New California Health Care Foundation Report Highlights Key Factors Behind COVID-19 Outbreaks in Nursing Homes

Factors Include Ownership Status, Facility Size, and Staffing Levels


More than 29,000 nursing home residents in California have tested positive for COVID-19 this year, and skilled nursing facilities have reported 4,835 deaths

In a study of more than 800 nursing homes, researchers found substantial COVID-19 outbreaks between May and August — case rates and fatalities more than doubled during that time

Significantly higher COVID-19 spikes were found in for-profit and larger facilities, as well as those with inadequate staffing levels

A new study released today by the California Health Care Foundation highlights several key factors behind the substantial spread of coronavirus in California skilled nursing facilities between May and August, when the number of COVID-19 cases and deaths in nursing homes more than doubled.

The report, Factors Driving COVID-19 Cases and Deaths in California Nursing Homes, notes several facility and resident characteristics associated with higher case and death rates — including ownership status, nursing home size, and staffing level.

According to the California Department of Public Health, the state has had a cumulative 29,232 COVID-19-positive nursing home residents and 4,835 coronavirus-related deaths through November 15. While nursing home residents are less than one-half of 1% of the state’s population, about 26% of all deaths related to COVID-19 in California have occurred in those facilities.

To better understand the factors behind the spread of COVID-19, Cal Hospital Compare, in partnership with IBM Watson Health and the University of California, San Francisco, studied COVID-19 data from more than 800 nursing homes at two points in time during the pandemic — once in May 2020 and once in August 2020.

In May, 25% of nursing homes studied had one or more residents with COVID-19, and 16% had at least one resident death attributable to the coronavirus. By August, 66% of facilities had a COVID-19 case, and 37% had at least one resident who had died of COVID-19.

“Nursing homes have been carrying a heavy burden of COVID-19 cases in California and across the country,” says Kristof Stremikis, director of Market Analysis and Insight at the California Health Care Foundation, which commissioned the new report. “With coronavirus numbers climbing again this fall, these facilities and their vulnerable residents must be among the state’s most urgent health priorities.”

In addition to highlighting the dominant factors behind the spread of COVID-19 in nursing homes, the study’s authors also detail recommendations to address these issues — including increased state oversight over nursing home ownership and facility design, improved monitoring of staffing levels, and implementation of health equity measures.

“This new study underscores the evolving challenges facing nursing homes, as well as the critical, concrete steps that can be taken to make nursing facilities safer during this pandemic,” says Bruce Spurlock, MD, executive director of Cal Hospital Compare, one of the authors of the report. “There were challenges in providing quality care in nursing homes before the pandemic. COVID-19 has magnified these issues — and underscored the need for action.”

The report highlights four major factors driving COVID-19 case and death rates in nursing homes:

  • Ownership status: Early in the pandemic, for-profit nursing homes had COVID-19 case rates five to six times higher than those of nonprofit and government-run nursing homes.
  • Nursing home size: In August, larger nursing homes (those with more than 99 licensed beds) had case rates at least 55% greater than smaller facilities (those with 68 or fewer beds).
  • Staffing levels: COVID-19 case rates were significantly higher in nursing homes with staffing levels below those recommended for nurses (0.8 registered nurse hours per resident day) and total staff (4.1 hours per resident day). In August, nursing homes with RN staffing at recommended levels had 50% fewer COVID-19 cases than those with fewer RN hours per resident day.
  • Resident demographics: Resident demographics have become more significant risk factors as the pandemic spreads, including residents’ age (facilities with larger numbers of residents age 85 years or older have experienced a 70% higher COVID-19 death rate); gender (facilities with larger numbers of male residents had a more than 2.5-fold increase in COVID-19 case rates this summer); and race/ethnicity (COVID-19 case rates have been three times higher in facilities with larger numbers of Black residents and 57% higher in facilities with larger numbers of Latinx residents).

Contact Information:
Lisa Aliferis
Senior Communications Officer, High-Value Care


About the California Health Care Foundation

The California Health Care Foundation is dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford.