Nursing Home Design and COVID-19: Implications for Guidelines and Regulation. Academic Article uri icon


  • OBJECTIVES: Nursing homes (NHs) are important health care and residential environments for the growing number of frail older adults. The COVID-19 pandemic highlighted the vulnerability of NHs as they became COVID-19 hotspots. This study examines the associations of NH design with COVID-19 cases, deaths, and transmissibility and provides relevant design recommendations. DESIGN: A cross-sectional, nationwide study was conducted after combining multiple national data sets about NHs. SETTING AND PARTICIPANTS: A total of 7785 NHs were included in the study, which represent 50.8% of all Medicare and/or Medicaid NH providers in the United States. METHODS: Zero-inflated negative binomial models were used to predict the total number of COVID-19 resident cases and deaths, separately. The basic reproduction number (R0) was calculated for each NH to reflect the transmissibility of COVID-19 among residents within the facility, and a linear regression model was estimated to predict log(R0 - 1). Predictors of these models included community factors and NHs' resident characteristics, management and rating factors, and physical environmental features. RESULTS: Increased percentage of private rooms, larger living area per bed, and presence of a ventilator-dependent unit are significantly associated with reductions in COVID-19 cases, deaths, and transmissibility among residents. After setting the number of actual residents as the exposure variable and controlling for staff cases and other variables, increased number of certified beds in the NH is associated with reduced resident cases and deaths. It also correlates with reduced transmissibility among residents when other risk factors, including staff cases, are controlled. CONCLUSIONS AND IMPLICATIONS: Architectural design attributes have significant impacts on COVID-19 transmissions in NHs. Considering the vulnerability of NH residents in congregated living environments, NHs will continue to be high-risk settings for infection outbreaks. To improve safety and resilience of NHs against future health disasters, facility guidelines and regulations should consider the need to increase private rooms and living areas.

published proceedings

  • J Am Med Dir Assoc

altmetric score

  • 5.7

author list (cited authors)

  • Zhu, X., Lee, H., Sang, H., Muller, J., Yang, H., Lee, C., & Ory, M.

citation count

  • 4

complete list of authors

  • Zhu, Xuemei||Lee, Hanwool||Sang, Huiyan||Muller, James||Yang, Haoyue||Lee, Chanam||Ory, Marcia

publication date

  • February 2022