Mapping community-level determinants of COVID-19 transmission in nursing homes: A multi-scale approach.

Deaths from the COVID-19 pandemic have disproportionately affected older adults and residents in nursing homes. Although emerging research has identified place-based risk factors for the general population, little research has been conducted for nursing home populations. This GIS-based spatial modeling study aimed to determine the association between nursing home-level metrics and county-level, place-based variables with COVID-19 confirmed cases in nursing homes across the United States. A cross-sectional research design linked data from Centers for Medicare & Medicaid Services, American Community Survey, the 2010 Census, and COVID-19 cases among the general population and nursing homes. Spatial cluster analysis identified specific regions with statistically higher COVID-19 cases and deaths among residents. Multivariate analysis identified risk factors at the nursing home level including, total count of fines, total staffing levels, and LPN staffing levels. County-level or place-based factors like per-capita income, average household size, population density, and minority composition were significant predictors of COVID-19 cases in the nursing home. These results provide a framework for examining further COVID-19 cases in nursing homes and highlight the need to include other community-level variables when considering risk of COVID-19 transmission and outbreaks in nursing homes.