Understanding the Effect of Neighborhood on Nursing Home Outcomes

OBJECTIVES: Neighborhood context shapes the environment in which nursing homes (NHs) operate, yet its influence on NH outcomes remains insufficiently understood. This study examined whether NHs in socioeconomically disadvantaged neighborhoods experienced worse resident and staff COVID-19 outcomes and whether higher facility quality mitigated these neighborhood effects. DESIGN: Cross-sectional study linking facility, neighborhood, and community data from 10 public sources. SETTING AND PARTICIPANTS: Ohio Medicare- or Medicaid-certified, nonhospital-based NHs reporting COVID-19 data beginning May 24, 2020. Outcomes were assessed through January 31, 2021 (prevaccination) and January 30, 2022 (2 years). The analytic sample included 752 NHs. METHODS: Facility addresses were geocoded and linked to the 2019 Area Deprivation Index. Poisson regression models adjusted for facility, resident, and community characteristics assessed associations of neighborhood disadvantage and NH quality measured by Centers for Medicare & Medicaid Services 5-Star ratings and consumer satisfaction with COVID-19 outcomes (resident cases, resident deaths, and staff cases per 100 beds per month). RESULTS: Higher neighborhood disadvantage was associated with increased resident mortality in both the prevaccination period (incidence rate ratio, 1.004; P < .05) and the 2-year period (incidence rate ratio, 1.003; P < .05). Neighborhood disadvantage was not associated with resident or staff infections. Higher staffing ratings and resident satisfaction were linked to lower resident infection rates during the 2-year period, but no quality indicators predicted mortality. Higher Centers for Medicare & Medicaid Services ratings in some domains were associated with increased staff infection rates. CONCLUSIONS AND IMPLICATIONS: Neighborhood disadvantage was a persistent, independent driver of resident mortality and was not offset by higher facility quality. Quality indicators supported infection prevention but did not mitigate structural mortality risks. These findings highlight the need for place-based public health strategies and targeted resource and workforce investments for NHs serving disadvantaged communities. The Area Deprivation Index may help guide preparedness and resource allocation.