• 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. This was true of both independent nursing homes and those that are part of a corporate chain.
• Nursing home size: At the August time point, larger nursing homes (those with at least 99 licensed beds) had case rates at least 55% higher than those with 68 or fewer licensed beds. The COVID-19 case rate and death rate were consistently higher for larger nursing homes (those with at least 99 licensed beds) versus smaller facilities (those with 68 or fewer licensed 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 May, nursing homes with total staff levels under 3.8 hours per resident day had about twice the case rates of homes with staffing levels greater than 4.4 hours per resident day. As the pandemic progressed, nursing homes with adequate registered nurse (RN) staffing had greater protection against COVID-19 cases and deaths: Nursing homes with RN staffing greater than 0.8 hours per resident day had 50% fewer COVID-19 cases than those with fewer RN hours per resident day.
• Resident demographics: As the pandemic spread, some demographic factors of the nursing home population became more significant risk factors.
• Age: In August, nursing homes with more than 45% of residents age 85 or older had an almost 50% higher COVID-19 case rate and a 70% higher COVID-19 death rate.
• Gender: Between the May and August time points, nursing homes with more than 49% male residents experienced a more than 2.5-fold increase in COVID-19 case rates.
• Race/ethnicity: The COVID-19 case rate was disproportionately higher in nursing homes with a higher percentage of Black or Latinx residents. In May, nursing homes with at least 2% Black residents had COVID-19 case rates that were about three times higher than facilities with less than about 2% Black residents. By August, nursing homes with more than 26% Latinx residents had a 50% higher case rate than those with less than 6% Latinx residents.

Based on the research results, the CHC Project Team developed a series of recommendations aimed at meaningfully improving the quality of care in nursing homes during the current pandemic and going forward. Most can be implemented immediately. Five areas of recommendations are excerpted here:

• Ownership oversight: Researchers recommend that CDPH immediately strengthen oversight, especially in at-risk facilities, over minimum federal nursing home standards, including staffing, infection control, sanitation, and emergency requirements. The report also recommends giving the Department of Health Care Services (DHCS) more authority to increase annual financial disclosure requirements for nursing homes and to increase financial controls on cost centers.
• Facility size and design: The study suggests CDPH should launch a collaborative learning program among nursing homes to share effective practices that prevent and reduce the spread of infections. It also suggests nursing homes should reduce the number of residents within their largest facilities and increase the use of private rooms. The study also recommends establishing a statewide task force to study the feasibility and financial mechanisms for the future modernization, redesign, and rebuilding of nursing homes to reduce the size of facilities.
• Staffing: The study says CDPH should immediately require all nursing homes to meet Centers for Medicare & Medicaid Services requirements that facilities “have sufficient nursing staff with the appropriate competencies and skills sets.” Additionally, DHCS should develop pathways for nursing homes to reduce turnover and increase their staffing levels over the next two years by redesigning the Medi-Cal reimbursement system. The report also says CDPH should allow select family members and friends to be deemed essential workers in the time of crisis to supplement resident care.
• Health equity promotion and infection prevention: The study recommends that CDPH take a variety of steps to promote equity. Given the disproportionate number of COVID-19 infections in nursing homes with a large proportion of Black and Latinx residents, CDPH should ensure all facilities test staff weekly for COVID-19 and require at least annual training on issues from infection control to culturally sensitive care. CDPH should also distribute vaccines to residents and staff in the highest-risk facilities first.
• Transparency and public reporting of data: To make nursing home data more consistent and easier to access, the study recommends that CDPH develop a one-stop nursing home information dashboard, updated weekly, to monitor COVID-19 or other infectious disease outbreaks in nursing homes.

About the Authors

Bruce Spurlock, MD, is executive director of Cal Hospital Compare, and Alex Stack, MPH, is director of Programs & Strategic Initiatives, Cal Hospital Compare.

Charlene Harrington, PhD, RN, is professor emerita at University of California, San Francisco, and Leslie Ross, PhD, is specialist, Institute for Health & Aging / Department of Social & Behavioral Sciences at University of California, San Francisco.

The team from IBM Watson Health includes Mahil Senathirajah, MBA, senior director; Frank Yoon, PhD, senior statistician; Parker Lewis, senior manager of client services; and Richele Benevent, MS, senior programmer and data analyst.