The Association of Nursing Home Quality Ratings and Spread of COVID-19

Christianna S. Williams PhD; Qing Zheng PhD; Alan J. White PhD; Ariana I. Bengtsson MPP; Evan T. Shulman MS; Kurt R. Herzer MD, PhD; Lee A. Fleisher MD


J Am Geriatr Soc. 2021;69(8):2070-2078. 

In This Article

Abstract and Introduction


Objectives: The coronavirus disease 2019 (COVID-19) pandemic has severely affected nursing home residents. Given the continued high incidence of COVID-19, and the likelihood that new variants and other infectious agents may cause future outbreaks, we sought to understand the relationship of nursing home quality ratings and measures of COVID-19 outbreak severity and persistence.

Design: We analyzed nursing home facility-level data on COVID-19 cases and deaths, county-level COVID-19 rates, and nursing home data from the Centers for Medicare & Medicaid Services (CMS), including ratings from the CMS Nursing Home Five-Star Quality Rating System. We used regression analysis to examine the association between star ratings and cumulative COVID-19 incidence and mortality as well as persistent high resident incidence.

Setting: All nursing homes in the CMS COVID-19 Nursing Home Dataset reporting data that passed quality assurance checks for at least 20 weeks and that were included in the January 2021 Nursing Home Care Compare update.

Participants: Residents of the included nursing homes.

Measurements: Cumulative resident COVID-19 incidence and mortality through January 10, 2021; number of weeks with weekly resident incidence of COVID-19 in the top decile nationally.

Results: As of January 10, 2021, nearly all nursing homes (93.6%) had reported at least one case of COVID-19 among their residents, more than three-quarters (76.9%) had reported at least one resident death, and most (83.5%) had experienced at least 1 week in the top decile of weekly incidence. In analyses adjusted for facility and county-level characteristics, we found generally consistent relationships between higher nursing home quality ratings and lower COVID-19 incidence and mortality, as well as with fewer high-incidence weeks.

Conclusion: Nursing home quality ratings are associated with COVID-19 incidence, mortality, and persistence. Nursing homes receiving five-star ratings, for overall quality as well as for each domain, had lower COVID-19 rates among their residents.


The coronavirus disease 2019 (COVID-19) pandemic has profoundly affected the nursing home population. Nursing home residents are often frail, older individuals who cannot live independently due to their health status, functional limitations, cognitive and physical impairments, and other age-related disabilities.[1] COVID-19 has highlighted the vulnerability of nursing home residents, who have disproportionately suffered effects of the pandemic. They are at higher risk of severe disease and mortality from COVID-19 due to their age[2] and comorbidities.[3] In addition, nursing homes' communal living environment increases the risk of the spread of COVID-19, particularly for nursing homes that lack adequate infection prevention and control measures to prevent transmission.[4]

As of February 18, 2021, nearly 625,000 confirmed COVID-19 cases were reported among U.S. nursing home residents, representing about 23% of the total COVID-19 cases in the United States. During this period, nursing home residents accounted for 26% of reported COVID-19 related deaths.[5,6] More than 90% of nursing homes have had at least one confirmed COVID-19 case among residents, and about 77% of nursing homes reported at least one COVID-19 death among residents. In addition, COVID-19 infection and death rates vary considerably across nursing homes.

Given the continued high incidence of COVID-19, and the possibility of new variants or other infectious diseases that may cause future outbreaks, an understanding of the relationship between nursing home characteristics, in particular those that nursing homes can control, and COVID-19 incidence is critical. Several studies have examined the relationship of COVID-19 infections and/or mortality with nursing home quality[7–12] and nurse staffing levels.[12–14] However, the findings of these studies have been mixed partly because they either did not use national data and/or were conducted early in the pandemic, limiting their generalizability across states and across time periods with different COVID-19 infection rates. Furthermore, much of the existing literature has focused on COVID-19 incidence or mortality as the main outcomes of interest. Comparatively, little attention has been given to nursing homes with persistent COVID-19 burden. The lack of consistent understanding of factors related to COVID-19 outbreaks hampers the development of responses to mitigate COVID-19 effects.

In this study, we used national and publicly reported data from the Centers for Medicare & Medicaid Services (CMS) to examine the association between nursing home quality of care and COVID-19 incidence, mortality, and persistent burden. Understanding the extent to which nursing homes can mitigate outbreaks through better performance on health inspection surveys, improved quality of care, and higher nurse staffing can help target resources, which may help to mitigate the impacts of future outbreaks.