Nursing Home Size May Play Role in COVID-19 Infection Risk Along with Race, Location

Another study of early nursing home COVID-19 data has found that factors such as a facility’s racial demographics and location — as well as bed count — have a greater bearing on potential outbreaks than quality history.

“Larger facility size, urban location, greater percentage of African-American residents, non-chain status, and state were significantly related to probability of having a COVID-19 case,” the brief study, published this week in the Journal of the American Geriatric Society, concluded. “Five-star rating, prior infection violation, Medicaid dependency, and ownership were not significantly related. Outbreak size was significantly associated with facility size, for-profit status, and state, but not with other studied characteristics.”

The study — authored by researchers from Harvard, Baylor, UCLA, and Brown — analyzed state-level COVID-19 data from more than 9,300 facilities as of May 11.


In all, about 31.4% of those properties had COVID-19 cases as of that date.

Among properties with fewer than 50 beds, 86.9% were COVID-free, while just 48.3% of buildings with more than 150 escaped reporting cases.

“The negative relationship between outbreak and facility size indicates that while smaller facilities are less likely to have outbreaks, outbreaks at small facilities affect more patients-per-bed,” the team concluded. “This may reflect a number of features of small facilities, including higher patient turnover and the possibility that isolating COVID-positive residents is more challenging for small facilities.”


As similar research from the University of Chicago found, the racial demographics of a facility have a significant bearing on the likelihood of outbreaks: 28.3% of properties with a low proportion of black residents reported infections, as compared to 46.1% of facilities with a high share of black patients.

“Our finding that facilities with a high percentage of African-American residents are more likely to have COVID-19 cases echoes disparities in the pandemic at large, and indicates a critical health disparity to be addressed in the response to COVID-19 nursing home outbreaks,” the team noted.

But in terms of past quality, COVID-19 delivered the pain equally, at least according to the research.

About 30.5% of facilities with one star on the federal government’s rating scale for nursing homes had at least one COVID-19 case, while 30.9% of five-star buildings had cases.

Among properties with no history of infection-control problems, 30.5% had COVID-19 cases; for those with previous violations, the number was 32.5%.

David Grabowski, a Harvard professor and one of the report’s authors, cited these trends in criticizing the Centers for Medicare & Medicaid Services’ (CMS) decision this week to boost fines for infection-control violations, with increased amounts based on prior history of such deficiencies.

“We have all found that COVID-19 cases are largely a function of where the facility is located and not their prior quality,” Grabowski wrote to SNN. “This suggests COVID-19 in nursing homes is not limited to ‘bad apples,’ but rather a system problem requiring system solutions. CMS should focus on distributing testing and personal protective equipment to nursing homes. Increased fines to punish ‘bad apples’ are misguided right now.”

While the team acknowledged that further analysis of data is required to draw deeper conclusions about the effects of the novel coronavirus on nursing homes, the early data reflects “the unique infection control needs of COVID-19.”

“The rapid evolution and mortality of nursing home outbreaks of COVID-19 reflect the need for continued community-facility contact restrictions, increased testing of residents and staff, and heightened infection control including increased access to personal protective equipment for staff,” they wrote. “As the COVID-19 crisis continues, nursing homes are in critical need of these resources to protect their vulnerable populations.”