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Nursing home administrators are caught in a "perfect storm" of rapidly increasing health care costs, decreasing reimbursement, and increasing competition. This paper documents how these pressures create cascading misalignments resulting in compromises of the quality of comfort care. These problems are inevitable, given the increase in unfunded mandates, where performance evaluation is decoupled from actual performance. Ambient technologies are explored as a means of tracking actual care versus reported care. Independent quality of care tracking and documentation of ambient data, coupled with best practice research and rewards, are explored to promote quality care as a marketing advantage. Implications are discussed.