The PELI-D II Study: Development and Preliminary Validation of the Preferences for Leisure Activities Inventory (P-LAI) for Adult Day Services.

OBJECTIVES: The current study aimed to develop and preliminarily validate an initial version of an instrument to assess the leisure activity preferences of people receiving adult day services (ADS). METHODS: Based on previously conducted concept mapping steps, we identified 12 clusters of preferences for leisure activities. We adopted the structure of the Preferences for Everyday Living Inventory and phrased our cluster labels as questions to develop a first draft of the Preferences for Leisure Activities Inventory (P-LAI). We conducted cognitive interviews (n = 8) to revise, preliminarily validate, and preliminarily finalize the P-LAI. RESULTS: The draft of the P-LAI included 25 questions. Based on the results of the cognitive interviews, the number of questions was reduced to 21, three questions were rephrased, and evidence to support the preliminary validity of the P-LAI based on the response processes was provided. CONCLUSIONS: The P-LAI is the first instrument to assess preferences for leisure activities in the ADS environment. CLINICAL IMPLICATIONS: The preliminary results of the P-LAI allow ADS providers and healthcare professionals to assess the preferences for leisure activities of people who receive ADS in a structured way. Based on these results, preference-based services can be designed and planned, and the person-centered philosophy of care can be further operationalized in the ADS environment.

Evaluating the Implementation of the Individualized Positive Psychosocial Interaction (IPPI) as a Quality Improvement Project in Nursing Homes.

OBJECTIVES: The Individualized Positive Psychosocial Interaction (IPPI) is a non-pharmacological, person-centered, intervention for nursing home (NH) residents living with moderate to severe dementia. The purpose of this study was to assess the pragmatic implementation of the IPPI by leveraging Ohio's Nursing Home Quality Improvement Program (QIP). METHODS: Implementation teams collected resident mood ratings pre- and post-IPPI and completed virtual interviews to assess their Organizational Readiness for Implementing Change as well as the acceptability, feasibility, and appropriateness of the IPPI. Implementation strategies included: providing ongoing consultation; identifying and preparing champions; assessing for readiness and identifying barriers; and developing and distributing effective educational materials. RESULTS: Fifteen NHs completed the QIP (65% completion rate) and reported high organizational commitment to change and high change efficacy. NHs engaged n = 65 residents in n = 638 IPPIs. Residents experienced a positive mood change after 47% of IPPIs. NHs found the IPPI program to be highly acceptable, feasible, and appropriate. CONCLUSIONS: Overall, 65% of NHs successfully implemented the IPPI QIP with people living with moderate to severe dementia. CLINICAL IMPLICATIONS: Given the positive mood changes and high staff satisfaction, results suggest that these brief, individualized activities can be effective strategies to address the communication of distress among PLWD.

"This is Slowly Becoming my Interest ": The Understanding of Leisure and Preferences for Leisure Activities of People Receiving Adult Day Services.

Currently it is unknown what people receiving adult day services (ADS) understand as leisure and the activities they prefer remain unknown. To address these gaps, we investigated the understanding of leisure of people receiving ADS. We conducted semistructured interviews with 15 people receiving ADS in Germany. Interviews were analyzed using reflexive thematic analysis. The sweet bitter symphony emphasizes the sensations that shape participant's understanding of leisure. Young, wild & free! describes the types of preferred activities. Is this our last tango? refers to the barriers. Anchors aweigh! the [ongoing] voyage describes the process by which leisure is transferred from private domain to the ADS environment. The beginning is the end is the beginning illustrates the paradox of understanding the ADS as offering a form of leisure and the adaptation to engage in nonpreference-based activities. Our findings indicate the importance in offering leisure activities that enable preference-based engagement in the ADS.

Associations between Complaints and Organizational Characteristics among Ohio Nursing Homes.

OBJECTIVES: In recent years, Ohio nursing homes (NHs) have received an increasing number of complaints. The current study aims to gain a better understanding of the relationship between NH organizational characteristics and the number of complaints. DESIGN: Secondary data analysis was used. SETTING AND PARTICIPANTS: Four data sources on Ohio NHs were merged. Ohio NH complaints data reported in 2018 and 2019 was linked with the 2017 Ohio Biennial Survey of Long-Term Care Facilities, 2017 Ohio Nursing Home Resident Satisfaction Survey, and 2018 Ohio Nursing Home Family Satisfaction Survey. METHODS: Descriptive analysis, bivariate tests (ie, analysis of variance and χ2 test), and multinomial logistic regression analyses were conducted. RESULTS: Findings included that urban location, NH administrator (NHA) and director of nursing (DON) turnover in the previous 3 years, NH size, occupancy rate, certified nursing assistant (CNA) retention, and overall family satisfaction were significantly associated with total complaints. NHA and DON turnover, NH size, CNA retention, and overall family satisfaction were found to be significantly associated with substantiated complaints. CONCLUSIONS AND IMPLICATIONS: The importance of leadership (ie, NHA and DON) turnover, CNA retention, and family satisfaction indicates that specifically targeted efforts to improve in these areas can have a positive impact on NH quality.

Exploration of the Content and Structure of Preferences for Leisure Activities of People Receiving Adult Day Services Using Concept Mapping.

BACKGROUND AND OBJECTIVES: Providing preferred leisure activities appears to be an important approach to support and empower people receiving adult day services (ADS) allowing them to age in place. To provide the conceptualization for a preference instrument, we actively involved people receiving ADS in exploring the content and structure of their preferences for leisure activities. RESEARCH DESIGN AND METHODS: We chose a concept mapping methodology and involved 16 people receiving ADS. We systematically reviewed the literature and conducted semistructured interviews to generate a set of 80 preferences. Analysis of structuring these preferences resulted in a 3-dimensional cube with 12 clusters. A graphical representation was then interpreted, and the clusters were labeled. RESULTS: Our conceptualization divides preferences for leisure activities into the following: 1. Take a trip, 2. Revel in memories and catch up on the news (most important), 3. Do something for yourself and come to rest, 4. Play intelligence and parlor games, 5. Make/produce and try something alone or in a group, 6. Keep fit and cheer others on in sports (least important), 7. Learn, educate, and share knowledge, 8. Have contact with other people, 9. Attend at entertainment, cultural, and amusement events, 10. Enjoy music, your homeland, or other countries, 11. Engage in outdoor activities, and 12. Get involved, offer support, and provide companionship. DISCUSSION AND IMPLICATIONS: Our results may lead to the development of instruments and thus opens the field for further research and theory building on preferences for leisure activities of people receiving ADS.

Can Implementing Person-Centered Care Tools Reduce Complaints? Evidence from the Implementation of PELI in Ohio Nursing Homes.

Nursing homes receive complaints when actual care provided to residents misaligns with desired care, suggesting that person-centered care (PCC) and honoring resident preferences in care delivery may help prevent complaints from arising. We explore whether nursing home implementation of a PCC tool, the Preferences for Everyday Living Inventory (PELI), is related to measures of complaints. Publicly available data on Ohio nursing homes was used to examine 1,339 nursing home-year observations. Regression techniques were used to evaluate the relationship between the extent of PELI implementation and four complaint outcomes: any complaint, number of complaints, any substantiated complaint, and number of substantiated complaints. Nursing homes with complete PELI implementation were less likely to have any complaints by 4.7% points (P < .05) and any substantiated complaints by 11.5% points (P < .001) as compared to partial PELI implementers. When complete PELI implementers did have complaints, they were fewer than partial PELI implementers. Complete PELI implementers were not immune from receiving complaints; however, the complaints they did receive were fewer in number and less likely to be substantiated as compared to communities who only partially implemented a PCC tool.

Participatory development of a framework to actively involve people living with dementia and those from their social network, and healthcare professionals in conducting a systematic review: the DECIDE-SR protocol.

BACKGROUND: Systematic reviews summarize and evaluate relevant studies to contribute to evidence-based practice. Internationally, researchers have reached a consensus that the active involvement of the public leads to better research. Despite this agreement, there are many reviews of research concerning healthcare interventions intended to promote the care of people living with dementia and those from their social network (e.g., close contacts, both family and non-family members) primarily involve only healthcare professionals and other experts. Due to the lack of a dementia-sensitive framework to actively involve people living with dementia and those from their social network, and healthcare professionals as co-researchers in systematic reviews, it is important to develop a framework to inform practice. METHODS: For this framework development process, we will recruit four people living with dementia and a total of four people from their social network, and three healthcare professionals working in acute or long-term care settings. We will conduct regular meetings with these groups of the public and healthcare professionals to include them in all stages of the systematic review. We will also identify and develop methods necessary to ensure meaningful involvement. The results will be documented and analyzed for the development of a framework. For the planning and preparation for these meetings, as well as the conduct of the meetings themselves, we will be guided by the principles of the INVOLVE approach. In addition, the ACTIVE framework will be used to guide the degree of involvement and the stage in the review process. DISCUSSION: We assume that our transparent approach to the development of a framework to support the active involvement of people living with dementia and those from their social network, and healthcare professionals in systematic reviews will serve as an impetus for and provide guidance to other researchers with the goal of increasing researchers' focus on this topic and facilitating systematic reviews that apply participatory approaches. TRIAL REGISTRATION: Trial registration is unnecessary as no intervention study will be conducted.

Systematic reviews summarize and evaluate studies on a particular topic. They provide information, for example, regarding whether an intervention is beneficial. This type of review is particularly important for healthcare professionals because they can use the results of the review to guide their actions. There is a growing awareness that the public, including people living with dementia and those from their social network (e.g., relatives, friends), need to be actively involved in the process of preparing these reviews when they are concerned with the topic of the reviews. Despite this consensus, it is often the case that only healthcare professionals are involved in such reviews. At present, no framework for the active involvement of people living with dementia and those from their social network, and healthcare professionals in systematic reviews has been developed. Therefore, we will develop such a framework together in collaboration with a range of members of the public and healthcare professionals. For this purpose, in addition to healthcare professionals, we will involve people living with dementia and those from their social network. Over the course of several meetings, we will engage in discussion with them and identify the stages of the process of conducting a systematic review in which their involvement as members of the researcher team is meaningful. We will furthermore identify the requirements associated with such an active involvement. A written report of these discussions will be produced in collaboration with the group. This will contribute towards the development of a framework for other researchers. The framework will later be made available to the public free of charge to increase awareness of this topic and to contribute towards more frequent, well-organised and meaningful involvement of people living with dementia and those from their social network, and healthcare professionals in systematic reviews.

Exploring the Relationship Between Extent of Person-Centered Care Implementation and Staffing Levels in Ohio Nursing Homes.

Background: The Preferences for Everyday Living Inventory (PELI) is a person-centered care (PCC) tool that uncovers/honors older adults' important preferences. PCC implementation in nursing homes (NHs) often requires additional resources, such as staff time. We explored if PELI implementation is associated with NH staffing levels. Methods: Using NH-year as the unit of observation (n = 1307), 2015 and 2017 data from Ohio NHs was used to examine the relationship between complete versus partial PELI implementation and staffing levels, measured in hours per resident day, for various positions and total nursing staff. Results: Complete PELI implementation was associated with higher nursing staff levels in both for-profits and not-for-profits; however, total nursing staff levels in not-for-profits were higher than for-profits (0.16 vs. 0.09 hours per resident day). The specific nursing staff associated with PELI implementation varied by ownership. Discussion: For NHs to fully implement PCC, a multifaceted approach to improve staffing is needed.

Organizational and Resident Characteristics of Nursing Homes Associated With Partial and Complete Implementation of the Preferences for Everyday Living Inventory.

Background and Objectives: Person-centered care practices are essential to providing high-quality care for nursing home (NH) residents. A key component of implementing person-centered care is the assessment and fulfillment of residents' preferences. However, few NHs consistently assess and implement residents' preferences into care. From 2015 to 2019, the Ohio Department of Medicaid added the Preference for Everyday Living Inventory (PELI), a scientifically validated tool to assess residents' preferences, as a quality indicator to improve the person centeredness of Ohio's NHs. In this study, we sought to identify the associations between resident and organizational characteristics and PELI implementation in Ohio NHs. Research Design and Methods: We constructed an NH-level database that merged data from the Ohio Biennial Survey of Long-Term Care Facilities, Ohio Medicaid Cost Reports, the Certification and Survey Provider Enhanced Reports data, the WWAMI Rural Health Research Center, and the Minimum Data Set. Freestanding NHs were included if they were owned by a for-profit or not-for-profit organization, and had data collected in 1 of 2 years (n = 1,320; year 2015, n = 814; year 2017, n = 506). Descriptive statistics and multiple logistic regression were used to understand the relationships between resident demographics, NH organizational characteristics, and partial versus complete PELI implementation. Results: Most NHs (71.2%) reported complete implementation of the PELI over 2 years with implementation increasing over time. There was a relationship between complete PELI implementation and for-profit status, higher number of beds, higher Medicare funding, higher certified nursing assistants and activity staff hours, and urban location. Discussion and Implications: This work has important implications for the implementation of person-centered care interventions in NHs and our understanding of what NH characteristics are related to successful implementation. The next steps should include a continued, detailed assessment of PELI implementation and an exploration of the potential impact of PELI implementation on residents, staff, and organizational outcomes.

Changes in Tangible Social Support Over Time Among Older Adults Receiving Long-Term Services and Supports.

The purpose of this study was to examine changes in and predictors of perceived tangible social support over a 2-year period among older adults new to LTSS. Linear mixed effects models were used to model repeated measures of tangible social support as a function of LTSS type [NH, AL, HCBS], personal, clinical, and health-related quality of life variables. AL residents reported greater initial tangible social support, but NH and HCBS residents improved more over time. Predictors of increased tangible social support over time included greater positive affect, sense of aesthetics, education, satisfaction with family relationships, and total number of close friends and family. Decreased tangible support over time was associated with greater depressive symptoms. Findings indicate the positive influence of NH and HCBS services on perception of tangible social support, and the importance of addressing depressive symptoms and assisting with the maintenance of important relationships.

Impact of Implementing the Preferences for Everyday Living Inventory on Nursing Home Survey Deficiencies.

OBJECTIVES: The purpose of this study is to expand on previous work testing the relationship between person-centered care (PCC) and quality outcomes in the nursing home (NH) setting. We explore if the Preferences for Everyday Living Inventory (PELI) implementation is a predictor of NH quality, as defined by deficiencies. DESIGN: Secondary data analysis of repeated cross-sections. SETTING AND PARTICIPANTS: Data from 6 sources on Ohio NHs were merged to examine 1300 NH-year observations. METHODS: Logistic regression techniques were used to evaluate the relationship between PELI implementation and 3 survey deficiency outcomes: whether the NH had a 4- or 5- deficiency star rating, deficiency score, and whether the NH had a deficiency score of 0. RESULTS: NHs with complete PELI implementation increased the probability of having a 4- or 5- deficiency star rating by 6 percentage points (P = .039). Results also show complete PELI implementation is related to lower deficiency scores and an increased probability of having a deficiency score of 0, but only a 0 deficiency score was marginally significant. CONCLUSIONS AND IMPLICATIONS: The findings indicate PCC stands to improve quality outcomes; however, benefits take time to show. Future research should seek to help improve NHs level of commitment to PCC and buy-in from policymakers.

"It Hits Me Right Here at my Heart": Promoting Emotional Health of Home Care Workers.

Demand for home and community-based services continues to outpace employment of home care workers (HCWs) who provide this vital assistance. HCWs face challenges that contribute to inadequate staff retention. Of particular concern is the lack of research on HCWs' emotional health. This research describes facilitators and resources that support HCW emotional health. Qualitative descriptive interviews were conducted with a purposive sample of HCWs (n = 17) who were formally recognized for their success. Interviews were audio recorded, transcribed verbatim, and coded in Dedoose. Thematic analysis revealed three facilitators of emotional health that HCWs link to their professional success: "right state of mind," practicing self-care, and a combined sense of appreciation and support. HCWs highlight specific, practicable resources that promote their emotional health. Policy implications connects low wages and benefits to HCW emotional health, and practice implications for enhancing training and support to retain these important workers.

Preference Importance Ratings among African American and White Nursing Home Residents.

OBJECTIVES: The Preferences for Everyday Living Inventory (PELI-NH) assesses psychosocial preferences of nursing home (NH) residents. This study explored the association of race with importance ratings of self-dominion preferences (i.e., preferences for control). METHODS: PELI-NH interviews were conducted with 250 NH residents. Tests of mean differences compared African American (n = 57) and White (n = 193) residents on demographic (age, gender, education, length of stay) and clinical attributes (self-rated health, depressive symptoms, anxiety, functional limitations, hearing, vision, cognition). Stepwise multiple regression accounted first for associations of demographic and clinical attributes then for the unique association of race with total importance of self-dominion preferences to determine whether African American and White residents differ. For between group demographic/clinical differences, interaction effects were tested. RESULTS: African Americans were younger and more functionally impaired. After accounting for the effects of gender (female), age (younger), anxiety (greater), and functional impairment (less) with higher reports of importance of self-dominion preferences, race was significant. There were no significant moderating effects. CONCLUSIONS: African American residents reported greater importance of self-dominion preferences than Whites. CLINICAL IMPLICATIONS: Cultural sensitivity is critical; it may be more important to provide opportunities for autonomous decision-making for African American than for White residents.

Emotion-focused communication training online: Development and evaluation of acceptability.

Emotion-focused communication can improve the delivery of care for long-term care recipients, especially individuals' living with dementia. The purpose of this manuscript is to describe the process of translating the Emotion-Focused Communication Training (EFCT) for long-term care staff from an in-person workshop to an online program and evaluate its acceptability and impact on knowledge of emotion-focused communication and perceived self-efficacy for utilizing emotion-focused communication. The online course was developed following the ADDIE (Analysis, Design, Development, Implementation, Evaluation) Model. The program teaches participants to better identify and manage their own emotions and others' emotions in care. Pre- and post-training t-test comparisons on data collected from 247 caregivers across disciplines in long-term care (direct care workers, life-enrichment/activities staff, health care providers, case managers, health educators, students, administrators, ombudsmen, dietary, housekeeping, or maintenance staff, human resources employees, family care partners, and others) indicated a significant increase in level of knowledge of emotion-focused communication and confidence in applying the learned knowledge and skills in care (increased self-efficacy). Participants also reported high levels of program acceptability. Overall, findings indicate the benefits of translating an in-person training opportunity for caregivers into an interactive online experience; implications for caregivers and care recipients are discussed.

Investigating impacts of small dams and dam removal on dissolved oxygen in streams.

Small surface-release dams are prevalent across North American watersheds and can alter stream flow, thermal regimes, nutrient dynamics, and sediment transport. These dams are often implicated as a cause of negative water quality impacts-including reduced dissolved oxygen (DO)-and dam removal is increasingly employed to restore natural stream processes and improve DO. Published impacts of small dams on DO vary widely across sites, and even less is known about the extent and timescale of DO recovery following removal. Therefore, we sought to quantify the effects of small dams and dam removal on DO and determine the dam, stream, and watershed characteristics driving inter-site variation in responses. We deployed continuous data loggers for 3 weeks during summer months in upstream (reference), impoundment, and downstream reaches at each of 15 dammed sites and collected equivalent data at 10 of those sites following dam removal. Prior to dam removal, most sites (60%) experienced a decrease in DO (an average of 1.15 mg/L lower) within the impoundment relative to upstream, but no consistent impacts on diel ranges or on downstream reaches. Before dam removal, 5 impacted stream reaches experienced minimum DO levels below acceptable water quality standards (<5 mg/L); after dam removal, 4 of 5 of these reaches met DO standards. Sites with wider impoundments relative to upstream widths and sites located in watersheds with more cultivated land experienced the greatest decreases in impoundment DO relative to upstream. Within one year following dam removal, impoundment DO recovered to upstream reference conditions at 80% of sites, with the magnitude of recovery strongly related to the magnitude of pre-removal impacts. These data suggest that broadly, small dams negatively affect stream DO, and the extent of effects are modulated by impoundment geometry and watershed characteristics. These results may help practitioners to prioritize restoration efforts at those sites where small dams are having outsized impacts, and therefore where the greatest water quality benefits may occur.

A Process Evaluation of Developing Older Adult Research Advisory Boards in Long-term Care Settings.

BACKGROUND: Enhancing the capacity of researchers, providers and older adults to collaborate in research is critical for promoting relevant, useful research findings. OBJECTIVES: The Sages in Every Setting project aimed to disseminate a flexible model for developing research advisory boards (RABs) comprised of older adults receiving long-term services and supports (LTSS) via partnerships between academic researchers and LTSS providers. METHODS: Process evaluation assessed the feasibility of using resources to develop RABs. Partners sought regular feedback from facilitators and RAB members, which was shared with the evaluator. The evaluator conducted regular debriefings with academic partners and observed some RAB meetings. LESSONS LEARNED: The development of RABs was impacted by pre-existing collaborations, characteristics of providers, flexible use of the resources, facilitator capacity, member capacity, and researcher capacity. CONCLUSIONS: Developing RABs was feasible. Long-term partnerships between research institutions and LTSS providers that serve diverse populations could improve successful dissemination of this model.

Exploring the Criterion Validity of Pragmatic Person-Centered Care/Culture Change Measures.

BACKGROUND: Nursing homes (NHs) are required to provide person-centered care, efforts often folded into broader culture change initiatives. Despite the known benefits of culture change, it is difficult to measure. This study aims to assess the criterion validity of the Preferences for Everyday Living Inventory (PELI) Implementation Indicator with other culture change measures. METHODS: Using data from Ohio-based NHs (n = 771), logistic regression techniques demonstrated the relationship between the PELI Implementation Indicator and two validated culture change measures, the Resident Preferences for Care (RPC) and Certified Nursing Assistant (CNA) Empowerment scales. RESULTS: There was a significant relationship between the two scales and complete PELI implementation holding all other variables constant. The RPC and CNA Empowerment scales were significantly associated with complete PELI implementation. DISCUSSION: Findings suggest that the PELI Implementation Indicator can be used as a pragmatic indicator of a community's adoption of person-centered care and culture change.

Applying Agile Methodology to Reengineer the Delivery of Person-Centered Care in a Nursing Home: A Case Study.

Nursing home (NH) providers would benefit from adopting evidence-based measures for gathering and utilizing resident preference information in their daily care activities. However, providers face barriers when implementing assessment tools used to promote person-centered care (PCC). Although Agile methodology is not commonly used in NH settings, this case study shows how it can be used to achieve the goal of delivering preference-based, PCC, within a large NH. We present a road map for breaking down care processes, prioritizing, and implementing iterative plan, do, study, act cycles using Agile methodology to enhance group collaboration on quality improvement cycles, to achieve our goal of providing preference-based PCC. We first determined if care plans reflected each resident's important preferences, developed a method for tracking whether residents attended activities that matched their preferences, and determined if residents were satisfied that their preferences were being met. These efforts had positive effects throughout the NH particularly when COVID-19 limited visitors and significantly modified staff workflow. Specifically, Agile processes helped staff to know how to honor preferences during quarantines which necessitated a shift to individualized (and not group) approaches for meeting preferences for social contact, comfort, and belonging. The ready availability of preference-based reporting was critical to quickly informing new staff on how to meet residents' most important preferences. Based on lessons learned, we describe a developmental approach that other providers can consider for adoption. Implications of this work are discussed in terms of the need for provider training in Agile methodologies to support iterative improvements, the need for policies that reimburse providers for their efforts, and additional research around workflow processes.

The Stability of Nursing Home Residents' Ratings of Importance of Recreation Preferences Over One Year.

Long-term stability of nursing home (NH) residents' everyday preference remains unknown. We examined 1-year stability in reports of importance of 34-recreational activity preferences (8-MDS 3.0 Section F items; 26-Preferences for Everyday Living Inventory-NH items) by NH residents (N = 161). We examined mean differences on demographic and clinical characteristics of residents for preferences showing change. Importance ratings of preferences were highly stable over 1-year, with 91% of items retaining the same valence of importance for the majority of the sample (<20% change). Three preferences showed greater change. More functionally able residents were more likely to change their importance on "being with groups of people," and older residents were more likely to change their preferences for being "involved in religious practices" and "around animals such as pets". Overall, annual assessments of recreational activity preferences capture an accurate representation of preferences with reassessment only needed in a few circumstances.

Examining Face Validity of Visual Stimuli Used in Preference Assessments for Older Adults With Communication Impairments.

PURPOSE: Preference assessment is integral to person-centered treatment planning for older adults with communication impairments. There is a need to validate photographs used in preference assessment for this population. Therefore, this study aimed to establish preliminary face validity of photographs selected to enhance comprehension of questions from the Preferences for Everyday Living Inventory-Nursing Home (PELI-NH) and describe themes in older adults' recommendations for revising photographic stimuli. METHOD: This qualitative, cognitive interviewing study included 21 participants with an average age of 75 years and no known cognitive or communication deficits. Photographic stimuli were randomized and evaluated across one to two interview sessions. Participants were asked to describe what the preference stimuli represented to them. Responses were scored to assess face validity. Participants were then shown the PELI-NH written prompt and asked to evaluate how well the photograph(s) represented the preference. A semideductive thematic analysis was conducted on interview transcripts to summarize themes in participant feedback. RESULTS: Forty-six (64%) stimuli achieved face validity criteria without revisions. Six (8%) stimuli achieved face validity after one partial revision. Twenty (28%) stimuli required multiple revisions and reached feedback saturation, requiring team review for finalization. Thematic analysis revealed challenges interpreting stimuli (e.g., multiple meanings) and participant preferences for improving photographs (e.g., aesthetics). CONCLUSIONS: Cognitive interviewing was useful for improving face validity of stimuli pertaining to personal care topics. Abstract and subjective preferences (e.g., cultural traditions) may be more challenging to represent. This study provides a framework for further testing with older adults with cognitive, communication, and hearing impairments.