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

J Am Geriatr Soc. 2020 Oct;68(10):2167-2173. doi: 10.1111/jgs.16752. Epub 2020 Aug 21.


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.

Keywords: COVID-19; SARS-CoV-2; facility; long-term care; nursing home; skilled nursing.

Publication types

  • Multicenter Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged
  • Aged, 80 and over
  • COVID-19 / epidemiology*
  • COVID-19 / transmission
  • Case-Control Studies
  • Cross-Sectional Studies
  • Humans
  • Infection Control / standards
  • Nursing Staff / statistics & numerical data
  • Pandemics
  • Prevalence
  • Risk Assessment
  • SARS-CoV-2
  • Skilled Nursing Facilities / organization & administration
  • Skilled Nursing Facilities / statistics & numerical data*
  • United States / epidemiology