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July 14, 2021

Policy Change to Put the Home Back Into Nursing Homes

Charles P. Sabatino and Charlene Harrington

The PDF in which this article appears can be dowloaded here: Bifocal Vol. 42 Issue 6.

During 2020 and into the start of 2021, the COVID-19 pandemic swept through U.S. nursing homes and other long-term care facilities with relentless devastation, inflicting illness and death on throngs of frail older people and people with disabilities, as well as on their caregivers.1  According to the Kaiser Family Foundation Covid-19 Coronavirus Tracker, as of March 15, 2021, there have been over 1.4 million cases of Covid-19 in long-term care facilities, including both skilled nursing homes, assisted living and other congregate care facilities, accounting for 5% of all cases in the U.S.2  More astounding is the death rate which resulted in nearly 180,000 deaths in long-term care facilities, accounting for 34% of total pandemic fatalities in the U.S.   This article examines the connection between nursing home facility size and density and the risk of COVID-19 illness and death and makes the case for a fundamental change in nursing home facility standards that would radically downsize the size and density and physical design of nursing facilities. 

Deaths in long-term care facilities have concentrated heavily in skilled nursing homes.  According to March 2021 CMS data, nursing home resident and staff Covid-19 cases combined have totaled 1,196,418, and deaths 131,921.3  This means that 74% of all the deaths in long-term care facilities occurred in nursing homes.  These statistics are all the more stark given the fact that skilled nursing home residents are less than one half of one percent of the total US population.4

At the state level, nursing home resident deaths as a percentage of total deaths varied widely, exceeding 50% in 11 states (the highest being New Hampshire at 70%).  In 10 states the resident percentage constituted less than 25% of all deaths; and in the other 29 states, between 25% and 49% of all deaths.5  Overall, 5 percent of the country’s cases have occurred in long-term care facilities, yet deaths related to Covid-19 in these facilities account for about 38 percent of the country’s pandemic fatalities.6

Black, Hispanic, American Indian, and Alaska Native populations are disproportionately affected by COVID-19 infections. Nationwide data show that the majority of nursing homes with a substantial black or Latino population (25 percent or more) had reported at least one COVID-19 case by May, 2020.7  Nursing homes with a higher proportion of racial and ethnic minority residents in Connecticut had 15-16 percent more confirmed COVID-19 cases, than similar facilities with less diverse populations.8 Nationally, nursing homes that had disproportionately more racial/ethnic minority residents had more confirmed cases and/or deaths.9

The COVID-19 infections and deaths and the excess deaths in nursing homes are not inevitable.  More robust federal and state policy directives and nursing home actions can reduce nursing home infections and deaths. Research has identified several aspects of nursing home care where policy changes and regulatory oversight can improve US nursing home care, including:

  • Nurse staffing and workforce (staffing adequacy, standards, training, wages and benefits)
  • PPE, testing, and emergency support
  • Regulation and enforcement
  • Design and environmental standards
  • Transparency and accountability of nursing home ownership and management
  • Government payment, financial transparency, and accountability issues

This article focuses on only one of these major risk factors, because it is structural in nature, easily identifiable and measurable in implementation, and which has been shown to be highly correlated to the rate of infection and death experienced in nursing homes: nursing home design and environmental standards related to size, design, and occupancy arrangements.

Snapshot of Today’s Nursing Homes

The nursing home industry in the U.S. has changed dramatically over the years.  Post World War II, the nation’s nursing home industry grew primarily from small privately-owned homes to larger facilities after 1965 when Medicare and Medicaid began providing stable funding to nursing homes that met federal standards.  In 2016, there were 1.4 million people living in approximately 15,600 nursing homes in the United States.10

The majority of nursing homes today (69%) are operated by for-profit corporations; 58 percent are operated by corporate chains.11 Twenty-four percent are not-for-profit facilities; seven percent are government owned.  Over time, there has been a decline in public and non-profit nursing homes and beds with an increase in growth by investor-owned regional and national chains. The increasingly complex nursing home organizations with multiple corporate owners have trended toward focusing heavily on profitability for investors.12

The vast majority of nursing home residents, 85 percent, are older than 65 years; 45 percent of residents are 85 and older. The majority of residents have chronic illnesses and need assistance with daily living activities and/or have cognitive impairments (61 percent).  Overall, nursing home residents are a highly vulnerable population.13

Size Matters

In 2018, the overall average facility size was over 100 beds.  States, however, vary in their average facility size with nonprofit and rural facilities generally having smaller size than for-profit and urban.14  Research on nursing homes has found that size is a strong predictor of nursing home COVID-19 infection rates.15  Nursing homes that are larger in size have more employees and more residents and therefore, the residents have a greater likelihood of exposure to infected staff and larger outbreaks.

One of the earlier studies of trends during the pandemic found that larger facility size, urban location, and greater percentage of African American residents were significantly related to the increased probability of having COVID‐19 cases.16

An enlightening study published September 30, 2020, by Mathematica focused on one state, Connecticut with 216 nursing homes, and reported results consistent with the above studies.17 Key findings included:

  • Larger nursing homes had more Covid-19 deaths per licensed bed.
  • For-profit nursing homes had about 60 percent more deaths per licensed bed than nonprofit nursing homes.
  • Nursing homes that were part of a chain had about 40 percent more deaths than independently owned nursing homes.
  • Nursing homes with higher star ratings for staffing had fewer Covid-19 deaths.
  • Overall star ratings and star ratings for Quality were not related to rates of Covid-19 deaths.18

A recent study of Ontario, Canada, nursing homes also found that size matters.  The odds of a COVID-19 outbreak were associated with the number of residents living in nursing homes and with older design standards (including multiple residents per room), controlling for other factors.  The lack of privacy for nursing home residents also results in unpleasant and undesirable living conditions.19

Perhaps the most remarkable study, because of its use of technology and big data, was undertaken by the National Bureau of Economic Research.  It consisted of a national analysis of nursing home connections via shared staff and contractors, using geolocation data from 50 million smartphones over and 11-week period. The researchers were able to construct network measures of connectedness which showed that, on average, nursing homes shared connections (i., persons moving between facilities) with 7 other facilities.20  Thus, it is not surprising to see how the traffic of staff in and out of multiple facilities impacts the spread of infection. Larger facilities invariably have larger staffs and more interfacility traffic.

Nursing Home Residents Do Not Have Private Rooms.  Most nursing home residents are living in rooms with two to four beds and share toileting facilities which can be a risk for spreading infections.  Moreover, Medicare and Medicaid only pay for shared rooms so private rooms are subject to private pay rates which are much higher.21

The extent of room sharing is a measure of crowding or density in facilities.  A recent Canadian study of more than 78,000 residents in 618 nursing homes in Ontario, Canada, found COVID-19 incidence and mortality in homes with low crowding (one per room) was less than half than that of homes with high crowding (2 or more residents per room)22.

Many Nursing Home Buildings Are Old and Outdated. A major portion of nursing home buildings are old, outdated, poorly configured, and out of scale for consumer tastes.23 Unfortunately, no national inventory of the age and condition of the nation’s nursing homes exists. The COVID-19 pandemic has exposed serious problems with design and layout that facilitated the rapid and unchecked spread of the virus.  The nation’s facilities are subject to a variety of natural disasters including but not limited to earthquakes, fires, storms, power shortages, and floods. Although CMS has regulatory standards for fire and life safety and gives deficiencies for failure to meet the standards, nursing homes have been found to violate these standards frequently.24 Existing guidelines on design have largely overlooked infection control.

The Need for Facility Design Reform

There is general agreement that alternative models are needed to ensure quality of life and  improve infection control and pandemic preparedness.25 For quality of life, researchers and advocates have identified a multitude of factors: proximity to a person’s home community, integration and health and social care and emergency services, neighborhood and public services, improved care models and building configurations, expanded resident spaces with private rooms and bathrooms, air circulation and ventilation to reduce infection exposure, transitional spaces, outdoor areas and spaces to exercise, staff spaces, and other modern features.26  As noted at the outset, we focus here on facility design.

Norway, Denmark, and other nations have pioneered the design and operation of small modern nursing home clusters.  These have residential, home-like environments, private rooms and bathrooms, therapeutic outdoor spaces, and other environmental and safety features that ensure the protection of residents.27

Clustered neighborhood design has become a model for nursing homes around the world where the clusters have 8-12 people, each with their own room.  This helps limit virus transmission while allowing for more targeted and intimate care.  Within each cluster of rooms, there is a living room, dining room, kitchen and adequate space for residents, families, and nursing staff. Research shows such architectural factors have a strong influence on improvements of quality of life and quality of care for nursing home residents.28

The Green House Project®In the United States, a variety of small homes representing the “household model” have been successful, but they currently represent a small proportion of nursing home beds.  There is no official definition of what constitutes “small,” but 20 or fewer residents has been a common cut-off.29  The most visible and well established is The Green House® Project, originally funded by the Robert Wood Johnson Foundation.  There are 300 Green House homes nationally, normally built-in clusters of five or six homes, each with 10 or 12 residents who have single rooms and private baths.  Urban variations also exist with a multi-floor building comprised of the separate homes on each floor.

In the Green House model, homes are designed around a living room with a fireplace and an open kitchen where meals are prepared and shared. The cross-trained staff teams, backed by nurses and doctors, engage with residents, serving as nurse aides, cooks, cleaners and participants in meals and social activities. Green House staff turnover appears to be well below that of traditional nursing homes.30  Residents are exposed to fewer staff, because Green House care staff are cross-trained to handle multiple aspects of daily life from resident care to cooking, cleaning, and recreation.  Of importance to both the public and policymakers, Green House Project homes have been proven to have high resident, family and worker satisfaction; better quality of care and quality of life than traditional nursing homes; care costs comparable to traditional nursing homes and, most importantly in the midst of the pandemic, a much greater ability to prevent and contain illness.31

A survey of 229 Green House nursing homes that participate in Medicare or Medicaid compared Covid-19 infection rates and death rates to those in traditional nursing homes geographically near them.  The traditional nursing homes were grouped into smaller traditional homes (those with <50 beds) and larger traditional homes (those with ≥50 beds).  Regardless of size, traditional homes generally had multiple residents per room and greater division of labor among multiple staff roles.  Green House homes were compared to both the larger and smaller traditional homes during a study tracking period that ran from January 20, 2020 to July 31, 2020.32

The results were astounding. The median death rate per 100 residents for nursing homes with 50 or more beds was 12.5%, and 10% in homes with 49 or fewer beds; but in Green House homes the rate was statistically 0.33  The zero rate in Green House homes does not mean there were absolutely no deaths at all; but rather, the number was so low that the median is mathematically zero. 

The results for infection rates were equally dramatic.  Infection rates were defined as new positive Covid-19 cases and persons admitted or readmitted who were previously hospitalized for Covid-19.  Rates were expressed in terms of numbers per 1000 residents. Because those ratios are quite low on that scale, the researchers found it useful to compare the 75th percentile of Covid-19 cases in each of the three groups.  On that metric, traditional nursing homes <50 beds and ≥50 beds had twice and 9 times the 75th percentile rates of Covid-19 cases, respectively, as Green House homes.

The authors acknowledge that the advantage of Green House homes comes from more than mere size.  They have the advantage of private bedrooms and bathrooms, limited ancillary staff, and fewer admissions.  Together these factors point to the need to fundamentally change the physical plant structure of nursing homes as an essential starting point in preventing a long-term care pandemic debacle from ever happening again.

Options Government Needs to Consider

As long as the nursing home industry can rely on the flow of federal money for the current model of care, it has no financial incentive to change, especially after the coronavirus catastrophe has passed. To move the industry toward the small house model, government will need to consider both legislative and regulatory change.  The Centers for Medicare and Medicaid Services (CMS) has established fire life safety codes for certified Medicare and Medicaid nursing homes.  These standards need to be revisited to ensure private rooms and bathrooms and safe living environments that can protect in the era of pandemics.  CMS does not pay for single rooms, except under limited circumstances.34  The pandemic experience and the research showing that density increases disease spread demonstrates the needs to change this, so that single rooms may become the norm.

There is also a Facility Guidelines Institute (FGI)  that provides direction on programming and sets minimum safeguards for nursing homes and assisted living.35 Building inspectors use the International Building Code, which is updated every three years by the International Code Council.  The NFPA 101, Life Safety Code, updated by the National Fire Protection Association every three years, guides fire officials.36 These standards set comprehensive, coordinated building safety and fire prevention codes to protect public safety.  These standards need review with the objective of better accommodating small home-like models of skilled care.  Once established, all levels of government should support phase in of the standards over time to allow providers to make capital investment in new facility design feasible and competitive. 

Such a transition also requires Congress to change the conditions of participation in Medicare and Medicaid to mandate a parallel phase in of small household models and phase out larger facilities.  As a first step, CMS could remove a federal regulatory barrier that prevents reimbursement for private, single rooms under Medicare and Medicaid unless required for a medically necessary reason such as infection control.37  Private rooms not only reduce infection spread but also conform to most adults accustomed living preference.  This is an action that can be done now, regardless of the outcome of a review of design standards.

Financial incentives are equally essential to move the field forward.  The Department of Housing and Urban Development (HUD) could, by regulation, or with the help of Congressional action, stimulate the development of small nursing homes by restructuring the HUD program to allow the program to finance the redesign, remodeling, building, and rebuilding of new nursing homes using mortgage loan programs, direct loans, bonds, and other mechanisms, provided through the HUD program.  Programs such as the HUD Section 202 Supportive Housing for the Elderly Program would be a logical vehicle, because the program already provides interest-free capital advances to private, nonprofit sponsors to finance the development of supportive housing for the elderly.  Other mechanisms such as targeted low-cost mortgage loan programs, direct loans, bonds, tax incentives, or other incentives may also be appropriate.  At the same time, CMS may need to override or waive state certificate of need requirements to allow redevelopment and replacement of traditional facilities to proceed.


As a nation, we need to reconsider the building design required standards for nursing homes as a necessary first step to ensure the safety of nursing home residents.  By itself, design does not ensure safety, quality of life, or quality of care, but the evidence overwhelmingly suggests it is a major factor.

Nursing homes already meet a variety of federal, state, and local requirements for design and safety.  A key lesson of the pandemic is that those standards need rethinking.  Home-like, residential household designs of 20 or fewer beds each, arranged in single rooms with private baths already exist and participate in Medicare and Medicaid, the most established being Green House Project homes with a capacity of no more than 12 beds, typically in clusters of units to enable administrative efficiencies and professional support.  The existence of existing, successful models should point the way forward.

To accomplish a transition to newer design standards, both carrots and sticks are needed. The stick should be the mandatory phase-in of household model design standards over an extended period of time.  The carrots for nursing home redesign can come from many sources such HUD loan programs, the Internal Revenue Service, CMS in the form of reimbursement rates, and other executive branch agencies that could provide special financing or subsidies for the redesign, remodeling, building, and rebuilding of new nursing homes.  If in the end, all nursing homes look, feel, and operate as small home-like environments, we will have put the “home” back into nursing homes. 


1 The Commission on Law and Aging acknowledges the singular assistance of Dr. Charlene Harrington, RN, PhD, FAAN, of the University of California San Francisco in the drafting of this report.

2 The Kaiser Family Foundation (KFF) COVID-19 Coronavirus Tracker,, updated as of March 18, 2021.  The definition of long term-care facility differs by state, but the KFF data reflect a combination of nursing homes, assisted living facilities, adult care centers, intermediate care facilities, and/or other long-term care facilities.

3 Centers for Medicare & Medicaid Services, COVID-19 Nursing Home Data, as of Week Ending: 03/07/2021.  The data was broken down by resident cases (641,608) and deaths (130,296) and staff cases (554,810) and deaths (1,625).

4 Centers for Disease Control and Prevention.  US Total Cases.  Cases and deaths among health care personnel.  Total US Population. (328 million).

5 See KFF supra note 2.

6 Id.

7 Robert Gebeloff et al., “Striking Racial Divide: How COVID-19 Has Hit Nursing Homes,” The New York Times May 22, 2020, at A1. .

8 Yue Li et al., “COVID-19 Infections and Deaths among Connecticut Nursing Home Residents: Facility Correlates,” 68(9) JAGS 1899 (June 18, 2020),

9 Yue Li et al., “Racial and Ethnic Disparities in COVID-19 Infections and Deaths Across U.S. Nursing Homes.” 68(11) JAGS 2454 (Nov. 2020).

10 Centers for Medicare and Medicaid Services (CMS). Nursing Home Data Compendium 2015 Edition (2016).

11 Charlene Harrington et al., “Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2009 Through 2016,” KFF report, Apr. 3, 2018. .

12 David G. Stevenson, Jeffrey S. Bramson, & David C. Grabowski, “Nursing Home Ownership Trends and their Impacts on Quality of Care: A Study Using Detailed Ownership Data from Texas,” 25(1) J. of Aging & Social Policy 30 (2013).

13 Centers for Medicare and Medicaid Services supra note 10.

14 Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. Chapter 8. Washington, D.C. March 2020, p.219-244.

15 See Charlene Harrington, et al., “Nursing Staffing and Coronavirus Infections in California Nursing Homes,  21(2) Policy, Politics, & Nursing Practice 174 (2020); Nathan M. Stall et al., “For-Profit Long-Term Care Homes and the Risk of COVID-19 Outbreaks and Resident Deaths,”  192 (33) Canadian Med Ass’n J. E946 (Aug. 17, 2020); Jose F. Figueroa, et al., “Association of Nursing Home Ratings on Health Inspections, Quality of Care, and Nurse Staffing with COVID-19 Cases,” 324(11) JAMA 1103 (2020); Hanna R. Abrams, et al., “Characteristics of US Nursing Homes with COVID-19 Cases,” 68 (8) JAGS 1653 (2020).

16 Hann R. Abrams, supra note 15.

17 Mathematica, A Study of the COVID-19 Outbreak and Response in Connecticut Long-Term Care Facilities: Final Report (September 30, 2020), file:///C:/Users/sabatinc/Downloads/CT_LTC_Facilities_Final_Report.pdf .

18 Id., at Exhibit B.9.

19 Nathan M. Stall supra note 15.

20 M. Keith Chen, Judith A. Chevalier, & Elisa F. Long, Nursing Home Staff Networks and Covid-19, National Bureau of Economic Research, Working Paper 27608 (July 2020),

21 American Council on Aging.  Nursing Home Costs by State and Region – 2019.  October 24, 2019.

22 Keven A. Brown et al., “Association Between Nursing Home Crowding and COVID-19 Infection and Mortality in Ontario, Canada,” JAMA Internal Medicine (published online November 9, 2020), .

23 See Justin Davidson, “The American Nursing Home Is a Design Failure,” New York Magazine, Cityscape, June 25, 2020.; Dave Altimari, “Connecticut Nursing Homes Are Old and Ill-Equipped to Contain Viral Spread” Hartford Courant (Dec 20, 2020),

24 Office of the Inspector General (OIG). California Should Improve Its Oversight of Selected Nursing Homes’ Compliance with Federal Requirements for Life Safety and Emergency Preparedness. A-09-18-02009. Washington, DC: OIG, November 2019.

25 Dana C. Anderson et al., “Nursing Home Design and COVID-19: Balancing Infection Control, Quality of Life, and Resilience,” 21 (11) JAMDA 1519 (2020).

26 Id. at 1520.

27 Victor A. Regnier, Housing Design for an Increasingly Older Population: Redefining Assisted Living for the Mentally and Physically Frail. (2018).

28 AnneMarie Eijkelenboom et al., “Architectural Factors Influencing the Sense of Home in Nursing Homes:  An Operationalization for Practice” 6 Frontiers of Architectural Research, 111 (2017).

29 See Action Pact, a long-term care culture change company that promotes the Household Model, .

30 Sheryl L. Zimmerman et al., “New Evidence on the Green House Model of Nursing Home Care: Synthesis of Findings and Implications for Policy,” Health Services Research, Special Issue, 51:1, Part II (February 2016); Nicholas G. Castle, “Measuring Staff Turnover in Nursing Homes,” Gerontologist, 2006 Apr;46(2):210-9.

31 Id.

32 Sheryl Zimmerman et al., “Nontraditional Small House Nursing Homes Have Fewer COVID-19 Cases and Deaths,” 22 J. Am. Med. Directors Ass’n, 489 (Published online: January 25, 2021).

33 Id. At 490

34 42 C.F.R. §483.10(f) & §483.10(h).

35 Facility Guidelines Institute (FGI) Guidelines for the Design and Construction of Residential Health, Care, and Support Facilities, 2018.

36 Liao, A., “Getting Better with Age: Design for Senior and Assisted Living Facilities,” Architect.  June 29, 2018. .

37 42 C.F.R. §483.10(f) & §483.10(h).