More Profitable Nursing Homes Log Fewer Infection Control Citations, Study Finds

Nursing homes with the highest profit margins were significantly less likely to be cited for infection control violations between 2017 and 2019 than their less profitable counterparts, a new study has determined.

Among facilities in the top quintile of profitability over that span, 7.6% were cited for infection control violations in all three years, as compared to 13.7% in the lowest quintile of profit margins, the University of Iowa study found.

While study authors Hari Sharma and Lili Xu emphasized the importance of proper enforcement, they concluded that more resources may be necessary for facilities to avoid citations and improve care.


“Our finding that nursing homes with fewer resources, as characterized by lower profit margins, are substantially more likely to have repeated deficiency citations for infection prevention and control is worth emphasizing,” the pair wrote in the study, published in the Journal of the American Medical Directors Association. “If we want nursing homes to improve quality, we should enforce regulations by citing facilities for substandard care but also need to provide nursing homes with the resources to improve quality.”

The study focused on data from 12,194 facilities across the country, using Centers for Medicare & Medicaid Services (CMS) cost reports to determine profitability. The most profitable quintile of facilities logged an average profit margin of 11.2% over that span, while the lowest came in at -14.5%.

“Facilities with the lowest profit margins (first quintile) had 54.3% higher odds of being cited in at least one year and 87.6% higher odds of being cited in each of the three years compared with facilities with the highest profit margins (fifth quintile),” the authors noted.


During that three-year period prior to the COVID-19 pandemic, most facilities were cited for infection control, a common problem in the sector; just 26.5% had no citations between 2017 and 2019, while 64% received one or two and 10% had citations in all three years.

“Among the control variables, higher occupancy percentages and higher RN hours per resident day were associated with lower odds of deficiency citations,” the pair wrote. “We did not find any relationship between competition and citation for infection prevention and control.”

Infection control and prevention emerged early in the COVID-19 pandemic as a key area of enforcement focus for CMS. The agency immediately refocused its survey process around the domain in March 2020, and as the pandemic raged into the summer, then-CMS administrator Seema Verma was vocal about the lapses seen at facilities across the country.

“What we are seeing are significant deficiencies in infection control practices,” Verma said last August. “A lot of your management seems to be very attuned to the requirements and the guidelines. These are long-standing guidelines that we’ve had in place. Unfortunately, what we’re seeing on the ground is that some of the translation to frontline staff — sometimes that there are issues there.”

“Immediate jeopardy” citations — the most serious on CMS’s scale — regarding infection control tripled in 2020, with one attorney predicting that the number could quadruple or quintuple.

Resident advocates and industry critics have long argued that the problem rests not with a lack of resources but low fines and lax enforcement strategies that do not sufficiently push operators to invest in staff and infection-control training.

The issue of nursing home profitability has also come under scrutiny, as the industry and several independent sources point to low Medicaid rates and persistently low margins for the average American nursing home as reasons for more government support. But researchers and plaintiff’s attorneys have argued that nursing homes frequently obscure their true revenue and expenses behind webs of related-party entities, essentially withholding funds that could be used to bolster care.

The University of Iowa study concluded with a suggestion that a more balanced approach is necessary, with both enforcement and funding providing a potential path forward.

“Managing the spread of infections such as COVID-19 is challenging and enforcing existing regulations or imposing new regulations is not enough,” the team wrote.