Category Archives: Senior Housing

If Alzheimer’s disease isn’t a secret, then why are we whispering?

Alzheimers Research Funding Lags Other Diseases- Dementia – AARP.  The January/February 2015 AARP Bulletin focuses on the prevalence of Alzheimer’s disease in America.  The cover contains photos of fifteen celebrities who died from the disease.  Some of those spotlighted may surprise you because their cause of death was not broadcast to the media.

What a shame.

Quiet 2It’s a shame that the stigma attached to the disease still manages to relegate Alzheimer’s to the closet.  Cancer used to be that closeted disease – so much so that many years ago people shied away from even mentioning the word, preferring to call it “The Big C.”  Before Alzheimer’s disease, cancer was the whispered disease but now the populous embraces each and every body part afflicted, even those considered of a private nature: breast, ovary, prostate, rectum. Continue reading

Welcome to the year 2015!

2015 New Years

If you’re like me, you’re wondering how another year has slipped by so quickly.  I’m sure there were a few of the 52 weeks that seemed to slog by, but all in all we can now look back and marvel at what we accomplished, or what others accomplished in our stead, during the past 365 days.

An accomplishment with which I’m happy is having authored this blog for the past three and a half years.  I’ve provided this blog for you, but I’ve also provided it for me because I truly enjoy having the opportunity to share my experiences and my viewpoints; I hope in the process that I have encouraged, helped, and entertained you.  From the start of Baby Boomers and More in 2011 to the end of 2014, I posted 520 articles.  I’d be a very happy blogger if the quality of those articles surpassed the quantity because if I’m just talking into thin air without benefit to others, its hardly worth the space my blog occupies.

Here are links to the five most visited articles in the year 2014 based on WordPress statistics:
Continue reading

Fine tune your “boogie” for your later years

Please Santa, let me be the smiling lady that gets up and dances.

(photo courtesy of Pixabay)

(photo courtesy of Pixabay)

Are you preparing right now to never lose your boogie, no matter your age?  I am.  The attached article is a delightful story of how music affects the elderly – whether cognitively impaired or not.

The Alive Inside program proved how beneficial music therapy is to those whose world has diminished and whose communication and connection with others has been cut off.  Regardless of the music’s era, regardless of the generation listening to it, everyone can harken back to long-ago memories just by listening to familiar tunes that meant something to us then, and that mean something to us now.

Retaining ones essence and ones individuality goes far towards announcing to the world, “I’m still here; I’ve still got it; I’m still vital.”  As expressed in the article I’ve shared from a fellow blogger, I hope I will indeed be the smiling lady that gets up and dances, and I hope you’ll join me on the dance floor.

Long-term care residents’ rights: Part 6

Photo credit: Ian Merritt

Photo credit: Ian Merritt

Thank you for returning to this multi-part series on long-term care residents’ rights.  At the bottom of this article, you will find links to the previous five postings.  As this is the last in the series, I want to advise my readers that I have in no way covered every topic that could be covered in a series such as this one.  I have, however, covered complaint topics that quite commonly occur in long-term care settings.  In most complaint categories, more than one residents’ rights law has been violated.  For the most part, I have only mentioned one aspect of the law that addresses the rights violations.

Today’s topic covers the umbrella topic of dignity and quality of life.  Without exception, every rights violation is an infringement of a resident’s dignity and a detriment towards enhancing the quality of life residents should expect to experience.  The same holds true whether that resident lives in a “Champagne and Chandelier” facility or a “Generic Brand X” facility.  Regardless of how fancy, regardless of how bland, the same rights are afforded to all residents.  All situations listed in this six-part series assume a resident is cognitively capable of making his or her own decisions.

Breakfast in bed, pee on the side

I rolled over in bed thinking I might get a few additional minutes of sleep, but those potential minutes were rudely interrupted by the assault from the room’s overhead light, the hustle of someone rushing into my room, and the abrupt raising of the head of my electrically powered bed. I don’t know if you’ve ever tried to remain curled up on your side while half of your bed is put at a 90 degree angle, but trust me, it’s not possible and it’s not comfortable.

“Hey, Gloria, time for breakfast. Come on, open your eyes and sit up so I can give you your breakfast tray.”

I’ve lived in this nursing home for three months now and every time one of these care people talks to me, they call me by my first name, and in my eyes, that’s a sign of disrespect. “First of all, I’ll remind you that my name is Mrs. Lewis, and second of all, I absolutely cannot eat the morning meal prior to going to the bathroom. Please help me to the toilet and then I’ll have my breakfast.”

“No can do, Gloria, you’re just one of forty other patients I have to personally deliver meals to this morning. You should have thought of that earlier and asked one of us to take you to the toilet before we started delivering meals.”

“But I was asleep, and besides, I told the head nurse many times that I require toileting assistance and that I require it before my morning meal. How many other times must I make this request?”

“I don’t know, how many?”

I looked at this uncaring individual and pleaded with her. “Please won’t you take me to the potty? My bladder is ready to burst!”

“Look, I’m already running behind. Just go in your pants, that’s what your nighttime diaper is for any way. Sometime after your breakfast, someone will clean you up, but it won’t be me.  After I deliver all my trays, my shift is over.”

Imagine, if you can, not having the opportunity to use the bathroom after a full night’s sleep, and trying to enjoy a meal that is placed before you.  Then imagine not being able to hold it any longer and peeing yourself and sitting in it for who knows how long.  The above scenario is real.  A family member of mine experienced this exact scenario.  I also am acquainted with a gentleman who, after asking three times in a half hour period to be assisted to the restroom so he could evacuate his bowels, he was told “Go in your pants.  I don’t have time to help you right now.”  That neglect does not preserve a person’s dignity, nor does it promote quality of life.

42 CFR 483.15  Quality of life.  A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident’s quality of life.

(a)  Dignity.  The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect in full recognition of his or her individuality.  See also Washington State law RCW 70.129.005 and RCW 70.129.140

What follows are a few other frequently occurring scenarios found in LTC residential settings:

Visitation policies: residents have the right to receive visitors of his/her choosing and a facility must not interfere with such access. There is no such thing as visiting hours, regardless of the LTC setting.  If an adult son’s work schedule is such that he can only visit before 8 a.m. or after 9 p.m., reasonable accommodation must be made to facilitate his visit.

Choices regarding schedules, clothing: regardless of LTC dining room and meal hours, a resident has the right to receive meals outside of those hours.  For example, if a resident is not an early-riser, he should still be able to acquire a suitable breakfast meal; this does not mean that he has full access to all that was offered prior to the “end” of breakfast hours, but he should still be able to eat breakfast items.  A peanut butter & jelly sandwich does not qualify as such – unless, of course, that’s his choice.  Unless a resident has turned over the responsibility of making daily clothing choices to a staff person, a resident must be given the opportunity to make clothing choices that are important to her.  Clothing choices promote individuality.  Each of you reading this article dress as you please; that shouldn’t change just because you move into an institutional setting.

Isolation & seclusion: punishment to a resident for perceived misbehavior in the form of prohibiting participation in dining room meals and/or activities of his choosing, is not appropriate and is a complete violation of a resident’s rights.  A better response to behavioral issues is to discern the cause of said issues, e.g., depression, medication anomalies, medical conditions such as a urinary tract infection (UTI).  Resolve the cause, and you resolve the effect.

Series links:  Part 1, the right to make choices that are important to the resident; Part 2, admission polices, waivers of liability; Part 3, eviction and discharge process; Part 4, substandard and neglectful care; Part 5, accepting or rejecting medical care.

If you or a loved one need assistance regarding LTC residents’ rights, contact your local LTC Ombudsman office which can be located at the National Long-Term Care Ombudsman Resource Center.

 

Long-term care residents’ rights: Part 5

Photo credit: Ian Merritt

Photo credit: Ian Merritt

Welcome to Part 5 of my series on long-term care (LTC) residents’ rights.  Part 1 focused on a resident’s right to make choices that are important to her.  In Part 2, I discussed the topic of LTC admission procedures, specifically, a Waiver of Liability document that is oftentimes included  in the admission packet.  Part 3 addressed eviction/discharge from a long-term care facility, and Part 4 addressed abuse and substandard care.  Today’s topic addresses a resident’s right to choose, or reject, prescribed medical care.

A pile of poo disguised as a hot dog

I guess when you don’t have a choice in the matter you gradually come around to liking life in the assisted living “community” as the staff at this facility like to call it. When I couldn’t get around my old place without the constant threat of falling in the neighborhood or falling asleep at the wheel of my 1994 Mercury Sable, I took my son’s advice as gospel, and let him move me five miles from my lady friends, and ten miles from the Baptist church I had attended for God knows how long.

Now, my only option is to attend an ecumenical service in the activity room each Sunday – it more or less satisfies those who rely on some sort of ritual to get them through the following week – and I have a completely new set of lady friends with whom I eat every meal.

It must be baseball season; for lunch today, the dining room is decorated with red, white, and blue crepe paper and the centerpieces contain a miniature bat and ball placed “just so” surrounded by a pile of sticky Cracker Jacks that we’re told are not edible, but I try one anyway and add credibility to the admonishment by spitting it out into my napkin.

Lord have mercy, we even have a special lunch menu from which we can choose what apparently is considered food one would eat at sporting exhibitions: hot dogs, hamburgers, fries, all served with a gigantic phallic-looking dill pickle on the side. Now, don’t act so shocked.  The young people don’t think us older folk know what the intimate body parts are called and that we would never know what to do with them even if we did, but let me tell you, my group of lady friends have a laugh or two over things of a sexual nature. We’re not dead yet and most of our memories of such things are still intact.

The four of us ordered the chili dog special and got caught up on all the latest news since the previous time we saw each other. About ten minutes later, my meal was served, followed by everyone else’s, and the young server said, “Bon appetite!” But something was horribly wrong. Before the gal got too far away, I beckoned her back to the table. “Sweetie, what is this pile of dog-poop looking stuff on my plate?”

“That’s your chili dog.”

“My lady friends ordered the same thing I ordered and yet look at each of theirs: a hot dog is nestled into a bun, smothered by chili, cheddar cheese, and a few onions. My hot dog, on the other hand, looks like a pile of poo!”

The waitress addressed me, and therefore all the other ladies at the table.  “We have a Special Menu report the kitchen & wait staff are required to review before each meal. There was an entry for you stating that all your food must be pureed because you’ve been having difficulty swallowing. Evidently, when you went out to dinner with your son a couple days ago, you almost aspirated on a piece of flank steak.  Remember?   The Maitre d’ of that restaurant had to Heimlich you. You could have choked! You won’t choke on pureed food – or at least we hope you don’t – so that’s what you have to eat. Doctor’s orders.”

My lady friends looked embarrassed for me and pretended that this youngster wasn’t talking about my health issues in front of everyone within hearing range. But that’s not the only thing that’s bothering me right now: I want to eat a chili dog that looks like the rest of the chili dogs on the table so I decided to tell the server. “I’m sorry, remind me of your name, sweetie?”

“My name is Jessica.”

I picked up the plate of poo and shoved it towards her. “Jessica, please toss this mess in the trash and bring out a real chili dog, and while you’re at it, I want a hefty serving of French fries as well.”

“I can’t do that Mrs. Bellamy, I’ll get in trouble.”

“You’ll get in trouble if you don’t provide me with the food that I’ve requested. Please take this plate away from me, my arm is getting tired holding it up.”

The youngster took my plate and with the other hand, signaled her boss to join her in the kitchen – no doubt to report my aberrant behavior. My lady friends, however, applauded my assertive efforts, and offered me a bite of their dogs while I waited for mine to be served.

Mrs. Bellamy’s pureed diet was prescribed by her doctor; as such, it is now a part of her medical profile at the assisted living facility in which she lives.  Mrs. Bellamy chose to ignore her doctor’s orders – certainly her right whether she lived in her private home or this public facility.  Residents at LTC facilities have the right to refuse prescribed treatments such as restrictive diets, medications, or physical therapy to name a few.  As cognitively capable adults, they have the right to go against doctor’s orders, fully understanding the risks of not abiding by such orders.

42 CFR 483.10

(b) Notice of rights and services.

(1) The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and rules and regulations governing resident conduct and responsibilities during the stay in the facility…

(3)  The resident has the right to be fully informed in language that he or she can understand, of his or her total health status, including but not limited to, his or her medical condition;

(4) The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive as specified in paragraph (8) of this section;  …

(d)  Free choice.  The resident has the right to –

(1)  Choose a personal attending physician;

(2) Be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the resident’s well-being; and

(3) Unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, participate in planning care and treatment or changes in care and treatment.  See also Washington State law RCW 74.42.040(3)

Additionally, Mrs. Bellamy’s medical condition should  not have been discussed in front of everyone within hearing distance: her lady friends, other residents seated adjacent to Mrs. Bellamy’s table.  The HIPAA Privacy Rule also applies in LTC settings.  Jessica, the server, violated Mrs. Bellamy’s right to privacy by talking about her medical condition.

If you or a loved one need assistance regarding LTC residents’ rights, contact your local LTC Ombudsman office which can be located at the National Long-Term Care Ombudsman Resource Center.

Part 6, the final installment of this series, will deal with dignity and quality of life.  Part 6 will be posted on Wednesday morning, November 26.

Long-term care residents’ rights: Part 4

Photo credit: Ian Merritt

Photo credit: Ian Merritt

Welcome to Part 4 of my series on long-term care (LTC) residents’ rights.  Part 1 focused on a resident’s right to make choices that are important to her.  In Part 2, I discussed the topic of LTC admission procedures, specifically, a Waiver of Liability document that is oftentimes included  in the admission packet.  Part 3 addressed eviction/discharge from a long-term care facility.  Today’s topic addresses substandard and neglectful care.  Let’s look at this scenario:

Take the pressure off Mom

My mother was the quintessential social butterfly but not in the way one might imagine. Her social involvement didn’t include tennis or golf, nor did it center on being seen at extravagant galas around the city. My mother, Joan Young, socialized with the homeless, the hungry, and the vulnerable. Mom was a volunteer extraordinaire whose monthly calendar was filled with opportunities in which she would donate her time, her resources, and her compassion.

One of her most time-consuming, but most gratifying volunteer venues, was as an activity assistant at Shady Rest Nursing and Rehab Center. That same venue is now her permanent home where she’s lived the past month and a half since a massive stroke robbed her of the ability to speak or move her limbs. We think she understands what we say to her because oftentimes she’ll get a twinkle in her eye that appears to relay some sort of connection with us. The experts say she most likely still recognizes us, but even if that is not the case, I hope the presence of smiling, happy visitors go far towards improving her quality of life.

The last few days, however, mom was withdrawn, and more often than not, she slept through my visit. Because I live within close proximity of the Shady Rest, I visit her almost daily. Dad and his wife live another state over, so although they were on speaking terms prior to mom’s stroke, speaking to anyone isn’t really mom’s strong suit right now. I don’t mind carrying the torch for mom; she’d do the same for me.

After four days of a significant reduction in alertness, I talked to the head floor nurse to discuss mom’s change in condition. She assured me that one can expect sudden changes in levels of cognition after the assault that was placed on her body as a result of the stroke. The nurse told me to toss my cares aside and trust the Shady Rest staff with mom’s care. “She’s in good hands, Robin. There’s no need for you to worry. If there is ever anything that needs medical attention, be assured we’ll take care of her.”

But they didn’t.  Three days later, I noticed a fetid smell as soon as I entered her room. At first I thought that perhaps mom had gone Number 2 in her adult diapers but when I lifted up the sheet that covered her body, I saw she wasn’t wearing any.  But oh my God, the smell was even worse. I looked behind me to see if anyone was looking, and seeing that the coast was clear, I gently rolled my mother’s body away from me and discovered the source of the stench: an oozing, red and green sore about the size of a quarter on her left buttocks. I couldn’t help myself; I ran into the bathroom and threw up the lunch I had eaten prior to arriving.

Then I pushed the Call Button which is supposed to summon a health worker post-haste – or so I was told when mom first moved in. Three minutes ticked by: no response. I pushed the button again, this time walking to the doorway of mom’s room to look up and down the hallway for signs of incoming staff members. Not a soul in sight.

I left my mother’s room in search of a staff person and landed in front of the nurses’ station. I pounded on the counter, “Hello! I’m Robin, Joan Young’s daughter. I called you twice from my mom’s room.” That’s when I heard, for the first time, a sound that in the past always seemed to be an indeterminate background noise: the persistent dinging of Call Button tones from various rooms on the floor. A quick glance up and down the hallway also showed lights blinking above numerous rooms that coincided with each ding.

I pounded the counter again and pointed at the LPN sitting at a computer. “You, follow me.”

“Miss Robin, I’m finishing up a report, I can’t leave my desk right now.”

I tossed all protocol to the side, walked behind the counter, pulled the computer mouse out of her hand, jerked her chair back and tilted it forward. “Come with me, now.”

That seemed to work but I didn’t take any chances. I held her hand and pulled her down the hallway into my mother’s room. “Do you smell that?” And then I pulled down the sheet on my mother’s bed, gently rolled her away from us and added, “Do you see that?”

“Oh my, Mrs. Young has a bed sore.”

“Ya’ think? This sore didn’t just materialize in the past three hours ya know. It’s been festering.”

“You could be right.”

“No, I am right. I want you to summon the head of nursing and I want you to summon her now. Tell her to meet me in my mom’s room, ASAP.”  The LPN didn’t move, so I pushed her out the door. “Go!”

*****

The bed sore – or decubitus – had yet to go bone deep. Had that been the case, mom would most likely not have recovered from the infection. As it was, her health never returned to its previous state, even with the excellent care she receives at a different nursing home, thirty miles away from where I live. Sunnyside Nursing Home wasn’t as fancy as the other place, but obviously, looks can be very deceiving. What my mom saw as an activity assistant volunteer was far different from what she experienced as a patient. When we chose Shady Rest as her new home, we did so without the benefit of readily available resources that would have provided red flags as to the quality of care provided. We figured, “Heck, mom loved volunteering at Shady Rest, why look any further?”

Shame on us.

Joan Young was the victim of willful inaction that caused a potentially fatal injury to her person.  Joan’s inability to verbalize or express her pain and discomfort, other than the withdrawal and malaise eventually recognized by her daughter, put Joan at even greater risk of serious health decline resultant from the unattended bedsore.  Facilities must assure that a resident’s body is routinely turned to different and varied sitting and lying positions in an effort to prevent such bedsores.  In addition to bedsore prevention, if Joan had been diligently cared for – for example, if her ongoing bathing and care plan had been strictly followed – any skin abnormalities would have been immediately noted and attended to and infection could have been avoided.

42 CFR 483.25 Quality of care. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care …

(c)  Pressure sores.  Based on the comprehensive assessment of a resident, the facility must ensure that -

(1)  A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and

(2)  A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.  See also Washington State law RCW 74.34.

Some of you readers might be thinking, Well, if her daughter had been more attentive, she would have noticed the sore earlier or Why didn’t she say something about her mother’s malaise right away instead of waiting several days?  Being an armchair quarterback is a very easy position to play.  The very unfortunate – yet somewhat understandable – attitude of some family members and/or patients is: This is a licensed facility staffed by medical professionals; who am I to question their ability to take care of my mother?  The answer to that is obvious: even when a family member moves into a long-term care setting, you must continue to exercise your role as family advocate.  I understand the relief one feels of trusting ones care to a staff of professionals, but the unfortunate truth is sometimes that trust is misplaced.

If you or a loved one need assistance regarding LTC residents’ rights, contact your local LTC Ombudsman office which can be located at the National Long-Term Care Ombudsman Resource Center.

Part 5 of this series will deal with a resident’s right to make choices about their own medical treatment.  Part 5 will be posted on Friday morning, November 21.

 

Long-term care residents’ rights: Part 3

Photo credit: Ian Merritt

Photo credit: Ian Merritt

Welcome to Part 3 of my series on long-term care (LTC) residents’ rights.  Part 1 focused on a resident’s right to make choices that are important to her.  In Part 2, I discussed the topic of LTC admission procedures, specifically, a Waiver of Liability document that is oftentimes included  in the admission packet.  Today’s topic speaks of the practice of illegal discharge from a LTC residential setting.

Adios, Mr. Reilly

“What do you mean I have a week to move my father? For what reason?”

Raymond Ortiz, the Easy Breezy Group Home owner, situated himself in the plush chair in which he was sitting, opened up the manila folder that was on the desk in front of him, put on his reading glasses, scanned the piece of paper inside, and then closed the folder. “I know this seems to be coming out of the blue, but the staff and I have decided that your father just doesn’t fit in with the rest of the residents. They, and us, would be happier if Harold wasn’t living here.”

I couldn’t believe what I was hearing; dad had lived at this group home for three months without a complaint from anyone, and now this? “What specifically has he done – or not done – that renders him an unsuitable resident? What do those notes in my dad’s file specify as the reason?”

“You see, it’s not as simple as that. Your father hasn’t complied with the way the other residents live, and let’s not forget, they were here before him.”

I was having a hard time controlling my temper. Through gritted teeth I said, “Specifics, please.”

“For one, he wakes up earlier than the other five residents – sometimes as early as 6 am – and in the evening, he insists on staying up well past 10 pm. His early morning schedule disturbs those who are sleeping, as does his late night schedule. I’m sure you can understand that sleep is a very important aspect of our residents’ healthcare and when that is jeopardized because of just one of our residents, we have to take measures to accommodate the majority.”

“Wait a minute, you mean to tell me that the other residents’ schedules are more important than my father’s? That’s utterly ridiculous. Tell me, is my father doing jumping jacks in the middle of the living room with the stereo blaring while everyone is asleep?”

“Now you’re being silly.”

“No, Mr. Ortiz, now I’m getting angry. If dad isn’t making a ruckus, why the concern? My father has always been an early riser – moving in here shouldn’t require that he change that feature of his life; same goes for staying up later than the others. His end-of-day routine has always involved sitting down with a good book and reading – sometimes for hours on end. What’s so disruptive about that?”

“Two things, really. He flushes the toilet, which of course makes noise, and the resident on the other side of the bathroom hears the flush and his sleep is disturbed. Also, the evening caregiver has evening chores to do and afterwards, lays down on the couch to be rested up for the next day’s activities. He can’t sleep while your father is still awake.”

I closed my eyes and tried to compose myself. “Look, when my dad moved in, you made a point of telling us that Easy Breezy is his home, just as if he owned the place, just as if he’d lived here all his life. Kind of like, ‘Mi casa es su casa’ and I took you at your word. Nothing you’ve said today jives with that sentiment, and I’m quite sure that nothing you’ve mentioned is grounds for throwing him to the curb. First of all, I know you have to give written notice and it has to be given with more notice than you’ve given me, and I’m damn certain your flimsy reasons won’t stand up to legal scrutiny once I’ve looked into this.”

“Now Ms. Reilly, no need to get all huffy about this. That’s just the way it is; majority rules.”

I stood up, slung my purse over my shoulder and said, “We’ll see about that Mr. Ortiz. I’ll be back.”

As Ms. Reilly surmised, any notice of discharge must be made in writing and must be provided at least 30-days from the date of discharge from the facility (said requirements stated at length in 42 CFR 483.12.)  Federal and State governments make it very difficult for administrators/owners to move a resident out of their property.  As stated in the CFR below, there must be a very valid reason, e.g., health and safety of individuals are in jeopardy, and certainly that is not the case in the scenario above.

42 CFR 483.12  Admission, transfer and discharge rights.

(2)  Transfer and discharge requirements.  The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless –

(i)  The transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility;

(ii)  The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility;

(iii)  The safety of individuals in the facility is endangered;

(iv)  The health of individuals in the facility would otherwise be endangered;  See also Washington State law 70.129.110

If you or a loved one need assistance regarding LTC residents’ rights, contact your local LTC Ombudsman office which can be located at the National Long-Term Care Ombudsman Resource Center.

Part 4 of this series will deal with abuse and neglect of residents in LTC facilities.  Part 4 will be posted on Wednesday morning, November 19.