Variation in SARS-CoV-2 Prevalence in U.S. Skilled Nursing Facilities

Elizabeth M. White, APRN, PhD; Cyrus M. Kosar, MA; Richard A. Feifer, MD, MPH; Carolyn Blackman, MD; Stefan Gravenstein, MD, MPH; Joseph Ouslander, MD; Vincent Mor, PhD


J Am Geriatr Soc. 2020;68(10):2167-2173. 

In This Article

Abstract and Introduction


Objective: To identify county and facility factors associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks in skilled nursing facilities (SNFs).

Design: Cross-sectional study linking county SARS-CoV-2 prevalence data, administrative data, state reports of SNF outbreaks, and data from Genesis HealthCare, a large multistate provider of post-acute and long-term care. State data are reported as of April 21, 2020; Genesis data are reported as of May 4, 2020.

Setting and Participants: The Genesis sample consisted of 341 SNFs in 25 states, including a subset of 64 SNFs that underwent universal testing of all residents. The non-Genesis sample included all other SNFs (n = 3,016) in the 12 states where Genesis operates that released the names of SNFs with outbreaks.

Measurements: For Genesis and non-Genesis SNFs: any outbreak (one or more residents testing positive for SARS-CoV-2). For Genesis SNFs only: number of confirmed cases, SNF case fatality rate, and prevalence after universal testing.

Results: One hundred eighteen (34.6%) Genesis SNFs and 640 (21.2%) non-Genesis SNFs had outbreaks. A difference in county prevalence of 1,000 cases per 100,000 (1%) was associated with a 33.6 percentage point (95% confidence interval (CI) = 9.6–57.7 percentage point; P = .008) difference in the probability of an outbreak for Genesis and non-Genesis SNFs combined, and a difference of 12.5 cases per facility (95% CI = 4.4–20.8 cases; P = .003) for Genesis SNFs. A 10-bed difference in facility size was associated with a 0.9 percentage point (95% CI = 0.6–1.2 percentage point; P < .001) difference in the probability of outbreak. We found no consistent relationship between Nursing Home Compare Five-Star ratings or past infection control deficiency citations and probability or severity of outbreak.

Conclusions: Larger SNFs and SNFs in areas of high SARS-CoV-2 prevalence are at high risk for outbreaks and must have access to universal testing to detect cases, implement mitigation strategies, and prevent further potentially avoidable cases and related complications. J Am Geriatr Soc 68:2167–2173, 2020.


The COVID-19 pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has disproportionately affected long-term care residents in the United States, who represent 1% to 31% of cases across states, but 33% to 82% of deaths.[1] As of June 25, at least 52,000 long-term care residents have died, but incomplete data mean these are undercounts.[1] Long-term care residents account for 36% to 62% of total deaths in Canada and European countries.[2]

Skilled nursing facilities (SNFs) provide a mix of post-acute and long-term care to medically complex older adults who are particularly vulnerable to SARS-CoV-2.[3,4] Asymptomatic transmission seems to be the major contributing factor to SNF outbreaks due to the high-touch care and communal living environment.[5,6] Surveillance studies of two facilities with severe outbreaks documented high prevalence of SARS-CoV-2 within just 3 weeks of their index cases, demonstrating rapid dissemination.[4,6] Even with universal visitor bans, cessation of group activities, and regular symptom monitoring of residents and staff,[7] at least 10,400 U.S. facilities have had outbreaks as of June 25.[1]

SARS-CoV-2 represents the most serious challenge to SNFs in decades because of its lethality in older adults and ease of transmission. A major barrier to developing appropriate clinical and operational responses to mitigate the pandemic's effects is the lack of comprehensive information on the determinants of outbreak. In the absence of national data, we took advantage of SARS-CoV-2 tracking data from a large post-acute and long-term care provider, and linked these with publicly available state, county, and other administrative data. We describe the evolving prevalence of SARS-CoV-2 in SNFs and examine county- and facility-level factors associated with outbreaks.