Nursing homes with higher rates of complaints and deficiencies had more reported COVID-19 cases, according to a “snapshot” study of nursing homes that reported cases in late April 2020. The research, published July 29, 2020, on JAMA Network Open, also found that COVID-19 rates were significantly higher in counties where facilities had cases, showing how community spread affects local nursing homes.1

“Nursing homes are at the heart of this pandemic,” explains lead author Paula Chatterjee, MD, MPH, assistant professor in the Division of General Internal Medicine at the University of Pennsylvania in Philadelphia. “We wanted to evaluate whether there were differences in the types of nursing homes that were reporting COVID-19 cases early on in the pandemic compared to nursing homes that were not reporting cases.” 

On April 19, 2020, the Centers for Medicare & Medicaid Services (CMS) posted a requirement that nursing homes must report “communicable diseases, healthcare-associated infections and potential outbreaks” to the Centers for Disease Control and Prevention.2 Chatterjee and her colleagues took data collected from state governments and departments of public health from 23 states and the District of Columbia from April 22 to April 29. Since states reported on the number of cases differently, the researchers did not collect the case numbers.

Then, they took the Medicare provider numbers for the facilities reporting cases and linked it to’s Nursing Home Compare to get facility characteristics and quality. They also looked at the Certification and Survey Provider Enhanced Reporting data for other characteristics. Furthermore, the researchers looked at the counties surrounding these facilities for their COVID-19 cases per 100,000 residents as of April 29, 2020.

The sample for the study included 8,943 nursing homes in the 23 states and the District of Columbia, with 3,021 reporting COVID-19 cases by April 29. The researchers found that the facilities that reported COVID-19 cases had more health deficiencies, emergency preparedness deficiencies, reported incidents, and substantiated complaints than the facilities that did not report cases.

In addition, more for-profit facilities and more facilities that had a higher mean percentage of Medicaid-insured residents reported cases. The most significant finding was that the rate of COVID-19 cases was nearly twice as high in counties where facilities reported cases.

“Nursing homes with COVID-19 infections were in counties with high community rates,” said co-author Rachel Werner, MD, PhD, on her Twitter account. Werner is the executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania. “The pandemic isn’t a problem in isolated nursing homes. It’s everywhere the infection is.”

Need for Funding

“In addition to better infection control in surrounding communities, nursing homes need resources,” Chatterjee said on her Twitter account. “Chronic underfunding has made it very hard for them to respond to the pandemic. Better data and higher wages for nursing home workers are good places to start.”

CliftonLarsonAllen Wealth Advisors in Minneapolis found evidence of severe financial pressures for skilled nursing facilities (SNFs) when it examined SNF cost-reported data released by CMS as of July 2019. The company’s “34th SNF Cost Comparison and Industry Trends Report” found that, although even the top quartile of SNF financial performers are reporting diminished returns, the bottom quartile is “spiraling” to the point of possibly going out of business. “The concern has been documented in a number of articles in 2019, reporting SNF closures, receiverships, and bankruptcies, particularly in states where Medicaid rates are among the lowest in the country,” the report stated.3

The financial trends show that “many operators are struggling to generate sufficient cash flow, are taking out additional financing to support operations, and do not have excess funds to reinvest in their communities. Without some disruption to status quo operations, we do not see this trend reversing in the near term,” the report said.

“Many nursing homes have been underfunded for decades, although, unfortunately, we didn’t have the data to assess whether the financial status was related to the differences we saw,” Chatterjee says.

The research from Chatterjee and her colleagues points to a higher COVID-19 infection rate in for-profit facilities. A recent study shows that private equity (PE) investment in nursing homes, with the strategy of increasing profits, has led to declines in patient health and compliance with care standards.4 PE firms now own more than 11% of all facilities, the study said. “Following buyouts, we observe higher patient volume on the extensive and intensive margins, leading to an increase in bed utilization. We also find a robust decline in nursing staff, leading to greater decline in per-patient nursing staff availability.”

The study found significant declines in outcomes associated with quality of care, such as “staff per-patient, readmission rates, and ultimately in Five Star ratings awarded by the federal government.”

“Nursing homes care for aging adults with chronic conditions and have experienced years of declining revenues and financial instability,” Chatterjee and her colleagues said. “These factors have made many facilities ill prepared for a pandemic, and stemming the spread of COVID-19 in nursing homes will not be easy.” 

Staff in Danger

As the COVID-19 research shows, nursing home infection rates reflect their local community infection rates. One reason could be worker mobility. “Due to low wages, a large portion of nursing home workers have multiple jobs or are employed at several different nursing homes,” Chatterjee says. “This could be a possible vector for transmission given the association we saw with community-case rates of COVID-19.”

A recent study indicates that low-income healthcare workers (HCWs) are especially susceptible to illness.5 The researchers looked at interviews from the National Health Interview Surveys taken between 2007 and 2014.

They further narrowed their sample to participants 30 to 64 years of age. They defined HCWs as any individual working in hospitals or health services. The researchers looked at the workers’ mortality and their self-reported annual family income.

They found that mortality rates among HCWs decreased with income and that the lowest-income HCWs had a nearly six-fold higher risk of death relative to the highest-income HCWs.5 “Our findings suggest that further growth in job opportunities for low-income HCWs is unlikely to mitigate widening income-based longevity gradients in the [United States]. This is particularly worrisome for underrepresented minorities and women, who comprise the bulk of low-income HCWs,” the researchers said. “These findings also have implications of the COVID-19 pandemic, given the intersecting risk factors of direct exposure, medical comorbidities, and poverty faced by low-income HCWs. More generally, given that healthy HCWs are critical for a well-functioning health system, reducing these disparities may improve healthcare delivery and quality.”

“In addition to better infection control in surrounding communities, nursing homes would benefit from more dedicated resources given their history of chronic underfunding and low wages for nursing home workers,” Chatterjee says.

Transformation Needed

A recent perspective in the New England Journal of Medicine said “COVID-19 has exposed the cracks in our tenuous system of providing and funding long-term care” and called for a transformation in how long-term care is paid for and provided.6

First, the authors said, Medicaid should invest considerably more in care in all settings, including home-based care. Second, families need “safe, affordable residential options,” such as smaller-scale, high-quality group models. Finally, Medicare and Medicaid should reconsider their “piecemeal approach” to paying for long-term care.

The authors advocated for more comprehensive funding through existing social insurance programs or stand-alone universal long-term care insurance for everyone. “[We] need a combination of funding, regulation, and a new strategy that fully supports a range of institutional and noninstitutional care,” they said.

“We are in a moment of crisis for nursing homes. Now should be a time of reckoning with the fundamental flaws in the organization of long-term care in this country,” the authors said. “There are no easy fixes, but we must do better.”


  1. Chatterjee P, Kelly S, Qi M, Werner RM. Characteristics and quality of US nursing homes reporting cases of coronavirus disease 2019 (COVID-19). JAMA Netw Open 2020;3:e2016930.
  2. Centers for Medicare & Medicaid Services. Upcoming requirements for notification of confirmed COVID-19 (or COVID-19 persons under investigation) among residents and staff in nursing homes. April 19, 2020.
  3. Rutledge C, Wocken M, Wilson S. 34th SNF Cost Comparison and Industry Trends Report – National Themes, Local Insights. Oct. 10, 2019.
  4. Gupta A, Howell ST, Yannelis C, Gupta A. Does private equity investment in healthcare benefit patients? Evidence from nursing homes. SSRN. March 9, 2020.
  5. Matta S, Chatterjee P, Venkataramani AS. The income-based mortality gradient among US health care workers: Cohort study. J Gen Intern Med 2020; June 30. doi: 10.1007/s11606-020-05989-7. [Online ahead of print].
  6. Werner RM, Hoffman AK, Coe NB. Long-term care policy after COVID-19 – Solving the nursing home crisis. New Engl J Med 2020; May 27. doi: 10.1056/NEJMp2014811. [Online ahead of print].