My sister was a resident of the Willamette View Health center for several months before her death. She had enjoyed living in the independent level (Manor) for six years before her move to the Health Center. We were impressed with the Manor staff and were hoping for a similar quality of care in the Health Center but were disappointed, especially with the lack of licensed or registered nurses. The Health Center has 4 'units' or neighborhoods, each with about 15 residents. On day shifts, there is a Registered Nurse on duty but she is in charge of two units and also has managerial responsibilities, so has little time doing direct nursing care or assessment. Frequently the nurses on duty were from a temp agency and not familiar with the residents. On some evening shifts, an LPN is present but has to divide her time between two units. During some evening shifts and most night shifts, it was not unusual to have only nurse’s aides on duty – no LPNs or RNs. Medications (including narcotics such as morphine) were usually administered by nurse’s aides. In the last weeks of my sister's life, she often needed her scheduled medication to be ‘held’ (not given) due to risk of oversedation. This is a nursing decision which nurse’s aides are not trained for. In the last week of my sister’s life she was not fully conscious and her level of conciousness was decreasing daily. She was being given sips of water and liquid morphine but as her level of conciousness deepened I noticed that she began to aspirate on any liquid and was showing symptoms of pneumonia. She needed a nursing assessment to be made about whether to continue medication and in what form to give it. However that evening there were no nurses on duty - only nurse’s aides. As an RN, I was surprised at the lack of nursing presence on the units. Often the nurse’s aides seemed to lack the leadership and direction that would typically come from an LPN or RN in charge. In the evening or night they would spend quite a bit of time sitting, chatting together or on their phones. My recommendation would be to hire more LPNs with training or experience in geriatric and end-of-life care and replace one nurses aide on each shift with an LPN, so that every shift there is a licensed nurse to give medications, do assessment, make nursing diagnoses and decisions, and give leadership and direction to the nurses aides.