need for physicians and other health professionals who understand geriatrics in nursing facilities and B&C homes may be a factor in appraising the patterns of complaints and issues of quality of care in LTC facilities.

Quality of Life

Quality of life is an expansive topic that encompasses broad notions of human existence. Highly personal views about one’s environment and living situation, as well as profound philosophical, religious, and spiritual beliefs and attitudes about life and death inform each person’s position on the subject (Lohr, 1992). Anthropological and ethnographic studies in nursing facilities point to problems in achieving a reasonable quality of life (Shield, 1988; Lidz et al., 1992; Gubrium, 1993). After all, a nursing facility is more than a setting in which residents receive care, it is their home, although for some it is only a temporary home. Unfortunately, however, the physical structure of most nursing facilities allows for little privacy, especially as most residents must share rooms. Partly because of routines and conventions—many of which are providers’ responses to regulations—and partly because of room sharing, residents maintain little personal control over many aspects of their daily lives. Disputes arise over matters such as roommate and table-mate selection. Residents who are cognitively intact complain about enforced proximity to residents who are cognitively impaired. Residents who are cognitively impaired may be restricted in their activities, both for their own safety and so that they do not intrude on the space and possessions of others. Many residents may lack meaningful activities. Kane and Caplan (1990) pointed out the myriad difficulties of developing normal lifestyles in traditional nursing facilities given heterogeneous populations, rules and regulations that govern conduct of residents, and lack of physical space and privacy.

In 1987, partly as a result of an earlier IOM study (1986), Congress enacted a comprehensive nursing facility reform law that emphasized the need to ensure that residents achieve a good quality of life. Mandates in the law included new general conditions or standards for nursing facilities to meet regarding residents’ rights and quality of life. The same reform required that those who inspect nursing facilities observe and speak to samples of residents themselves to determine whether these conditions are met, rather than relying solely on medical records and staff reports.

Despite the substantial progress of the 1987 reform, quality of life is an elusive concept to define and to measure in the nursing facility or LTC context. It encompasses such constructs as dignity, satisfaction, social involvement, autonomy, and happiness. For those who cannot participate in an interview because of cognitive or sensory impairments, the difficulties of measuring quality of life are immense. Even cognitively intact residents may

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