The Long Term Care Ombudsman Program is administered by the Administration on Aging, within the Administration of Community Living (ACL) of the U.S. Department of Health and Human Services (DHHS).

The idea for the Long Term Care Ombudsman Program (LTCOP) was developed by Dr. Arthur Flemming, Commissioner on Aging to President Nixon. He envisioned the program as an advocacy program for residents. The Older Americans Act (OAA). The OAA of 1965 created a National Aging Network comprised of federal, state, and local supports and services for individuals ages 60 and older. In addition to providing comprehensive services for older adults, the OAA established the LTCOP. OAA Title VII, Chapter 2, Sections 711/712 pertains to the LTCOP.

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The State of Elder Care in Central Minnesota

March 2020

Elder Voice Advocates did a review of the long-term care provider investigations in the Central Minnesota area. We found that 44% have been investigated in the past 2 years and 8 facilities has several investigations in this time period indicating a pattern of subpar care.

This report is intended to help Central Minnesota citizens be informed consumers of the elder care services that are offered in their region. We have reviewed the investigations by the Minnesota Department of Health (MDH), Office of Health Facilities Complaints (OHFC) of neglect, abuse and exploitation. Some of the information you will read is disturbing. Our aim is not to frighten or shock, but rather to educate you about the many factors that can affect the quality of care elders and vulnerable adults receive. You will also see that there are some investigations that are not a serious issue or that they have been quickly and effectively addressed. Our hope is that after reading this report you will be equipped to ask the right questions so you can make more informed decisions about any elder care services you may choose, whether it is for yourself, a family member, or a friend.

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Inhumane and Deadly Neglect Revealed in State Assisted Living Facilities

April 2019

Elder Voice Advocates’ (Elder Voice) review of substantiated investigations reveals shocking deaths and suffering that need urgent solutions that only the Minnesota Legislature can remedy. We undertook this review of publicly available investigations data from the Minnesota Department of Health’s (MDH) Office of Health Facilities Complaints (OHFC) to get a clearer picture of what is happening in assisted living facilities throughout Minnesota and why is it happening. Elder Voice reviewed OHFC Investigative Reports of maltreatment in Assisted Living Facilities and identified many systemic problems.

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A federal survey deficiency citation is needed for resident-to-resident aggression in U.S. nursing homes

July 2017

Resident-to-resident aggression (RRA) in nursing homes is a prevalent and concerning public health problem. A rapid growth in the number of research studies has led to advancements in understanding and awareness of these incidents. However, no state survey deficiency citation (F-Tag) currently exists to capture RRA in a structured way in the Centers for Medicare & Medicaid Services’ (CMS) nursing homes F-Tags Coding System.


This omission represents a major barrier to State Survey Agencies, CMS, consumers, and care advocacy organizations’ efforts to keep vulnerable and frail residents safe and free from psychological harm. The commentary makes the case for development and implementation of a new RRA-specific F-Tag by identifying 20 problem areas and the ways in which this F-Tag could address them. The new F-Tags Coding System (part of the new Federal Nursing Home regulations) represents a rare and time-sensitive opportunity to bridge this major gap in practice, research, and policy.

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The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes

April 2016

Many U.S. nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. This commentary focuses on two issues.


First, there is a need for higher minimum nurse staffing standards for U.S. nursing homes based on multiple research studies showing a positive relationship between nursing home quality and staffing and the benefits of implementing higher minimum staffing standards. Studies have identified the minimum staffing levels necessary to provide care consistent with the federal regulations, but many U.S. facilities have dangerously low staffing.


Second, the barriers to staffing reform are discussed. These include economic concerns about costs and a focus on financial incentives. The enforcement of existing staffing standards has been weak, and strong nursing home industry political opposition has limited efforts to establish higher standards. Researchers should study the ways to improve staffing standards and new payment, regulatory, and political strategies to improve nursing home staffing and quality.

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Protecting Resident Privacy and Prohibiting Mental Abuse Related to Photographs and Audio/Visual Recordings by Nursing Home Staff

August 2016

Recent media reports have highlighted occurrences of nursing home staff taking unauthorized photographs or video recordings of nursing home residents, sometimes in compromised positions. The photographs are then posted on social media networks, or sent through multimedia messages.

Nursing homes must establish an environment that is as homelike as possible and includes a culture and environment that treats each resident with respect and dignity. Treating a nursing home resident in any manner that does not uphold a resident’s sense of self-worth and individuality dehumanizes the resident and creates an environment that perpetuates a disrespectful and/or potentially abusive attitude towards the resident(s). Federal nursing home regulations require that each nursing home provides care and services in a person-centered environment in which all individuals are treated as human beings.

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Elder Mistreatment: Priorities for Consideration by the White House Conference on Aging

April 2015

Elder mistreatment is recognized internationally as a prevalent and growing problem, meriting the attention of policymakers, practitioners, and the general public. Studies have demonstrated that elder mistreatment is sufficiently widespread to be a major public health concern and that it leads to a range of negative physical, psychological, and financial outcomes.


This article provides an overview of key issues related to the prevention and treatment of elder mistreatment, focusing on initiatives that can be addressed by the White House Conference on Aging. We review research on the extent of mistreatment and its consequences. We then propose 3 challenges in preventing and treating elder mistreatment that relate to improving research knowledge, creating a comprehensive service system, and developing effective policy. Under each challenge, examples are provided of promising initiatives that can be taken to eliminate mistreatment. To inform the recommendations, we employed recent data from the Elder Justice Roadmap Project, in which 750 stakeholders in the field of elder mistreatment were surveyed regarding research and policy priorities.

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An Examination of Resident Abuse in Assisted Living Facilities

March 2013

An estimated 39,100 Assisted Living (AL) settings exist in the U.S., with about
971,900 beds, providing services to 733,300 persons every day. Elders living in AL settings may be particularly vulnerable to abuse because many suffer from cognitive impairment, behavioral abnormalities, or physical limitations – factors that have been reported as risk factors associated with abuse. In this research, perceptions of abuse in AL coming from a large sample of Direct Care Workers (DCWs) and administrators are examined.

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Abuse and Neglect in Assisted Living Facilities

July 2013

You’ve seen the sales pitches about America’s assisted living facilities. Seniors can flourish in bright, cheery alternatives to nursing homes and live out their golden years securely, monitored by medical professionals who tend to their every need.


The business of assisted living paints a depressingly different picture, according to a provocative new documentary from PBS Frontline airing this Tuesday night, accompanied by a series from ProPublica that is being published this week.

Nearly 750,000 American seniors live in assisted living facilities today – but instead of being cared for, many are abused and neglected, according to a year-long investigation.

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A Room With A Grim View: The 'Ambient Despair' That Marks Life in Assisted Living

July 2012

After entering an assisted living facility at age fifty-three because of young-onset Parkinson’s, an observer-advocate contemplates the dire need for long-term care reform.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America


Since the late 1970s when Congressman Claude Pepper held widely publicized hearings on the mistreatment of the elderly, policy makers and practitioners have sought ways to protect older Americans from physical, psychological, and financial abuse. Yet, during the last 20 years fewer than 50 articles have addressed the shameful problem that abusers—and sometimes the abused themselves—want to conceal.


Elder Mistreatment in an Aging America takes a giant step toward broadening our understanding of the mistreatment of the elderly and recommends specific research and funding strategies that can be used to deepen it. The book includes a discussion of the conceptual, methodological, and logistical issues needed to create a solid research base as well as the ethical concerns that must be considered when working with older subjects. It also looks at problems in determination of a report's reliability and the role of physicians, EMTs, and others who are among the first to recognize situations of mistreatment.

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Resident Abuse in Nursing Homes - Understanding and Preventing Abuse

April 1990

The OIG conducted this study to promote a better understanding of abuse in nursing homes. This is the first of two reports. It examines the nature of abuse and ways to prevent it. The second report Resident Abuse in Nursing Homes: Resolving Physical Abuse Complaints examines existing processes for resolving physical abuse
complaints. Both reports reflect the experiences and perceptions of knowledgeable individuals who 1) play some part, directly or indirectly, in the resolution of abuse complaints, or 2) have an interest in nursing home or elder issues.

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