Grow A Culture of Critical Thinking to Calm Survey Angst

This article was written by Action Pact writer Keith Schaeffer for the Pioneer Network, and published on their blog on June 12, 2018

Anxiety over the new Mega Rule survey process that examines caregivers’ critical thinking skills may have some long-term-care providers on edge, but not at Garden Spot Village in New Holland, PA.

“Our focus on critical thinking and empowering staff over the years in working with Action Pact has put us in better position,” says Steve Lindsey, CEO. “Getting everyone involved, not just assigning tasks but helping them understand the big picture, the issues, and how to make decisions has created a high level of critical thinking throughout the organization.”

How to achieve all that is the subject of Action Pact’s intensive session, Navigating the Mega Rule; Building a Highly Involved Culture of Critical Thinkers, at the Pioneer Network’s 2018 Annual Conference in August.  Presenters include LaVrene Norton, MSW, Megan Hannan, MS, Gloria Blackmon, RN, Glenn Blacklock, MS, and Linda Bump, MPH, RD, NHA.

Their purpose isn’t to tell attendees how to develop critical thinking among their staff, says Hannan, but to give them the information and understanding needed to chart their own course.

“We really appreciate that Action Pact’s is not a cookie cutter, pre-formulated approach,” says Lindsey. “It’s a journey of learning together and shaping something that is different for each organization’s culture.”

Garden Spot Village operates six skilled nursing households, each with its own culture shaped by those working and living there. Staff’s critical thinking abilities enable them to weigh carefully what they want to do while understanding it within the context of the regulatory environment and the lives of the people they serve, says Lindsey.

But most care homes leave critical thinking to the leadership,middle management, and nurses, says Norton. CNAs and others are simply told what to do, often without understanding the importance or context of their tasks within a person-centered, resident-directed culture.

But now, CMS expects hands-on caregivers to be critical thinkers, as well. Brains

All staff must know about the new survey requirements and their organization, residents, and services provided, and how to use that knowledge to better serve the residents. Do they know what to do when an incident occurs … that pudding should not be offered to Vivian because she is allergic to eggs … or that serving George dinner in his favorite nook outside the usual dining areas still requires proper hand hygiene and food safety practices?

Nurses develop critical thinking in college and in clinical training while going through a process of study, discussion, practice, feedback, reflection, further study, and more discussion. CNAs and other hands-on caregivers rarely get the opportunity.

“If we really expect them to think things through, know how to collaborate as a self-led team, and make decisions, then let’s give them the time, information, and education to develop critical thinking,” says Norton.

Person-centered environments with permanently-assigned, cross-trained staff working in teams to serve small groups of residents naturally enable caregivers to know the elder’s needs and desires well.

But staff’s capacity to contribute becomes much higher when they also are taught critical thinking skills … how to analyze, develop good judgement, and make decisions, says Norton.

For instance, CNAs know to inform the nurse when something doesn’t seem right. But what if the nurse fails to follow up after being told?

Rather than letting the matter drop or complaining to peers that “I told the nurse but nothing was done,”a CNA trained in critical thinking understands it’s important to follow up to ensure the nurse got the message.

“A sense of responsibility grows along with a more integrated understanding about how to serve the resident, and thoughts and actions toward her become more accurate,” says Norton.

As information is shared, the whole work team gains a deeper understanding and capability. They think through challenges as they arise, day or night, “determining whether to take the initiative and deal with it in the moment, or knowing when they shouldn’t take the initiative and call in resources from outside their team,” says Norton.

“It bubbles up in different ways in how life is lived and the sense of empowerment that residents and staff have … to live life on their own terms,” says Lindsey.  That and a CMS Five-Star rating has come from growing critical thinking skills at Garden Spot Village, he concludes.

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Life Soars at St. John’s New CCRC in Albert Lea, Minnesota

Eagle crop2Residents will have eagle eyes watching over them when they move into one of the new households at Fountain Lake in Albert Lea, MN – especially if it’s nesting season.

“We didn’t know a bald eagle’s nest was on the property until about a year after we purchased it,” says Scot Spates, Administrator at St. John’s Lutheran Community.

Continue reading “Life Soars at St. John’s New CCRC in Albert Lea, Minnesota”


Refining the Household Model is an endless journey of challenge, personal fulfillment

By Dr. Matthew Bogner*M Bogner Head 2015

We all want to feel a sense of meaning and purpose in our lives – to be part of something bigger than ourselves and aspire to a higher moral purpose. Many of us find this meaning in our work and implementing the Household Model enables us to do just that because even on difficult days we feel fulfilled knowing we are enabling a better life for our most vulnerable. Continue reading “LESSONS FROM THE ROAD”

Joy in Mudville: Casey Goes to Bat at The Piper

Yes, pitcher Casey Barnes was on the Kansas City (KS) T-Bones disabled list in 2015 after catching a sizzling line drive with his bare hand, injuring a thumb.

No, that is not why he moved into The Piper Assisted Living and Memory Support for the 2016 baseball season. Continue reading “Joy in Mudville: Casey Goes to Bat at The Piper”

The Magic of Music

Music-key to memory-editedEnjoying and appreciating music may still appeal to persons living with dementia, but music may offer a lot more than pleasure: a connection to memory and emotional expression that might not be otherwise accessible. Read these simple but powerful stories to be reminded of the myriad ways we might incorporate music into daily life, to both entertain and ENGAGE!


The following story is from The Piper Assisted living and Memory Care in Kansas City, KS. Steve Harman, a Household Coordinator, is working on his CNA, and during a recent clinical at another community, he had this great experience.

Bologna Song Whets one Appetite!

Recently I spent a few hours with Mrs. B., who has pretty severe dementia and is known for not eating her meals. Usually when Mrs. B. sits down to eat, she is “full” before the meal is even served. The more people try to get her to eat, the more she refuses to eat. My experiment was to ask her about anything but her meal. My niece and I used to sing songs at the dinner table, which kept her from getting bored, so I tried this with Mrs. B. “Mrs. B., do you know any songs?” She replied, “Yes, all of them.” That being the case, I chose a musical masterpiece, the Oscar Mayer Bologna song. “Mrs. B., do you know this song? My bologna has first name...” She sang back to me, “it’s O-S-C-A-R!” “My bologna has a second name…,” I sang, and she replied with a full mouth. She had taken a big bite of food! So I patiently went through all the songs I knew the words for (5 commercials, Jessica by the Allman Brothers, and You Are my Sunshine). Somewhere in the middle, Mrs. B. started making up her own songs about the food on her plate. One was the word Gravy sung repeatedly to the tune of Happy Birthday. Another was a song about how good vegetables would be if they were cake. When she finally finished, she had consumed half of her plate, doubling her intake from the last three meals combined. Throughout this experience, she would occasionally ask to be taken to the front of the room where people congregate to watch television and other things. That was when it occurred to me: Mrs. B. was bored. She never asks to go home, or simply to leave the facility. She wanted to go to the front of the room because that’s where she can be entertained.  I took her to the area where a volunteer had started playing guitar. On our way up there, I overheard one of the staff say, “I’ve never seen Mrs. B. so lively or excited like that. She seems to be excited about music.” I’ve only spent a small amount of time with Mrs. B., but several people have informed me that this was very different from her usual behavior. She was deemed difficult or grumpy. This was such an encouraging experience.

Shared by Stephen Harman, Household Coordinator

The next four stories are from WindsorMeade in Williamsburg, VA

The Tide is Changing….

A few weeks ago I worked on an evening shift as a CNA on the HealthCare unit. When I came on to the shift, which wasn’t my regular shift or job duties, I was very task oriented. I was focused on what needed to be done: who needs vitals taken, who gets a shower, what time is the meal, etc. After dinner I went to give a shower to one of our residents. The resident, Mr. W., was not happy about me interrupting his evening; he was quite happy just flipping through his magazine. This resident usually doesn’t speak words, and if he does speak them, it is normally just a few that don’t make a complete sentence. Many times he communicates only with sounds like bee-bops. It had been a few days since his last shower, though, and he needed one. I was too focused on what I had to do next and the tasks of the evening, but then I just stepped back, looked at his blue eyes and smiled. The tide had changed… I started singing “ I got the whole world in my hands….” He started humming and by the third verse he was singing with me, teary eyed. I have never heard him sing before. Then I quickly thought about what other songs he might know. So I started singing Amazing Grace, and he began singing with me — and we sang all the way to the shower. We sang during and after his shower until he was all clean, dry and cozy in his pajamas, under his warm blankets and off to sleep.

Shared by Angela Peay, LPN, AL Nurse Manager

Our Song

Working in the Health Care dining room, I have had the pleasure of witnessing many beautiful moments.  This one brought tears to my eyes.

Mr. D has both memory and hearing loss.  His wife, Mrs. D, is an independent living resident, and comes to visit him regularly.  I have heard her say many times that she knows he recognizes her as his friend, but she isn’t sure if he remembers the life they made together.

Recently, WindsorMeade installed a new piano and placed it in the resident lounge next to health care dining.  On the weekends, we have volunteers come and play the piano during lunch and dinner services so the residents get to enjoy music while they dine.

A few weeks ago, Mr. D was already seated in the dining room and Mrs. D was walking up the hallway to join him.  The pianist was playing a song that I don’t know the name of, but Mr. D certainly did.  As he listened to the music, he stood up and called Mrs. D out by her nickname.  I had never before heard him call her by any name at all.  As she answered him from across the room, she stopped, looked at the pianist and said, “They played this song at our wedding 65 years ago.”  As they hugged each other, it was obvious that in that moment of clarity brought on by a familiar song, he knew exactly who she was.

Shared by Brian Eck, Health Services Dining Supervisor

Happily Lost in Music

I worked upstairs today in the HCU and ALU areas for the first time again in about two weeks. During lunch, a woman named Mrs. Kathy came in to play the piano. She started in the HC dining room and ended in the AL dining room. In HC, a few of the residents nodded their heads as she played. Mr. W. was one who stood out to me the most. He was nodding his head with his eyes closed, tapping his feet, and lightly tapping a fork on the table, enjoying the music. To be quite honest, I haven’t seen him this happy in such a very long time. His mood nearly brought tears to my eyes — tears of joy that is. Mrs. Kathy’s music generated so many smiles today that I asked her to return to us soon and to come more often.

Shared by Marquera Delk, Lead Server

Music Makes the Body Move

One of our residents loves music! Whenever he hears music, he is clapping his hands, moving his feet, and sings a long. We have purchased an Ipod shuffle for him and have downloaded music (Elvis is one of his favorites) onto the device. Family members have also brought in CDs for us to download music. Throughout the day, we give the resident his Ipod and he absolutely loves it! When he hears the music come on, he gives you the biggest smile and hug. When you walk onto Healthcare you will see him with his Ipod just dancing away. We are in the process of becoming “Music and Memory” Certified, where we will receive Ipods for the residents to listen to their preferred music. When that happens, I will sing, dance and clap, too!

Shared by Caroline Kaliris, Recreation Therapist

Dancing:  It’s not just for feet!

<p>Lakewood Hand Dancer from <a href=”″>Marsha Poulsen</a> on <a href=””>Vimeo</a&gt;.</p>


The following story is from Uniting Wontama Orange in NSW, Australia

Love for Dancing Remembered and Shared

Last Friday evening we held our Annual Cocktail party with the theme of ‘Mad Hatters’. All of our residents across the site were invited along with their families and participated in making a hat to wear. We had a wonderful turnout and brought many smiles to many faces. We also had our Old Time Dancers come along and dance for and with our residents. It was heart-warming to see our residents enjoy themselves so much, and to watch those people who either have limited mobility or changed cognition ‘come to life.’ Once the music and dancing started, a gentleman who faces some of the more challenging aspects of living with dementia, was on his feet and danced the night away. The conversations that were possible with him during this time were both insightful and emotional, especially his ability to talk about his love for dancing in his younger days. An important objective we have been working towards focuses on making every moment count, even in the smallest of ways. This felt like a big success.

Shared by Helen Mobbs, Service Director

This sound of life – music –  is SO IMPORTANT for us all. The common thread in these stories is that someone took the time to notice. The observations shared and then more people notice and are encouraged to provide music, share in the joy of music, or use it to help someone feel better and/or engage in a way they might not otherwise. So go out and look, listen and find ways to share music with those folks you serve. You will make life better in big and small ways, as Helen says above!

If you are fascinated by brain research and what scientists have learned about music, you must read the article “New Ways Into the Brain’s ‘Music Room’,” just published in the New York Times!   Read it now.


Action Pact In The News

Action Pact Receives BAM Award of Excellence

Recently the Kansas Department of Commerce named 23 Regional Business Excellence Award winners and 52 Merit Award winners as part of Business Appreciation Month, the Department’s annual celebration of Kansas businesses and their contributions to their communities and the state economy.  Among the 23 Business Excellence award-winners is Action Pact, based in Manhattan, KS.Award icon-orange

Award qualifications include:

  • Business expansion in Kansas
  • Successful employee retention and recruitment practices
  • Employee training/educational programs
  • Capital investment in Kansas
  • Support of local activities including school activities, community events, economic development and leadership programs

Read all about it.

Action Pact CEO Steve Shields Speaks in Ireland

Ireland_trad_counties_namedThe Irish Council for Social Housing invited Steve Shields to present at the ICSH BIENNIAL NATIONAL SOCIAL HOUSING CONFERENCE:  Turning the Tide for Social Housing, which took place this week (Sept. 16-17) in Co Offaly.  The topics he addressed were:

  • The need for a national debate in Ireland on how to offer greater choices and flexibility to older people who require housing and care / supports as they age.
  • At the moment many older people simply move out of their home into nursing home care when they require a little support.
  • How individual Departments, e.g. health, environment as well as local groups must come together to create safe, secure communities  for older people. Policy making comes mainly from silos in Ireland now!
  • There is an existing infrastructure of housing associations who provide housing and supports to older people in Ireland – funders and policy makers need to look at how best to further develop, utilise and fund this resource as well as replicating it, as it embodies much of what the Action Pact household model is based on.
  • Changing demographic trends (of an ageing population) means planning should be occurring now. Now is the time to look at developing appropriate housing options for older people which incorporate the following:

~ Community support – to ensure that the scheme is an integral part of the life of the local community and that residents of the scheme are given the opportunity to be involved in meaningful activities.

~ Appropriate Care supports – allocated to the scheme allowing for the changing needs as people age and to assist people to remain at home for as long as possible.

~ Age Friendly design – that is attractive, affordable and which addresses older persons needs.

~ Appropriate location – Close to those services that are most required as we age (post office, shops, health care services etc.).

Was it the Lure of Vegemite? 

Megan Hannan found herself in Australia for much of the summer (well, it was summer here) — working with our wonderful friends at Uniting and many of their 70 sites that are committed to moving to households.   First step:  Embracing Action Pact’s approach and philosophy of PersonFirst®.  She’s back in the U.S. now, but will boomerang back with LaVrene come November. These folks are serious in their commitment to culture change and to households!  (See the “Back to School” post for some of their stories)

WHAT HAPPENED THIS SUMMER? We Found Encouraging News From Around the Globe — Culture change: It works!

Remember the good old days when your teacher asked you what you did on your summer vacation? Well, the summer report is back! From near and far there is good news for the culture change movement.  Here are a few short stories to inspire you.


An email shared with us by The Hermitage in Richmond, VA

Subject: The coffee offer

Hi, Sue,

I just wanted to thank you again for letting us know that you “bribed” Mom to a social evCoffee Offerent with the promise of coffee. 🙂  While I know that she enjoyed the beverage, I can promise you, even more –knowing that you remembered her favorite and made a point of offering it with a dose of humor meant the world to her.  As you know, when one has lost so much over the years, being treated as a special person means everything. 🙂

Price of coffee:     < $1

The entire coffee “experience” with a smile:  Priceless!

That says it all!


This story shared with us by Karmen Payne from Fair Haven in Birmingham, Alabama

Elderly walking1

I want to share a story with you all. I asked the associates in our dementia care unit to discuss an afternoon walking club for after dinner. The associates gathered a banner, pom-poms and a group of residents with severe dementia who can still walk. As they walked, they all waved and other residents waved back to them. Some even joined the walkers. Now, nightly, as this occurs the residents smile and interact like neighbors should. A staff person shared with tears in her eyes, “this is how I dreamed it could be.” Just small steps in a big circle of change.

You can try this at home — your home!


It’s already widely understood that pets enhance the daily lives of a great many residents in care communities. When we think of pets, we often think of dogs, cats, hamsters, perhaps birds, right? But in Australia, it can be a different story….

In their rural setting, the residents of Wontama take great pleasure in animals that are closer to home, as many of them have some connection to the bush and no longer have access to the animals that they did in their earlier lives. Joey love Recently they were visited by a joey (baby kangaroo), and the residents “lit up” when they either saw or held this little kangaroo. What a lovely warm feeling it gave everyone involved.

You can see why! Clearly adorable.

Shared with us by Helen Mobbs of UnitingCare’s Wontama Village Home in Orange, NSW, Australia


This story comes to us from WindsorMeade in Williamsburg, VA

During a recent Steering Team meeting, WindsorMeade celebrated many accomplishments in their move toward Culture Change.  In an effort to highlight those accomplishments, Steering Team members were given a T-shirt with their new logo and tagline on the front, “Embracing Life at Home.”  The sunbeam graphic is a salute to the book, In Pursuit of the Sunbeam, and the tagline embodies the team’s sentiments in a short phrase. The back of the shirt has a double intent: it defines their location and also their commitment to make Embracing Life at Home the “way” they do things each and every day. Each WindsorMeade team member will receive a shirt.

WindsorMeade Tees

Thank you, WindsorMeade, for the lovely tribute.  We are rooting for you all the way as you pursue the life at home that you envision!

In Pursuit of the Sunbeam was co-authored by Steve Shields and LaVrene Norton, and is available in the Action Pact webstore.


This story comes from Susan Robertson at The Hermitage-Roanoke in Roanoke, VA

One day at Kroger, Susan noticed they were giving away bouquets of fresh flowers to their customers. The Hermitage had been looking for a source to purchase fresh flowers for their dining room tables for some time, but had not been able to find one. With that in mind, she asked the store manager if they would be interested in donating fresh flowers that are not sellable to a non-profit long-term-care retirement community. Lo and behold… Kroger, said yes!

Hermitage FloristEver since then, on an almost weekly basis, Kroger has been donating fresh flowers to Hermitage in Roanoke. One of the residents loves flower arranging and has been faithfully decorating her community with fresh flowers almost daily. Now she has organized a group of residents to assist her with this project. One day Kroger donated over a dozen bunches of flowers of all types … roses of all colors, mums, etc. This came in handy, as they were getting ready for an anniversary celebration the next day. Here is picture of the “florist” and some of her beautiful flower arrangements enjoyed by all.


From Renee England and the people of Annesley House, UnitingCare, in Leichhardt, NSW, Australia

Annesley House has been looking at current design plans and major refurbishments. In light of that, Renee decided to meet with the residents to ask what Home means to them. These are people with mental health issues and many have been chronically homeless for most of their lives, so what kind of answers would she get? The session was amazing, she reported – very interactive and truly inspiring. So much so that she wishes she’d filmed it.Home means

The notes say it all. Sheets from the session are shown here.