GGM-23-0124.R1 Proof Hi

Gerontology and Geriatric Medicine
Nursing Home Residents' COVID-19 Infections in the United

States – A Systematic Review of Personal and Contextual
Factors
Journal: Gerontology and Geriatric Medicine
Manuscript ID GGM-23-0124.R1
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Manuscript Type: Original Manuscript
Keywords: Nursing, Aging, Prevention, Systematic Review

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Background: This mixed methods systemic review synthesizes the
evidence about nursing home risks for COVID-19 infections. Methods:
Four electronic databases (PubMed, Web of Science, Scopus, and Sage
Journals Online) were searched between January 2020 and October
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2022. Inclusion criteria were studies reported on nursing home COVID-

19 infection risks by geography, demography, type of nursing home,
staffing and resident’s health, and COVID-19 vaccination status. The
Mixed Methods Appraisal Tool (MMAT) was used to assess the levels of
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evidence for quality, and a narrative synthesis for reporting the findings
by theme. Results: Of 579 initial articles, 48 were included in the review.
Abstract:
Findings suggest that highly populated counties and urban locations had
a higher likelihood of COVID-19 infections. Larger nursing homes with a
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low percentage of fully vaccinated residents also had increased risks for
COVID-19 infections than smaller nursing homes. Residents with
advanced age of racial minority, and those with chronic illnesses were at
higher risk for COVID-19 infections. Discussion and Implications:
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Findings suggest that along with known risk factors for COVID-19
infections, geographic and resident demographics are also important
preventive care considerations. Access to COVID-19 vaccinations for
vulnerable residents should be a priority.
https://mc.manuscriptcentral.com/ggm
Page 1 of 56 Gerontology and Geriatric Medicine
Running head: COMMUNITY SPREAD INFECTIONS RISKS

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4 1 Nursing Home Residents' COVID-19 Infections in the United States – A Systematic Review of
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6 2 Personal and Contextual Factors
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9 3 Abstract
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12 4 Background: This mixed methods systemic review synthesizes the evidence about nursing home
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14 5 risks for COVID-19 infections. Methods: Four electronic databases (PubMed, Web of Science,
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17 6 Scopus, and Sage Journals Online) were searched between January 2020 and October
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19 7 2022. Inclusion criteria were studies reported on nursing home COVID-19 infection risks by
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21 8 geography, demography, type of nursing home, staffing and resident’s health, and COVID-19
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9 vaccination status. The Mixed Methods Appraisal Tool (MMAT) was used to assess the levels of
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26 10 evidence for quality, and a narrative synthesis for reporting the findings by theme. Results: Of
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28 11 579 initial articles, 48 were included in the review. Findings suggest that highly populated
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12 counties and urban locations had a higher likelihood of COVID-19 infections. Larger nursing
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13 homes with a low percentage of fully vaccinated residents also had increased risks for COVID-
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35 14 19 infections than smaller nursing homes. Residents with advanced age of racial minority, and
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37 15 those with chronic illnesses were at higher risk for COVID-19 infections. Discussion and
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40 16 Implications: Findings suggest that along with known risk factors for COVID-19 infections,
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42 17 geographic and resident demographics are also important preventive care considerations. Access
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44 18 to COVID-19 vaccinations for vulnerable residents should be a priority.
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47 19 Keywords: COVID-19, COVID-19 vaccination, nursing homes, residents’ infection, risk
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20 factor.
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Gerontology and Geriatric Medicine Page 2 of 56
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3 1 Introduction
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6 2 The coronavirus (COVID-19) pandemic is becoming the new normal, with repeat spikes
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9 3 of infections in communities across the globe (Saito & Haruyama, 2023). It has
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11 4 disproportionately affected nursing homes in the United States in particular, with widespread
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13 5 outbreaks and an excess mortality rate of two to three times more than the general population (Li
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6 et al., 2020). The Centers for Medicare & Medicaid Services (CMS; 2021) reported 570,626
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18 7 nursing home residents’ infections and 112,383 residents’ deaths in the United States before the
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20 8 wide availability of COVID-19 vaccination in 2020 (e.g., Pfizer, Moderna, and Johnson and
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9 Johnson) for nursing home residents. In the early Delta stages of the pandemic (summer 2021) to
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25 10 winter 2022 (Omicron), nursing home residents were at excessive risk for severe infections and
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27 11 death (United States Government Accountability Office, 2023). As various the mutation of new
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29 12 variants and the introduction of vaccinations and their competing risks, there is need to establish
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32 13 baselines to benchmark new COVID-19 infections from emerging variants and how they affect
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34 14 nursing home residents. Findings would inform prevention and management strategies for
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15 minimizing excess infections and also reduce mortality in nursing home residents.
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39 16 Earlier empirical studies published in 2020 (e.g., Bui et al., 2020; He et al., 2020; Gorges
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17 & Konetzka, 2020) reported nursing homes COVID-19 infections were associated with nursing
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44 18 home characteristics such as staff, and resident’s demographic characteristics and the resident’s
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46 19 pre-existing comorbid conditions. However, there is a need for a systematic review that aims to
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48 20 integrate the evidence for guiding nursing home care services and their COVID-19 management
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51 21 plans, the new normal in which the virus is here to stay, much like the flu virus. Findings from a
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53 22 systematic review would also inform future related studies on COVID-19 among nursing home
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55 23 residents, of which they have. enormous diversity both in the U.S. and globally. Specifically, this
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3 1 systematic review aims to summarize the evidence on how the USA areas in which the nursing
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6 2 home is situated (e.g., counties) as well as how individual residents’ demography are associated
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8 3 with COVID-19 infections in order to guide future research and to inform related interventions.
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11 4 Conceptual Framework
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14 5 The conceptual framework for this systematic review is the Geographic Information
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16 6 Systems (GIS) Based Spatial Model (Tomlinson, 2007). The reason that GIS was used is that its
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7 GIS allows an extra analysis of information layers in social ecologies such as nursing homes in
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21 8 communities (eg counties). We used this to assess these characteristics for patterns in the data
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23 9 thus suggests inter-level associations important for planning decisions for prevention (Sugg et
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25 10 al., 2020). We used the GIS based spatial modelling to reveal and compare patterns across
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28 11 COVID-19 nursing homes (meso level) in order to assess environments at multiple levels of
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30 12 vulnerability for prevention intervention.

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13 The GIS has previously been utilized to examine COVID-19 outbreaks and infections
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35 14 with promising results (Franch-Pardo et al., 2020). Thus we utilized the GIS-Based Spatial
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15 Model in our systematic review on both meso (community level) and micro (nursing home
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40 16 characteristics, also resident profiles by demographics and vaccination statuses) levels.
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43 17 Community-level factors. In the 2020s, it appears that there is variability in COVID-19
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45 18 infection prevalence rates at the county level in the USA (Bui et al., 2020; Gorges & Konetzka,
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19 2020; White et al., 2020; Sun et al., 2020), suggesting contextual influences. In addition, high
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50 20 population density, locations (e.g., urban locations in the early pandemic), and subsequently high
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52 21 certificate of need (CON) laws have impacted nursing home residents’ COVID-19 infection rates
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54 22 (Gmehlin et al., 2021; Klompmaker et al., 2021; Sun et al., 2020). Thus, it is important to
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3 1 investigate those community-level factors that are related to COVID-19 infections in order to
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6 2 provide information for healthcare departments to enable them to monitor and evaluate the
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8 3 transmission of COVID-19 at the macro level. Consequently, health departments may be able to
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10 4 organize future approaches for efficient implementation of prevention measures for nursing
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5 homes.
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6 Nursing home characteristics and staffing. Larger nursing home facilities or those who failed
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18 7 to pass quality assurance had more residential COVID-19 infections (Gmehlin et al., 2021; Lane
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20 8 et al., 2020; Yin et al., 2021). Also, those who were privately owned and had low mask usage
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9 were also associated with higher COVID-19 infection rates (Abrams et al., 2020; Figueroa et al.,
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25 10 2020; Simoni-Wastila et al., 2021; Yin et al., 2021). However, in contrast, larger size nursing
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27 11 homes often had better resourcing and higher quality ratings, which would minimize risk for
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29 12 COVID-19 infections (Gopal, Han, & Yaraghi, 2021; Figueroa et al., 2020). Staffing levels and
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32 13 registered nurse hours were also associated with higher COVID-19 prevalences/rates (Gorges &
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34 14 Konetzka, 2020; Shi et al., 2020; Sun et al., 2020; Xu et al., 2020), likely from the asymptomatic
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15 staff spreading infections and who were unable to take time away from work. However, there is
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16 conflicting evidence regarding how nursing homes’ qualities (eg star ratings) affected residents’
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41 17 risk for COVID-19 infections (He et al., 2020; Temkin-Greener et al., 2020; White et al., 2020).
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44 18 Personal resident factors. Personal factors such as minority background (e.g., African
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46 19 Americans and Hispanic), gender (male), older age, and higher frequency of travel among
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48 20 individuals dwelling in higher-income communities have been associated with risk for infections,
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51 21 especially for nursing home residents with Medicaid (Bailey et al., 2020; Zhang & Schwartz,
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53 22 2020). For example, more African Americans and Hispanics had higher prevalence of COVID-
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55 23 19 infections (He et al., 2020; Mehta & Goodwin, 2021). In one study, it was found that male
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3 1 residents in nursing homes had a two-fold possibility of being infected compared to female
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6 2 residents (Shi et al., 2020). Another study reported older adult age was a risk factor for COVID-
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8 3 19 (Chen et al., 2021). In addition, past and present infections pre-existing chronic illnesses and
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10 4 decreased capabilities in activities of daily living were also reported as risk factors for COVID-
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5 19 infections (Bigelow et al., 2020; Shi et al., 2020).
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6 The present study. The few systematic review studies conducted previousy focused on long-
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18 7 term care facilities (e.g., assisted living, senior housing) (Bach-Mortensen et al., 2021; Konetzka
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20 8 et al., 2021). We believe residents in nursing homes are more vulnerable to COVID-19 due to
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9 their multiple chronic conditions and high chances of mortality. Thus a better systematic review
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25 10 is needed to expand on risk factors in the nursing home populations. Although a scoping review
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29 12 as of January 2021 we believe there is a need for a such a review to investigate relationship
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32 13 between COVID-19 infections and more individual, social and demographic risk factors not
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34 14 investigated by Giri et al in the nursing homes.
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37 15 Our mixed-method systematic literature review aims to summarize the research evidence
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39 16 of nursing home care and residents’ personal risk factors associated with COVID-19 infections
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17 over the pandemic period (January 1st, 2020 to October 31st, 2022) in the United States.
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18 Our specific research question was: What are the risk factors associated with nursing
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47 19 home residents’ COVID-19 infections over the critical pandemic period (January 1st, 2020 to
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49 20 October 31st, 2022) in the USA?
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52 21 We believe our findings would provide evidence that could inform the pandemic
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54 22 preparedness of nursing home care services and also to add to the growing body of literature for
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3 1 future related studies on resident’s COVID-19 infections in the USA.
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3 1 Methods
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6 2 Research Design
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9 3 Our systematic review protocol is registered with PROSPERO (CRD42023469015).
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11 4 This mixed methods systematic review integrated evidence from both qualitative and
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13 5 quantitative studies. “Mixed methods systematic reviews (MMSRs) have become an important
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6 development in evidence-based health care as they maximize the ability of review findings to
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18 7 assist in clinical and policy decision-making” (Stem et al., p. 121). Health systems managers find
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20 8 them more credible for providing guidance on evidence-based decisions than they would with
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9 single method approach findings. Ethics approval and Informed consent are not applicable for
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25 10 systematic reviews.
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27 11 Search Strategy
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30 12 The literature search included four databases (PubMed, Web of Science, Scopus, and
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35 14 term care" OR "residential care" OR "aged care facility") AND ("COVID-19" OR "coronavirus"
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37 15 OR "2019-ncov" OR "cov-19" OR "sars-cov-2") AND ("residents") AND ("factors" OR "causes"

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39 16 OR "influences" OR "reasons" OR "determinants" OR "predictors") AND (“United States” OR
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17 “America” OR “U.S.” OR “USA”).
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18 Selection Criteria
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19 Studies were included if they met the following criteria: (a) articles were published
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50 20 between January 1st, 2020 – October 31st, 2022, and in the English Language. The country and
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52 21 the setting were restricted to skilled nursing home facilities in the United States. Studies where
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3 1 The exclusion criteria were: (a) irrelevant to COVID-19 infections, (b) written in
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6 2 languages other than English, (c) comments, recommendations, letters, or editorials, not full
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8 3 research papers (d) countries other than the United States. A library reference librarian assisted
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10 4 our searches to maximize the yield.
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13 5 Search Outcome
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16 6 The predefined search strategy initially identified 579 records (99 in PubMed, 77 in Web
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7 of Science, 70 in Scopus, 333 in Sage Journals Online, and 2 from other sources), resulting in
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21 8 390 articles after removing duplicates. After using a combination of Medical Subject Headings
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23 9 (MeSH) and text-word to screen the title, abstract and full-text, a further 310 articles were
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25 10 removed, 80 articles sought for retrieval. Except one report not retrieved, assessment for
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28 11 eligibility resulted in forty-eight articles for the systematic review (Appendix 1) and excluded
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30 12 thirty-one articles with reasons (e.g., subjects not in nursing homes, articles not relevant to
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32 13 COVID-19 factors, and staff subjects) (Appendix 2).
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35 14 Risk of Bias and Quality Assessment
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38 15 Bias assessment was implemented through the usage of the Mixed Methods Appraisal
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16 Tool (MMAT), and each qualified study was appraised as low or high bias against the
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43 17 methodological quality of studies across five categories (qualitative, quantitative randomized
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45 18 controlled trials, quantitative non-randomized, quantitative descriptive, and mixed methods)
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19 (Hong et al., 2018). The value of the MMAT exists in its capacity to evaluate the appropriateness
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50 20 and accuracy of the methods utilized and the risk of bias in a study, thereby enhancing the
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52 21 overall reliability and validity of the findings (Hong et al., 2018). For example, the MMAT
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3 1 target population, which helps reviewers determine any biases or issues that are caused by
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6 2 inadequate sampling. The MMAT was applied at the outcome level. We also adopted the Levels
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8 3 of Evidence by Ackley et al. (2008) (also named Hierarchy of Evidence) to map each article’s
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5 (highest level) on the vertical line. It was utilized at the study level. See Appendix 3 for the
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18 7 Data Extraction
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21 8 The data extraction prioritized studies based on known risk factors associated with
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23 9 nursing home residents’ COVID-19 infections utilizing the Geographic Information Systems
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25 10 (GIS) Based Spatial Model as a framework (Sugg et al., 2020) (Appendix 4). These factors were
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28 11 abstracted and then categorized into different levels (geography, demography, nursing home
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30 12 characteristics, staffing, resident’s characteristics, and COVID-19 vaccination status).

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13 Three Reviewers independently screened the titles, abstracts and full-body of articles and
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35 14 then evaluated the full contents of those selected articles associated with nursing home residents’
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15 COVID-19 infection status. Data from prioritized studies were extracted by applying the
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40 16 Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines (PRISMA)
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42 17 guidelines (Page et al., 2021). Disagreements were handled by the first reviewer RefWorks
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18 software was employed to find and delete duplicated articles.
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47 19 Data Synthesis
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49 20 Then a narrative synthesis (Popay et al., 2006) was conducted for the prioritized studies
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51 21 (n = 48) which depended primarily on using the MeSH and text-word to identify common
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53 22 findings and themes from multiple studies. The narrative synthesis fitted this review because of
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23 the inconsistencies in the reporting of associations between the included variables and COVID-
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3 1 19 infections.
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6 2 Following the guidelines of the systematic review without meta-analysis (SWiM)
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9 3 (Campbell et al., 2020), the first listed author conducted a thematic analysis and assessed the
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11 4 extracted evidence for coherence, followed by checks by the second listed author. Any
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6 Subsequently, the first listed author categorized the evidence based on recurring themes and
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18 7 variables applying the GIS model (Sugg et al., 2020) by nursing home contexts, offering a
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9 the third listed author. The synthesis was performed in a narrative description that weaved the
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25 10 key findings and the implications of the combined evidence from mixed-method studies. The
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3 1 Results and Discussion
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6 2 We believe this mix-method literature review is the first investigating risk factors
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8 3 associated with nursing home residents’ COVID-19 infections in the United States into six major
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10 4 areas: factors associated with geography, demography, type of nursing home, staffing in nursing
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5 home, resident’s status, and COVID-19 vaccination status. These indicators are important for
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15 6 policy and practice improvements as well as for intervention research studies as discussed below.
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17 7 Forty-eight articles referring to nursing homes in the United States and published between
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8 January 2020 and October 2022 were selected in November 2022. Table 2 describes articles
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22 9 included for review in the order of author/year, number of settings/participants, study design, and
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24 10 key factors the adapted levels of evidence by Ackley et al. (2008), 92% articles were classified as
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29 12 Adopting the MMAT, 92% of articles were graded as four or five points based on their study
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31 13 design, reflecting a low bias and a high quality of these studies.
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33 14 More specifically, two control trials articles (range of nursing homes 34-196), nine
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15 retrospective cohort (range of nursing homes 2-15,038), seven case-control (range of nursing
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38 16 homes 1-15,236), twenty-eight cross sectional (range of nursing homes 1-15,390), and two either
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40 17 qualitative or mixed method were identified.
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18 Themes. Six major themes of risk factors in the studies included were explored and
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45 19 categorized: geography, demography, type of nursing home, staffing in nursing home, resident’s
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47 20 health, and COVID-19 vaccination status. Ten out of forty-eight studies (21%) identified
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49 21 geography, nine (19%) evaluated demography, twenty-four (50%) estimated type of nursing
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52 22 home, twelve (25%) determined staffing in nursing home, four (9%) analyzed resident’s health,
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54 23 and nine (19%) investigated COVID-19 vaccination status (see Figure 1 for a summary of
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17 Figure 1. Overview of study findings based on the modified GIS Model Framework and four
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34 18 main themes. Notes: Black-colored rectangles stand for reported studies and grey-colored
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37 20 Geography
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39 21 In summary, geography-level factors related to COVID-19 prevalence included COVID-
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42 22 19 prevalence in counties, counties with population density, and locations (urban/rural).
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44 23 Nursing home's county's infection prevalence/rate was the strongest predictor of resident
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46 24 infections (Gorges & Konetzka, 2020; Sun et al., 2020). Bui et al. (2020) and Mattingly et al.
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25 (2021) described it as a strong factor contributing to nursing home infections (e. g., OR = 4.38,
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51 26 95% CI = 2.24-8.56). If the county had a higher COVID-19 prevalence, nursing homes located in
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28 introduced via serving staff (White et al., 2020). Gorges et al. (2020) reported that nursing
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3 1 homes’ COVID-19 infection cases in the top 20th percentile of counties’ infection rate were at
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6 2 least six-fold higher compared to these nursing homes located in the bottom 20th percentile of
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10 4 Population density was also a risk factor, and thus counties with high population density
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5 had a higher likelihood of COVID-19 infections in nursing home residents (Sun et al., 2020). As
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15 6 COVID-19 is a respiratory virus, transmission is rapid among individuals living in high-density
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17 7 areas (see also Zhang & Schwartz, 2020). Thus, nursing homes in high population density areas
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8 had a greater risk of suffering outbreaks and infections. However, Sugg et al. (2020) reported
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22 9 that such a relationship was only proven in eleven states, such as California, Nevada, Missouri,
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24 10 Kansas, Iowa, and Indiana. Until September 2020, nursing homes located in urban areas were
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29 12 increased sharply in rural nursing homes (Gmehlin et al., 2021).
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31 13 Demography
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34 14 In summary, demography-level factors related to COVID-19 prevalence included
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15 percentage of the total Africa Americans or Hispanic population in counties, percentage of

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16 Africa American, Hispanic, and Asian residents in nursing homes, older age, male gender of
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44 18 Minority status. There was a higher prevalence of COVID-19 infections in a home with
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46 19 counties who had a higher percentage of minority populations (Hispanics, African Americans,
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48 20 and Asians) (Sugg et al., 2020). This is supported by evidence that the COVID-19 prevalence
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51 21 was higher (OR = 1.27) in counties with a higher percentage of African Americans. In addition,
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53 22 the rate was much more significant in the Southern U.S. states, such as Texas, Florida, and
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55 23 Louisiana (Sugg et al., 2020). It has been hypothesized that the COVID-19 deaths may be due to
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3 1 higher incidence of underlying health conditions and less access to medical care among minority
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6 2 populations (Patel et al., 2020; Thomeer et al., 2022). This further reveals the racial and ethnic
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11 4 A higher percentage of racial and ethnic composition of nursing home residents (e.g.,
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13 5 African Americans, Hispanics) was found to be a risk factor for COVID-19 infections (Cai et al.,
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6 2021; He et al., 2020; Mehta et al., 2021). Another correlated factor was that nursing homes with
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18 7 a higher percentage of African American residents were more reported to be likely to experience
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20 8 staff shortages and financial restrictions and have Medicaid-dependent residents (Travers et al.,
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9 2021). There were severe health disparities in COVID-19 prevalence and its related mortality
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25 10 during the pandemic (Abrams et al., 2020).
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28 11 Older age. Advanced age was reported that positively associated with resident COVID-
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30 12 19 cases (Chen et al., 2021). This may be because those who had more pre-existing chronic
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15 Being male. Men were reported to have a higher rate of COVID-19 infections in nursing
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40 16 homes compared to women (OR = 2.00) (Shi et al., 2020). Although unproven X-linked genetic
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42 17 differences and androgen promotion of TPRSS2 are hypothesized as being a causal factor and in
43
44
18 addition different gender-based personality factors such as risk-taking, impulsivity in men were
45
46
47 19 suggested as affecting high levels of perceived loneliness.
48
49
50 20 Per capita income. Bailey et al. (2020) determined that individuals dwelling in higher-
51
52 21 income communities tended to travel and thus introduced COVID-19 to communities during the
53
54 22 early pandemic. As the pandemic spread sharply in the United States, lower income and/or
55
56
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15
1
2
3 1 poverty became a risk factor associated with increased COVID-19 infections in poorer counties
4
5
6 2 (Zhang & Schwartz, 2020). Sugg et al. (2020) reported decreased COVID-19 infections in
7
8 3 nursing homes located in high per-capita income communities compared to these nursing homes
9
10 4 in low per-capita income communities.
11
12
13 5 Medicaid-based residents. Medicaid-based residents were found to be associated with
14
15
16
6 increased COVID-19 prevalence because these nursing homes were more likely to have
17
18 7 insufficient clinical and financial resources compared to their counterparts, and they tend to be
19
Fo
20 8 located in communities with lower socioeconomic situations. Thus as previously reported,
21
22
9 residents who receive poorer quality of care also experience worse health outcomes (Li et al.,
23
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25 10 2020). Medicaid-based nursing homes experienced more COVID-19 outbreaks and infections
26
ee
27 11 than Medicare-based nursing homes due to the disparities noted above (Chatterjee et al., 2020).
28
29 12 Li et al. (2020) reported that Medicaid residents had a higher chance of being infected compared
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30
31
32 13 to their counterparts (incidence rate ratio = 1.16).
ev
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35 14 Types of Nursing Homes
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iew
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15 In summary, nursing home-level factors related to COVID-19 prevalence included
39
40 16 number of beds, historical health deficiencies, count of fines, star rating, number of separate
41
42 17 units in nursing homes, governmental and private ownership, percentage of facility-wide testing,
43
44
18 pass quality assurance check, proportion of short-stay residents, shortage of N95 masks, the
45
46
47 19 Certificate of Need (CON) presence, and staff and resident density.
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50 20 Nursing home size. Nursing home size had a dominant association with residents'
51
52 21 COVID-19 infections in a large number of studies (Harrington et al., 2020; White et al., 2020;
53
54 22 Yin et al., 2021). It was found that the number of separate units in nursing homes was a
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16
1
2
3 1 substitute for the size of nursing homes (Sun et al., 2020). Specifically, in many studies, larger
4
5
6 2 facilities experienced a higher possibility of COVID-19 outbreaks and infections due to more
7
8 3 employees and admissions (Gmehlin et al., 2021; Kosar et al., 2021; Mattingly et al., 2021;
9
10 4 Ryskina et al., 2021; Zimmerman et al., 2021). Inversely, smaller nursing home facilities
11
12
13
5 experience fewer infections (Abram et al., 2020).
14
15
16
6 Nursing homes with CMS cited historical health deficiencies (e.g, staffing
17
18 7 insufficiencies, resident’s neglect or abuse, and dietary and nutritional deficiences) or a record of
19
Fo
20 8 frequent fines for violations (e.g., non-compliance with CMS infection control regulations) had
21
22
9 an increased likelihood of residents’ COVID-19 cases (OR ranges from 1.05 to 1.26 based on
23
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25 10 counties) (Harrington et al., 2020; Sugg et al., 2020).
26
ee
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28 11 Star rating. As a corollary of the above Quality Assurance measure, nursing homes with
29
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30 12 lower star ratings were more likely to have COVID-19 outbreaks and infections (Figueroa, et al.,
31
32 13 2020; Gopal et al., 2021; Williams et al., 2021). It has been hypothesized that lower star ratings
ev
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35 14 led to lack of the improvement of resident’s health outcomes because of reduction of nursing
36
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37 15 home costs (He et al., 2020). However, it was reported that lower-star-rated nursing homes were
38
39 16 generally located in higher COVID-19 prevalence areas and had more vulnerable residents who
40
41
42
17 were impacted by worse demographics compared to higher-rated nursing homes (He et al., 2020;
43
44 18 Khairat et al., 2021; Li et al., 2020), and thus the star rating was a marker for socioeconomic
45
46 19 level and demography.
47
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49 20 Types of nursing homes. Privately-owned nursing homes experienced more COVID-19
50
51 21 residential infections when compared with non-profit and government-owned nursing homes.
52
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54 22 However, it has been reported that this was due to the lower quality of care provided to residents
55
56 23 in privately nursing homes (Braun et al., 2020; He et al., 2020). However, in contrast, one study
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17
1
2
3 1 (Gmehlin et al., 2021) concluded that governmental ownership was associated with increased
4
5
6 2 COVID-19 infections within facilities, which was inconsistent with the above-mentioned studies
7
8 3 and probably dues to different counties. This discrepancy could be a marker of the fact that
9
10 4 Gmehlin was reporting infection rates in 2021 and also the difference in the prevalence of
11
12
13
5 COVID-19 in different counties (Gmehlin et al., 2021).
14
15
16
6 Nursing homes with enough resources to implement facility-wide COVID-19 testing
17
18 7 were found to be able to identify initial cases in asymptomatic residents and staff. Thus testing
19
Fo
20 8 helped nursing homes regulate infection prevention and thus further effective preventive
21
22
9 strategies. Hatfield et al. (2020) reported that nursing homes that conducted facility-wide testing
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25 10 identified 8 times higher COVID-19 cases compared to those that did not (25.7 vs. 3.5 on
26
ee
27 11 average).
28
29
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30 12 Quality assurance. Quality assurance refers to “the specification of standatds for quality
31
32 13 of services and outcomes, and a process throughout the organization for assuring that care is
ev
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35 14 maintained at acceptable levels in relation to those standards” (CMS, 2016). Thus quality
36
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37 15 assurance evaluates quality of staffing levels, safety measures, resident’s care, and compliance
38
39 16 with regulations (CMS, 2016). Nursing homes that did not meet these quality checks and then
40
41
42
17 failed Quality Assurance (QA) experienced more total counts of fines or total health deficiencies;
43
44 18 therefore, hence had a higher likelihood of COVID-19 infections (SE B = 1.98) (Yin et al.,
45
46 19 2021).
47
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49 20 Masks. Deficiency in the availability of N95 masks was a risk factor for increased
50
51 21 COVID-19 cases in nursing homes. It is well known that N95 masks prevent COVID-19 spread
52
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54 22 and penetration (Li et al., 2021). Thus the COVID-19 prevalence was reported to be higher in
55
56 23 nursing homes with shortage of N95 masks compared to those with sufficient N95 masks (OR =
57
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59
18
1
2
3 1 1.21), highlighting the role of N95 masks especially during the early phase of the pandemic
4
5
6 2 (Simoni-Wastila, et al., 2021).
7
8
9 3 Nursing homes with short stay. A short-stay residence is defined as a period of care in
10
11 4 nursing homes of less than 100 days. Nursing homes with a higher proportion of short-stay
12
13 5 residents were more likely to have COVID-19 outbreaks and infections in the early pandemic
14
15
16
6 (Mattingly et al., 2021). This was probably because of higher chances of introducing the virus
17
18 7 into the facilities from these short-stay residents who also required more care compared to long-
19
Fo
20 8 stay residents. This then resulted in more interactions and thus introduced and transmitted the
21
22
9 virus within facilities. Mattingly et al. (2021) proposed a possible intervention, which was to
23
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25 10 separate short-stay and long-stay residents into different units in nursing homes.
26
ee
27
28 11 The certificate of need (CON) laws are state-level regulatory mechanisms for controlling
29
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30 12 healthcare expenditures by avoiding overlapping services or unneeded expansion (National

31
32 13 Conference of State Legislatures, 2021), and it, as one of the healthcare policies in the long-term
ev
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35 14 care field, impacts the size of a nursing home indirectly. Nursing homes located in counties
36
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37 15 under the CON laws documented additional 104 COVID-19 cases than those were not subject to
38
39 16 the CON, on average (Kosar & Rahman, 2021). Larger nursing homes had more employees and
40
41
42
17 thus admissions, resulting in greater risks of introducing COVID-19 into nursing homes (Abram
43
44 18 et al., 2020; Gmehlin et al., 2021).
45
46
47 19 Density. As with geographic density, both staff and resident density were positively
48
49 20 associated with resident infections within nursing homes (Sun et al., 2020). Nursing homes with
50
51 21 a higher staff density had more employees and thus more frequencies of exposure from the
52
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54 22 outside community. Additionally, higher staff and resident density had subsequently more
55
56 23 interaction between staff and residents, and residents thus were more likely to be exposed to
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19
1
2
3 1 COVID-19 exposure. Zhu et al. (2022) found that by reducing density in nursing homes COVID-
4
5
6 2 19 cases could be reduced. Sun et al. (2020) proposed that by reducing occupied beds rates could
7
8 3 be a strategy to manage early transmission in the pandemic. However, an unintended
9
10 4 consequence was that this strategy impacted nursing homes that were depended on Medicare
11
12
13
5 revenue.
14
15
16
6 Staffing in nursing home
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18
19
7 Risk factors at the staff level are categorized into different types, including but not
Fo
20
21 8 limited to staffing levels, number of registered nurse hours, high COVID-19 prevalence/rate in
22
23 9 the staff residence, and asymptomatic subjects.
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25
26 10 Staffing numbers and types. Higher total staffing levels were examined as a protective
ee
27
28 11 factor for nursing home residents’ infections in the United States (Harrington et al., 2020). On
29
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31 12 the contrary, inadequate staff levels or staff shortages were related to residential COVID-19
32
13 infections (Li et al., 2020; Yin et al., 2021). Interestingly, shortage of clinical staff and licensed
ev
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35 14 nurse staff was reported as more significantly related to COVID-19 rather than nurse aids (Xu et
36
iew
37
38
15 al., 2020). It was reported that staff shortage of nurses resulted in deficient care, lower
39
40 16 substandards of monitoring, and thus worse resident outcomes during the COVID-19 pandemic.
41
42
43 17 In addition, a greater level of licensed practical nurses (LPN), nurses (not registered
44
45 18 nurses), and certified nursing assistants, compared to registered nurses, were found to be
46
47
19 associated with increased resident infections. And the result might be due to interacting closely
48
49
50 20 with more residents and their working experience and environment (e.g., less training, lower
51
52 21 pay) (Dube et al., 2022; Sugg et al., 2020). The reason for this finding was thought to be that the
53
54 22 level of qualified staff who were paid less often increased the possibility of spread the virus into
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20
1
2
3 1 nursing homes (Ladhani et al., 2020).
4
5
6 2 Staff residence. Staff’s residence was the most dominant factor in residents’ infection.
7
8
9 3 This association was similar to COVID-19 prevalence in counties at the external level, as staff
10
11 4 who lived in high COVID-19 prevalence areas had a greater likelihood of being infected
12
13 5 (symptomatic or asymptomatic) and unwittingly introduced the virus into nursing homes (Shi et
14
15
16
6 al., 2020). Similarly, untested asymptomatic staff were predictors of increased residential
17
18 7 infections (Quicke et al., 2020). Interestingly, Lennon et al. (2020) reported that over 90% of
19
Fo
20 8 staff working in assisted living and skilled nursing facilities in Massachusetts were tested as
21
22
9 asymptomatic. This facility-wide COVID-19 prevention and management, based on facility-wide
23
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25 10 testing strategies or availability of adequate PPE supplies, was debated in the literature (Telford
26
ee
27 11 et al., 2021).
28
29
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30 12 Nurse hours. Registered nurses who worked large numbers of hours were found to
31
32 13 increase resident infection rates in such facilities (Gorges et al., 2020). A possible explanation
ev
33
34
35 14 was hypothesized that nursing homes were shortage of staff and were difficult to recruit more
36
iew
37 15 staff. And thus these hired registered nurses needed to work longer than before.
38
39
40 16 In addition, the qualitative studies conducted by White et al. (2021) and by Miller et al.
41
42 17 (2020) reported factors as a) fears of being infected within facilities under the shortage of PPE
43
44
18 and testing, b) burnout due to staff shortage and increased workload, c) lack of team cooperation
45
46
47 19 and organizational communication during the pandemic and d) a lack of preparedness for
48
49 20 COVID-19 within facilities and access to PPE for direct-care workers. These four explanations
50
51 21 were also identified as risk factors for resident infections.
52
53
54 22 Asymptomatic subjects. Either asymptomatic staff or residents who are asymptomatic
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56
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21
1
2
3 1 unwittingly spread the virus within nursing homes without adequate COVID-19 testing (Shi et
4
5
6 2 al., 2020). One study (Arons et al., 2020) identified that 56% of residents were diagnosed as
7
8 3 asymptomatic in a nursing home. We believe this finding provides important information for the
9
10 4 challenges facing formulation of policies for COVID-19 prevention with hopefully future
11
12
13
5 universal testing.
14
15
16
6 Resident’s Health
17
18
19
7 In summary, resident’s health factors related to COVID-19 prevalence included dialysis
Fo
20
21 8 demands, diabetes, hypertension, higher BMI, and more bowel incontinence, lower Social
22
23 9 Vulnerability Index (SVI), activities of daily living scores, smoking, and asymptomatic residents.
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25
26 10 Chronic illnesses. Residents who required hemodialysis were a notably vulnerable
ee
27
28 11 population and were more likely to be infected during the pandemic due to the frequency of
29
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30
31 12 transport to dialysis centers and interactions with staff members (Bigelow et al., 2020). These
32
13 residents were a possible source for the virus transmission into nursing homes and might be an
ev
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35 14 undiagnosed (asymptomatic) source for both nursing homes and dialysis centers (Bigelow et al.,
36
iew
37
38
15 2020). Likewise, residents with bowel incontinence, diabetes, hypertension, high BMI, or
39
40 16 smoking increased close contact with staff and exposed themselves to higher risks of virus
41
42 17 contingence (Mehta et al., 2021; Shi et al., 2020).
43
44
45 18 It was found that when COVID-19 policies and nursing homes’ regulations (e.g.,
46
47
19 lockdown, keeping social distance) were implemented, residents subsequently had reduced
48
49
50 20 Activities of Daily Living (ADL) (Trevissón-Redondo et al.,2021). In addition, nursing homes
51
52 21 ranked in lower quartiles of the Social Vulnerability Index (SVI) experienced more total counts
53
54 22 of fines or total health deficiencies; therefore, their residents had a higher likelihood of COVID-
55
56
57
58
59
22
1
2
3 1 19 infections (LeRose et al., 2021).
4
5
6 2 COVID-19 Vaccination Status
7
8
9 3 As discussed in the previous section, risks for infections were higher among the
10
11
12 4 unvaccinated residents. Benin et al. (2021) pointed out that nursing homes with initial
13
14 5 vaccinations had 27% lower infection cases than those that did not start the vaccinations in early
15
16 6 2021. Nanduri et al. (2021) investigated the effectiveness of vaccinations (EV) (vaccinated vs.
17
18
19
7 unvaccinated) during the Delta period and reported a 51-53% EV range, which was lower than
Fo
20
21 8 the EV before the Delta period (74.5% on average). A newly published study (McConeghy et al.,
22
23 9 2022) reported a lower EV against infections (26%); however, the EV against hospitalization,
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25 10 death, and severity of COVID-19 was significantly improved (60.1%, 89.6%, and 73.9%,
26
ee
27
28 11 respectively).
29
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30 12
31
32 13
ev
33
34
35
36
iew
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
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1
2
3 1 Discussion
4
5
6 2 Implications for Practice
7
8
9 3 Our results suggest that while universal COVID-19 vaccination interventions reduced
10
11
12 4 risk for excess mortality from COVID-19, nursing homes still endure high mortality rates among
13
14 5 residents with COVID-19 (CMS, 2022), emphasizing that interventions are needed to consider
15
16 6 and take into account personal factors of residents, community factors, and nursing home
17
18
19
7 characteristics while switching the focus from infections to the severity/mortality of COVID-19
Fo
20
21 8 and COVID-19 vaccinations.
22
23
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24 9 Nursing homes could take into account both nursing home characteristics and resident
25
26 10 personal resident factors for improved COVID-19 risk management. The findings of nursing
ee
27
28 11 home characteristics suggest that residents experience high risk of COVID-19 exposure when
29
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30
31 12 their facilities endure multiple deficiencies, limited funding, a shortage of PPE and lack of
32
13 vaccines. Evidence from those studies has shown that these factors lead to poor management and
ev
33
34
35 14 control of COVID and lead to more vulnerability for residents. In addition, lack of staff and high
36
iew
37
38
15 workloads caused staff burnout and fear of infection. Inadequate organizational communication
39
40 16 induced insufficient COVID-19 management and control and also manifested psychological
41
42 17 burdens on staff and residents, especially for the residents in the initial lockdown period. The
43
44
18 review overall suggests that there is a need to manage COVID-19 infections while considering
45
46
47 19 mental wellness amongst residents and staff. Additionally, our review identified the importance
48
49 20 of community factors (e.g., high COVID-19 prevalence in counties especially when with high
50
51 21 minority composition) on nursing home residents’ COVID-19 prevalence. While chronic
52
53
54 22 illnesses are common in older adults, they are also an important comorbidity to COVID-19
55
56 23 infection rates in nursing homes.
57
58
59
24
1
2
3 1 Lower occupancy was seen as a protective predictor of residents' COVID-19 infections
4
5
6 2 and thus may be one potential strategy utilized in future (Sun et al., 2020). However, such
7
8 3 implementation causes financial issues, such as increased resident management costs and
9
10 4 curtailed Medicare revenue (Grabowski & Mor, 2020). Moreover, practitioners may endure low
11
12
13
5 occupancy penalization, which indicates potential unexpected consequences.
14
15
16
6 In summary, the evidence from our review has two main implications for policymakers
17
18 7 and researchers. We believe that the management and prevention of residents’ COVID-19
19
Fo
20 8 infections should not merely center on any specific category of factors. Based on the collated
21
22
9 evidence, most studies focused on nursing home characteristics and staffing factors. However,
23
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24
25 10 according to the modified GIS model as a framework, future policy should focus on those six
26
ee
27 11 main themes simultaneously. Our review suggests a need to prioritize universal COVID-19
28
29 12 vaccination interventions in COVID-19 mitigation at nursing homes, while also employing
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31
32 13 selective interventions by community-level factors; nursing home characteristics and targeted
ev
33
34 14 interventions by resident socio-demographic and personal characteristics.
35
36
iew
37 15 Limitations of the review and suggestions for further research

38
39
40 16 This mixed methods systematic review research has a few limitations. First, while mixed
41
42 17 methods systematic review has the strength of being inclusive, they also carry the limitation of
43
44
18 subjectivity in interpreting the findings in contrast to systematic reviews and meta-analysis of
45
46
47 19 purely quantitative studies. Second, all articles for review focused on the United States;
48
49 20 therefore, these risk factors may not apply to nursing homes in countries other than the U.S.
50
51 21 Another limitation is that our study only categorized factors associated with COVID-19
52
53
54 22 infections rather than factors related to the severity and mortality of the disease from COVID-19.
55
56 23 Some factors may interact to produce both COVID-19 infections and their severity; however,
57
58
59
25
1
2
3 1 further studies are required to center on those factors. The search for this review is limited to
4
5
6 2 studies that published in the English language, which excluded some relevant articles other
7
8 3 languages. We also should note that although we included vaccinations in this review, for almost
9
10 4 half of the time period considered vaccinations were not available.
11
12
13 5 Conclusion
14
15
16 6 This systematic review study categorized risk factors associated with COVID-19 amongst
17
18
19
7 nursing home residents into six major types during the pandemic based on the GIS model
Fo
20
21 8 framework: factors associated with geography, demography, type of nursing home, staffing in
22
23 9 nursing home, resident’s status, and COVID-19 vaccination status. Findings suggest nursing
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25 10 home characteristics of large nursing homes with lower star ratings, and asymptomatic staff to be
26
ee
27
28 11 associated with an increased risks for COVID-19 infection rates. Also, nursing homes with a low
29
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30 12 percentage of fully vaccinated residents or without COVID-19 (regardless of size of facility) had
31
32 13 lower rates of COVID-19 infection and death. Personal factors such as residents with advanced
ev
33
34
35 14 age, racial minority, and chronic illnesses were at higher risk for COVID-19 infections. County-
36
iew
37 15 level infection rates were an important context for the risk of infection in nursing homes and also
38
39 16 at the person level of their residents. We believe prioritizing universal COVID-19 vaccination
40
41
42
17 interventions at nursing homes, nursing home safety characteristics, and targeted interventions
43
44 18 by resident’s personal characteristics would lead towards long-term COVID-19 risk reduction for
45
46 19 nursing home residents in the USA.
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51
52
53
54
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1
2
3 1 References
4
5
6 2 Abrams, H. R., Loomer, L., Gandhi, A., & Grabowski, D. C. (2020). Characteristics of US
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8 3 nursing homes with COVID‐19 cases. Journal of the American Geriatrics Society, 68(8),
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10 4 1653-1656. https://doi.org/10.1111/jgs.16661
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5 Ackley, B. J., Swan, B. A., Ladwig, G., & Tucker, S. (2008). Evidence-based nursing care
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15 6 guidelines: Medical-surgical interventions. Mosby Elsevier.
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17 7 Alexander, V. D., Thomas, H., Cronin, A., Fielding, J., & Moran-Ellis, J. (2008). Mixed
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8 methods. Researching Social Life, 3, 125-144.
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22 9 Arons, M. M., Hatfield, K. M., Reddy, S. C., Kimball, A., James, A., Jacobs, J. R., Taylor, J.,
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24 10 Spicer, K., Bardossy, A. C., Oakley, L. P., Tanwar, S., Dyal, J. W., & Jernigan, J. A.
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26 11 (2020). Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing
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33 14 Bailey, M., Farrell, P., Kuchler, T., & Stroebel, J. (2020). Social connectedness in urban
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38 16 https://doi.org/10.1016/j.jue.2020.10364
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40 17 Benin, A. L., Soe, M. M., Edwards, J. R., Bagchi, S., Link-Gelles, R., Schrag, S. J., Herzer, K.,
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18 Verani, J. R., Budnitz, D., Nanduri, S., Jernigan, J., Edens, C., Gharpure, R., PharmD, A.
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45 19 P., Wu, H., Golshir, B. C., Jaffe, A., Li, Q., Srinivasan, A., … NHSN Team. (2021).
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47 20 Ecological analysis of the decline in incidence rates of COVID-19 among nursing home
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49 21 residents associated with vaccination, United States, December 2020-January
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52 22 2021. Journal of the American Medical Directors Association, 22(10), 2009-2015.
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54 23 https://doi.org/10.1016/j.jamda.2021.08.004
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3 1 Bigelow, B. F., Tang, O., Toci, G. R., Stracker, N., Sheikh, F., Jacobs Slifka, K. M., Novosad, S.
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6 2 A., Jernigan, J. A., Reddy, S. C., & Katz, M. J. (2020). Transmission of SARS-CoV-2
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8 3 involving residents receiving dialysis in a nursing home - Maryland, April 2020.
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10 4 Morbidity and Mortality Weekly Report, 69(32), 1089-1094.
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5 Braun, R. T., Yun, H., Casalino, L. P., Myslinski, Z., Kuwonza, F. M., Jung, H., & Unruh, M. A.
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15 6 (2020). Comparative performance of private equity–owned US nursing homes during the
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17 7 COVID-19 pandemic. JAMA Network Open, 3(10), e2026702.
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8 10.1001/jamanetworkopen.2020.26702
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22 9 Britton, A., Jacobs Slifka, K. M., Edens, C., Nanduri, S. A., Bart, S. M., Shang, N., Harizaj, A.,
23
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24 10 Armstrong, J., Xu, K., Ehrlich, H. Y., Soda, E., Derado, G., Verani, J. R., Schrag, S. J.,
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26 11 Jernigan, J. A., Leung, V. H., & Parikh, S. (2021). Effectiveness of the Pfizer-BioNTech
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29 12 COVID-19 vaccine among residents of two skilled nursing facilities experiencing
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31 13 COVID-19 outbreaks - Connecticut, December 2020-February 2021. Morbidity and
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33 14 Mortality Weekly Report, 70(11), 396-401.

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15 Bui, D. P., See, I., Hesse, E. M., Varela, K., Harvey, R. R., August, E. M., Winquist, A., Mullins,
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38 16 S., McBee, S., Thomasson, E., & Atkins, A. (2020). Association between CMS quality
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40 17 ratings and COVID-19 outbreaks in nursing homes - West Virginia, March 17-June 11,
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42
18 2020. Morbidity and Mortality Weekly Report, 69(37), 1300-1304.
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45 19 Cai, S., Yan, D., & Intrator, O. (2021). COVID-19 cases and death in nursing homes: The role of
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47 20 racial and ethnic composition of facilities and their communities. Journal of the American
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49 21 Medical Directors Association, 22(7), 1345-1351.
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54 23 Campbell, M., McKenzie, J. E., Sowden, A., Katikireddi, S. V., Brennan, S. E., Ellis, S.,
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3 1 Hartmann-Boyce, J., Ryan, R., Shepperd, S., Thomas, J., Welch, V., & Thomson, H.
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6 2 (2020). Synthesis without meta-analysis (SWiM) in systematic reviews: reporting
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3 1 and deaths. Journal of the American Medical Directors Association, 22(3), 489-493.
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3 1
4 Appendix 1. Flowchart of Article Selection for Systematic Review.
2
5
6 3
7 4 Records identified from*:
8 5 PubMed (n = 99)
Web of Science
Identification
9 6
PubMed (n = 77) Records removed before
10 7
11 Scopus PubMed (n = screening:
8 Duplicate records
12 70)
13
9 removed (n = 191)
10 Sage Journal Online
14
15 11 PubMed (n = 333)
16 12 Other sources (n = 2)
17 13
18 14
19
15
Fo
20 Records screened Records excluded
21 16
(n = 390) (n = 310)
22 17
23 18
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24 19
25 20
26
Reports sought for retrieval Reports not retrieved (n =
21
ee
(n = 80) 1)
Screening
27
22
28
29 23
rR
30 24
31 25 Reports assessed for Reports excluded:
32 26 eligibility Subjects not in nursing
ev
33 27 (n = 79) homes (n = 13)

34
28 Articles not relevant to
35
36
29 COVID-19 factors (n =
iew
37 30 15)
38 31 Staff subjects (n = 2)
39 32 Subjects not in the
40 33 United States (n = 1)
41 34
Included
42 Studies included in review

43 35 (n = 48)
44
45
46 36
47
48
49
50
51
52
53
54
55
56
57
58
59
40
1
2
3 Appendix 2. Articles were excluded in the systematic review.
4
5 Author(s), Title Reasons for the exclusion
6 publication year
7 Atalla et al., Clinical presentation, course, and risk Subjects are other long-term
8 2021 factors associated with mortality in a severe care facilities rather than
9 outbreak of COVID-19 in Rhode Island, nursing homes
10
USA, April–June 2020.
11
12 Bagchi et al., Rates of COVID-19 among residents and Article is irrelated to factors of
13 2021 staff members in nursing homes—United COVID-19 infections
14 States, May 25–November 22, 2020.
15 Baughman et Second job holding among direct care Subjects are other long-term
16 la., 2022 workers and nurses: implications for care facilities rather than
17 COVID-19 transmission in long-term care nursing homes
18
Cimarolli et al., Factors associated with nursing home Subjects are staff rather than
19
2022 direct care professionals’ turnover intent residents
Fo
20
21 during the COVID-19 pandemic
22 Das Gupta et Interpreting COVID-19 deaths among Article is COVID-19
23 al., 2021 nursing home residents in the US: The mortality
rP
24 changing role of facility quality over time

25 De Salazar et High coverage COVID-19 mRNA Subjects are not in the United
26
al., 2021 vaccination rapidly controls SARS-CoV-2 States
ee
27
28 transmission in Long-Term Care Facilities.
29 Ferdous, F., Social distancing vs social interaction for Article is irrelated to factors of
rR
30 2021 older adults at long-term care facilities in COVID-19 infections

31 the midst of the COVID-19 pandemic: A
32 rapid review and synthesis of action plans
ev
33
Figueiredo et Death and Other Losses in the COVID-19 Article is COVID-19
34
35 al., 2022 Pandemic in Long-Term Care Facilities for mortality
36 Older Adults in the Perception of
iew
37 Occupational Therapists: A Qualitative

38 Study
39 Gallichotte et Early adoption of longitudinal surveillance Subjects are other long-term
40 al., 2021 for SARS-CoV-2 among staff in long-term care facilities rather than
41
care facilities: prevalence, virologic and nursing homes
42
43 sequence analysis
44 Gallichotte et Longitudinal surveillance for SARS-CoV-2 Subjects are staff rather than
45 al., 2021 among staff in six Colorado long-term care residents
46 facilities: epidemiologic, virologic and
47 sequence analysis
48 Gardner et al., The coronavirus and the risks to the elderly Subjects are other long-term
49
50
2020 in long-term care care facilities rather than
51 nursing homes
52 1
53
54 2
55
3
56
57
58
59
41
1
2
3 Appendix 2. (Continued).
4
5 Author(s), Title Reasons for the exclusion
6 publication
7 year
8 Gharpure et al., Early COVID-19 first-dose vaccination Article is irrelated to factors
9 2021 coverage among residents and staff members of COVID-19 infections
10
of skilled nursing facilities participating in the
11
12 pharmacy partnership for long-term care
13 program—United States, December 2020–
14 January 2021
15 Greenwald et Covid-19 and excess mortality in Medicare Article is COVID-19
16 al., 2021 beneficiaries mortality
17 Hill & Farrell, A typology of COVID-19 data gaps and Subjects are other long-term
18
2022 noise from long-term care facilities: care facilities rather than
19
Approximating the true numbers nursing homes
Fo
20
21 Hill & Farrell, COVID-19 across the landscape of long-term Subjects are other long-term
22 2022 care in Alameda County: Heterogeneity and care facilities rather than
23 disparities nursing homes
rP
24 Kennedy, 2023 The Effect of Nurse Aide Retention on Subjects are not related to
25 Ohio’s Nursing Home Resident Care COVID-19
26
Experience Scores: A Facility-Level Analysis
ee
27
28 Konetzka et al., A systematic review of long‐term care Subjects are other long-term
29 2021 facility characteristics associated with care facilities rather than
rR
30 COVID‐19 outcomes nursing homes

31 Landes et al., Risk factors associated with COVID-19 Subjects are not either long-
32 2021 outcomes among people with intellectual and term care facilities or
ev
33
developmental disabilities receiving nursing homes
34
35 residential services
36 Lee et al., 2021 Disparities in COVID-19 vaccination Subjects are other long-term
iew
37 coverage among health care personnel care facilities rather than

38 working in long-term care facilities, by job nursing homes
39 category, National Healthcare Safety
40 Network—United States, March 2021
41
Levin et al., COVID-19 prevalence and mortality in Subjects are other long-term
42
43 2022 longer-term care facilities care facilities rather than
44 nursing homes
45 McGarry & Nursing homes and COVID-19: A crisis on Article is irrelated to factors
46 Grabowski, top of a crisis of COVID-19 infections
47 2021
48 Ouslander & COVID‐19 in nursing homes: calming the Article is irrelated to factors
49
50
Grabowski, perfect storm of COVID-19 infections
51 2020
52 Plummer & Nursing Home COVID Relief Under QIP’s Article is irrelated to factors
53 Wempe, 2022 Performance-Based Formula: Does of COVID-19 infections
54 Performance Actually Matter, and Should It?
55 1
56
57
58
59
42
1
2
3 1
4
5 Appendix 2. (Continued).
6
Author(s), Title Reasons for the exclusion
7
8 publication year
9 Power & The promise of transformed long-term care Article is irrelated to factors
10 Carson, 2022 homes: Evidence from the pandemic of COVID-19 infections
11 Recker et al., Factors affecting SARS-CoV-2 test Article is irrelated to factors
12 2022 discordance in skilled nursing facilities of COVID-19 infections
13 Sachar et al., The effect of age on fever response among Article is irrelated to factors
14
15
2022 nursing home residents with SARS-COV-2 of COVID-19 infections
16 infection
17 Sarah et al., Characterization of COVID-19 in assisted Subjects are other long-term
18 2020 living facilities—39 states, October 2020 care facilities rather than
19 nursing homes
Fo
20 Shen, 2022 Relationship between nursing home COVID- Article is COVID-19
21
19 outbreaks and staff neighborhood mortality
22
23 characteristics
rP
24 Tobolowsky et Signs, symptoms, and comorbidities Article is irrelated to factors

25 al., 2021 associated with onset and prognosis of of COVID-19 infections
26 COVID-19 in a nursing home
ee
27 Konetzka et al., A systematic review of long‐term care Subjects are other long-term
28 2021 facility characteristics associated with care facilities rather than
29
COVID‐19 outcomes nursing homes
rR
30
31 Wanger, 2021 The vulnerability of nursing home residents Article is irrelated to factors
32 to the Covid-19 pandemic of COVID-19 infections
Yang et al., COVID-19 in long-term care facilities: a Subjects are other long-term
ev
33
34 2022 rapid review of infection correlates and care facilities rather than
35 impacts on mental health and behaviors nursing homes
36
iew
2
37
38 3
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
43
1
2
3 Appendix 3. Matrix of quality rating and level of evidence.
4
5 MMAT2 MMAT3 MMAT4 MMAT5
6 Level 1
7 Evidence from a systematic review or
8 meta-analysis of all relevant RCTs
9 (randomized controlled trial) or ①Qualitative studies
10
evidence-based clinical practice
11 ②Non-randomized studies
highest
Fo
12 guidelines based on systematic reviews
13 of RCTs or three or more RCTs of ③Mixed methods studies
rP
14 good quality that have similar results
15 Level 2
16
ee
17
Evidence obtained from at least one
18 well-designed RCT
rR
19
20 Level 3 ②Ehrlich et al., 2021
21
ev
Evidence obtained from well-designed ②McConeghy et al., 2022
22
23
controlled trials without randomization
iew
24 Level 4 ②Bigelow et al., ②Abrams et al., ②Benin et al., 2021
25 Evidence from well-designed case- 2020 2020 ②Braun et al., 2020
26 control or cohort studies ②Chatterjee et ②Britton et al., ②Bui et al., 2020
27 al., 2020 2021 ②Cai et al., 2020
28 ②Quicke et al., ②Cavanaugh et ②Domi et al., 2021
29
2020 al., 2021 ②Dube et al., 2022
30
②Chen et al., 2021 ②Figueroa et al., 2020
31
32 ②He et al., 2020 ②Gmehlin et al., 2021
33 ②LeRose et al., ②Gopal et al., 2021
34 2020 ②Gorges & Konetzka, 2020
35 ②Li et al., 2020 ②Harrington et al., 2020
36 ②Sun et al., 2020 ②Hatfield et al., 2020
37
②Teran et al., ②Hege et al., 2022
38
39 2021 ②Khairat et al., 2021
40 ②Yin et al., 2021 ②Kim et al., 2022

41 ②Kosar & Rahman, 2021
42
43
44
46
47
44
1
2
3 ②Lane et al., 2022
4
②Longo et al., 2022
5
6 ②Mattingly et al., 2021
7 ②Mehta et al., 2021
8 ②Mor et al., 2021
9 ②Nanduri et al., 2021
10 ②Prasad et al., 2022
11
Fo
②Shi et al., 2020
12
②Simoni-Wastila et al.,
13
2021
rP
14
15 ②Sugg et al., 2021
16 ②Travers et al., 2021
ee
17 ②White et al., 2020
18 ②Williams et al., 2021
rR
19
②Xu et al., 2020
20
②Zhu et al., 2022
21
ev
22
23 Level 5
iew
24 Evidence from systematic reviews of
25 descriptive and qualitative studies
26
(meta-synthesis)
27
28 Level 6 ③Miller et al., ①White et al., 2021
29 Evidence from a single descriptive or 2020
30 qualitative study
31 Level 7
lowest
32 Evidence from the opinion of

33
authorities and/or reports of expert
34
35 committees
36 lowest highest
37
38
39
40
41
42
43
44
46
47
45
1
2
3 Appendix 4. Risk factors associated with COVID-19 infections in the United States
4
5
6 Nursing Home Residents’ COVID-19
7 Infections in the United States
8
9
10
11
12 Resident’s health
Type of nursing home Staffing in nursing home
13
14  Number of (occupied) beds  Number of staff with COVID-  Asymptomatic residents
15  Health deficiencies 19 cases
 Dialysis status
16  Star ratings  Registered nurse-hours
17  Bowel incontinence
 Count of fines  Staff shortages
18  Obesity
 Number of separate units  COVID-19 prevalence/rate
19  Hypertension
 Governmental and private staff
 Diabetes
Fo
20 ownership  Employed in different facilities
21  Dementia
 Percentage of facility-wide testing  Asymptomatic staff
22  Smoking habits
 Pass quality assurance check  Lack of training, access to PPE,
23  Social Vulnerability (SV)
rP
 Proportion of short-stay residents and organizational

24 communication and teamwork  Activities of daily living (ADL)
 Shortage of N95 masks scores
25  Fear of infection
 The certificate of need (CON)
26  Burnout due to increased
ee
presence
27 workloads and staff shortage
 Staff and resident density
28
29
rR
30
31
32
ev
33
34 Geography Demography COVID-19 Vaccination
35
Status
36
iew
37
38  Percentage of fully
 Covid-19 prevalence  Race
39 vaccinated residents
rate/county
40  Gender  Refused COVID-19
 Per capita income
41  Age vaccination
 Population density/county
42  Government subsidized care  Waiting COVID-19
 Urban/rural vaccination
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
1
1
2
3 Table 1. Basic Characteristics of Included Studies in the Systematic Review
4
5 Author(s), Purpose Design, study date, States/counties Data analysis Key risk factors
6 publication year and sample size associated with COVID-
7 19 infections
8 Abrams et al., To examine nursing Cross-sectional study, Thirty states Logistic and Large size nursing
9 2020 homes’ characteristics May 2020, n = (e.g., CA, CO, linear homes, urban locations,
10
with documented 9395 nursing homes CT, DE, FL) regressions high percentages of
11
Fo
12 COVID-19 infections African American
13 in 30 states. residents, and non-chain
rP
14 status
15 Benin et al., To assess the Case-control study, Nation wide Paired Facility-wide COVID-
16 2021 relationship between December 2020- difference-in- 19 vaccinations
ee
17 facility-wide January 2021, n = difference (protective factor)
18
vaccination status and 6059 nursing homes approaches
rR
19
20 residents’ COVID-19
21 infections
ev
22 Bigelow et al., To examine the Cross-sectional study, MD Chi-square tests Dialysis needs
23 2020 relationship between April 2020, n = 1
iew
24 dialysis demands and nursing home
25 COVID-19 infections
26
27
Braun et al., To examine the Cross-sectional study, Not applicable Poisson and Private-owned nursing
28 2020 performance of private- May 2020-July 2020, logistic homes
29 owned nursing homes n = 11470 nursing regressions
30 on COVID-19 homes
31 infections compared to
32 other types of nursing
33
homes
34
35 Britton et al., To determine the Retrospective cohort CT Time-to-event Effectiveness of partial
36 2021 effectiveness of study, December analysis vaccination (protective
37 COVID-19 2020-February 2021, factor)
38 vaccinations n = 2 nursing homes
39
40
41
42
43
44
46
47
2
1
2
3 Table 1. (Continued)
4
7 19 infections
8 Bui et al., 2020 To examine the Case-control study, WV Wilcoxon rank- Lower star rating,
9 association between March 2020-June sum tests, counties with high
10
CMS quality ratings 2020, n = 123 nursing Fisher’s exact incidences of COVID-
11
Fo
12 and COVID-19 homes tests, and logistic 19
13 outbreaks and regressions
rP
14 infections
15 Cai et al., 2020 To examine whether Cross-sectional study, Nation wide Spline Higher racial and ethnic
16 racial composition, June 2020-August regressions composition in nursing
ee
17 nursing homes’ 2020, n = 12123 homes and their
18
characteristics nursing homes communities
rR
19
20 associated with
21 residents’ COVID-19
ev
22 cases and death
23 Cavanaugh et To assess the Case-control study, KY Relative risks Effectiveness of
iew
24 al., 2021 relationship between March 2021, n = 1 and a sensitivity COVID-19 vaccinations
25 COVID-19 outbreaks nursing homes analysis (protective factor)
26
27
and COVID-19
28 variants after
29 vaccinations
30 Chatterjee et al., To describe risk factors Cross-sectional study, Nation wide Mean and Nursing homes with
31 2020 associated with April 2020, n = standard health deficiencies, high
32 COVID-19 infections 8943 nursing home deviation percentages of
33
from nursing homes’ Medicaid-insured
34
35 characteristics and residents, and for-profit
36 qualities nursing homes
37
38
39
40
41
42
43
44
46
47
3
1
2
4
7 19 infections
8 Chen et al., To identify factors Cross-sectional study, Not applicable One-way Activities of daily living
9 2021 associated with resident May 2020-October analysis of scores and older age
10
infections on nursing 2020, n = 3008 variance, X2
11
Fo
12 home characteristics nursing homes tests, and
13 multivariable
rP
14 linear
15 regressions
16 Domi et al., To examine the Retrospective cohort Seventeen states Zero-inflated Effectiveness of
ee
17 2021 effectiveness of study, December (not applicable) negative COVID-19 vaccinations
18
COVID-19 2020-February 2021, binomial mixed (protective factor)
rR
19
20 vaccinations n = 2501 nursing effects
21 homes regressions
ev
22 Dube et al., To estimate risks for Cross-sectional study, GA Multivariable Nurses and certified
23 2022 COVID-19 infections August 2020- logistic nursing assistants
iew
24 on nursing home staff November 2020 and regressions
25 February 2021-May
26
27
2021, n = 14 nursing
28 homes
29 Ehrlich et al., To examine whether Non-randomized CT Poisson Point prevalence survey
30 2021 the Point prevalence trial, May 2020-June regressions usage (protective factor)
31 surveys usage in 2020, n = 34 nursing
32 nursing homes could homes
33
prevent COVID-19
34
35 infections
36 Figueroa et al., To evaluate whether Case-control study, CA, CT, FL, IL, Ordinal logistic High ratings on nurse
37 2020 lower COVID-19 cases January 2020-June MD, MA, NJ, regressions staffing (protective
38 are associated with 2020, n = 4254 and PA factor)
39 nursing homes with nursing homes
40 lower ratings
41
42
43
44
46
47
4
1
2
3
4
5
Table 1. (Continued)
8 19 infections
9 Gmehlin et al., To evaluate the Retrospective cohort WI Pearson chi- Large numbers of beds
10
2021 relationships between study, June 2020- square and and average counts of
11
Fo
12 COVID-19 infections October 2020, n = Kruskal-Wallis residents per day,
13 and nursing homes’ 246 nursing homes tests, and governmental
rP
14 quality, location, and multiple linear ownership, urban/rural
15 staffing levels over regressions locations, and low-
16 time quality scores
ee
17 Gopal, Han, & To discover what kinds Cross-sectional study, CA Zero-Inflated Low-star ratings and
18
Yaraghi, 2021 of factors contribute to May 2020, n = 713 Bivariate for-profit nursing homes
rR
19
20 residents’ COVID-19 nursing homes Poisson
21 infections regressions
ev
22 Gorges & To evaluate whether Cross-sectional study, Nation wide Logistic High registered nurse
23 Konetzka, 2020 baseline nurse staffing May 2020-June 2020, regressions hours and high per
iew
24 impacts COVID-19 n = 13167 nursing capita COVID-19 cases
25 infections homes in counties
26
27
Harrington et To examine the Cross-sectional study, CA Bivariate, Large size nursing
28 al., 2020 relationship between April 2020-June correlation, and homes, high total health
29 COVID-19 cases and 2020, n = 1091 logistic deficiencies, total
30 nurse staffing nursing homes regressions registered nurse staffing
31 levels less than the
32 recommended minimum
33
standard
34
35
36
37
38
39
40
41
42
43
44
46
47
5
1
2
4
7 19 infections
8 Hatfield et al., To evaluate residents’ Cross-sectional study, AR, MI, NM, Logistic Facility-wide testing
9 2020 COVID-19 cases in March 2020- UT, VT, ND, generalized (protective factor)
10
nursing homes with the June2020, n = 288 SC estimating
11
Fo
12 intervention of facility- nursing homes equation with an
13 wide testing exchangeable
rP
14 correlation
15 structure
16 He, Li, & Fang, To examine the Case-control study, CA Multivariate Low-star ratings and
ee
17 2020 relationship between April 2020-June logistic high percentages of
18
nursing homes’ 2020, n = 1233 regressions minority residents
rR
19
20 reported quality and nursing homes
21 COVID-19 cases and
ev
22 deaths
23 Hege et al., To evaluate the Retrospective cohort Nation wide T-tests, Durbin- Shortage of nursing and
iew
24 2022 relationships between study, June 2020- Watson tests, staff, private-owned
25 residents’ COVID-19 January 2021, n = and maximum status, high prevalence
26
27
infections and factors 9990 nursing homes likelihood of COVID-19 in
28 from country-level and estimations counties, and high
29 nursing homes’ minority compositions
30 characteristics in nursing homes
31 Khairat et al., To evaluate the Cross-sectional study, Nation wide Negative Low-star ratings
32 2021 relationship between May 2020-December binomial
33
COVID-19 cases and 2020, n = 15390 regressions
34
35 nursing homes’ quality nursing homes
36 Kim et al., 2022 To examine what kinds Cross-sectional study, Cook County, Structural Low-star ratings, high
37 of community and January 2020- IL equation numbers of staff
38 facility factors impact September 2020, n = modeling COVID-19 cases, large
39 residents’ COVID-19 177 nursing homes minority composition
40 cases
41
42
43
44
46
47
6
1
2
3
4
5
8 19 infections
9 Kosar & To examine the Cross-sectional study, Nation wide Poisson Large sizes of nursing
10
Rahman, 2021 relationship between March 2020-June regressions homes and the CON
11
Fo
12 COVID-19 infections 2020, n = 2883 presence
13 and nursing homes’ nursing homes
rP
14 size and Certificate of
15 Need law presence over
16 time
ee
17 Lane et al., To discover predictors Retrospective cohort KY, VA, TN, Stepwise Nursing homes with
18
2020 of COVID-19 study, May 2020- NC, SC, GA, regressions large enrollment and
rR
19
20 outbreaks through February 2021, n = MS, AL, and high prevalence of
21 nursing homes and 2951 nursing homes FL COVID-19 cases in
ev
22 county-level in the counties
23 southern-eastern U.S.
iew
24 within three time
25 periods
26
27
LeRose et al., To examine the Cross-sectional study, MI Fisher exact X2 High-SVI quartiles
28 2020 relationship between May 2020, n = 103 tests, Wilcoxon
29 COVID-19 cases and nursing homes signed rank-sum
30 the Social Vulnerability tests, and Crude
31 Index (SVI) in linear
32 Michigan regressions
33
34
35
36
37
38
39
40
41
42
43
44
46
47
7
1
2
4
7 19 infections
8 Li et al., 2020 To evaluate the Cross-sectional study, CT Generalized Low-star ratings,
9 relationships between April 2020, n = 215 linear Medicaid residents, low
10
residents’ COVID-19 nursing homes regressions registered nurse staffing,
11
Fo
12 infections and factors and high racial residents
13 from staffing, quality
rP
14 of care, Medicaid, and
15 minority composition
16 in Connecticut
ee
17 Longo et al., To evaluate the Cross-sectional study, IL, FL, and MA Zero-Inflated High community
18
2022 relationship between June 2020-January Bivariate prevalence of COVID-
rR
19
20 COVID-19 cases and 2021, n = 1719 Poisson negative 19
21 accreditation status nursing homes binomial logistic
ev
22 regressions
23 Mattingly et al., To discover Cross-sectional study, MD T-tests, chi- High prevalence of
iew
24 2021 characteristics related January 2020-July square and COVID-19 cases in
25 to large outbreaks 2020, n = 216 nursing Fisher’s exact counties, large numbers
26
27
homes tests, and of licensed beds, great
28 multivariable proportion of short-stay
29 regressions residents
30 McConeghy et To evaluate the Non-randomized trial Nineteen states Kaplan-Meier Effectiveness of
31 al., 2022 effectiveness of a study, March 2022- (e.g., AL, AZ, estimators COVID-19 vaccinations
32 second COVID-19 July 2022, n = CT, DE, KY, (protective factor)
33
vaccination 196 nursing homes NC, SC, TN,
34
35 VT, VA, WA)
36 Mehta, Li, & To identify risk factors Retrospective cohort Nation wide Logistic High minority
37 Goodwin, 2021 for COVID-19 study, April 2020- regressions composition of residents
38 infections, September 2020, n = and residents with
39 hospitalization, and 15038 nursing homes increasing body mass
40 mortality index (BMI)
41
42
43
44
46
47
8
1
2
3
4
5
8 19 infections
9 Miller et al., To explore how nursing Mixed-methods Not applicable Qualitative Lack of staff
10
2020 home social workers study, April 2020- thematic preparedness for
11
Fo
12 perceive their May 2020, n = NA analysis, COVID-19
13 preparedness for percentage,
rP
14 COVID-19 mean, and
15 standard
16 deviation
ee
17 Mor et al., 2021 To compare rates of Case-control study, Twenty-one Pre and post- Effectiveness of
18
COVID-19 infections December 2020- states (Not tests COVID-19 vaccinations
rR
19
20 and 30-day January 2021, n = applicable) (protective factor)
21 hospitalization among 280 nursing homes
ev
22 nursing home residents
23 Nanduri et al., To evaluate the Case-control study, Nation wide Zero-Inflated Effectiveness of Pfizer
iew
24 2021 effectiveness of Pfizer March 2021-August Bivariate and Moderna vaccines
25 and Moderna vaccines 2021, n =15236 Poisson (protective factor)
26
27
nursing homes regressions
28 Prasad et al., To evaluate the Case-control study, Nation wide A zero-inflated Effectiveness of
29 2022 effectiveness of February 2022-March Poisson mixed COVID-19 vaccinations
30 COVID-19 2022, n = 14758 effects model (protective factor)
31 vaccinations nursing homes
32 Quicke et al., To assess the Retrospective cohort CO Deep sequencing Asymptomatic staff
33
2020 relationship between study, NA (five to six analysis
34
35 COVID-19 infections weeks in 2020)
36 and staff factors n = 5 nursing homes
37
38
39
40
41
42
43
44
46
47
9
1
2
4
7 19 infections
8 Shi et al., 2020 To evaluate risk factors Retrospective cohort Boston area, T-tests, X2 tests, Male gender, residents
9 associated with study, March 2020- MA and Poisson with bowel
10
COVID-19 infections May 2020, n = 8 regressions incontinence, and staff
11
Fo
12 in long-stay nursing nursing homes residence in areas with
13 home residents high prevalence of
rP
14 COVID-19 cases
15 Simoni-Wastila To evaluate the Cross-sectional study, Nation wide Multivariable Shortage of N95 masks
16 et al., 2021 association of facility- October 2020- logistic and high bed occupation
ee
17 level factors on December 2020, n = regressions rates
18
COVID-19 cases 13156 nursing homes
rR
19
20 Sugg et al., To determine the Cross-sectional study, Nation wide Backward Large total counts of
21 2021 association of COVID- April 2020-June stepwise fines and staffing levels,
ev
22 19 infections on 2020, n = 13709 regression and high minority
23 nursing home-level nursing homes generalized composition and
iew
24 metrics and county- linear mixed- population density in
25 level, place-based effect models communities, and per-
26
27
variables capita income
28 Sun et al., 2020 To identify risk factors Retrospective cohort MA, GA, and Mann-Whitney High COVID-19
29 associated with study, April 2020, n = NJ U tests, X2 tests, prevalence in counties,
30 COVID-19 cases and to 1146 nursing homes and logistic large numbers of
31 inform prevention regressions separate units in nursing
32 measures homes, high staff and
33
resident density,
34
35 historical health
36 deficiencies, and
37 county’s population
38 density
39
40
41
42
43
44
46
47
10
1
2
4
7 19 infections
8 Teran et al., To evaluate the Cross-sectional study, Chicago, IL Percentage Effectiveness of
9 2021 effectiveness of December 2020- COVID-19 vaccinations
10
COVID-19 March 2021, n = 75 (protective factor)
11
Fo
12 vaccinations nursing homes
13 Travers et al., To assess the Cross-sectional study, Nation wide Linear High proportions of
rP
14 2021 relationship between January 2020-July regressions black residents in
15 COVID-19 infections 2020, n = 3357 nursing homes
16 and the proportion of nursing homes
ee
17 black residents
18
White et al., To identify county and Cross-sectional study, Twenty-five T-tests, chi- Large sizes of nursing
rR
19
20 2020 nursing home factors April 2020-May states (e.g., CA, square tests, homes and high
21 related to COVID-19 2020, n = 3357 CT, NJ, NM, robust Poisson COVID-19 prevalence
ev
22 outbreaks nursing homes NV) regression in counties
23 White et al., To identify staff factors Interpretive Not applicable Qualitative Lack of organizational
iew
24 2021 during the pandemic description, May thematic analysis communication and
25 2020-June 2020, n = teamwork, fears of
26
27
NA (nursing homes) infection from direct-
28 care staff, burnout due
29 to increased workloads,
30 and staffing shortage
31 Williams et al., To evaluate the Cross-sectional study, Nation wide Zero-inflated Low-star ratings
32 2021 relationships between May 2020-January regressions
33
residents’ COVID-19 2021, n = 14693
34
35 infections and nursing nursing homes
36 homes’ quality ratings
37
38
39
40
41
42
43
44
46
47
11
1
2
4
7 19 infections
8 Xu et al., 2020 To evaluate the Cross-sectional study, Nation wide T-tests, X2 tests, Shortage of licensed
9 relationship between May 2020, n = 11920 and multivariate nurses and nurse aides
10
COVID-19 cases and nursing homes logistic
11
Fo
12 shortage of nursing regressions
13 home staff during the
rP
14 pandemic
15 Yin et al., 2021 To discover risk factors Cross-sectional study, TX Linear Large sizes of nursing
16 associated with May 2020, n = 958 regressions
homes, shortage of staff,
ee
17 residents’ and staffs’ nursing homes large numbers of
18
COVID-19 infections occupied beds, and
rR
19
20 in Texas nursing homes nursing homes failed to
21 pass assurance check
ev
22 Zhu et al., 2022 To examine the Cross-sectional study, Nation wide Zero-inflated Increased percentage of
23 relationship between June 2020-December negative private rooms and larger
iew
24 nursing home design 2020, n = 7785 binomial models living area per bed
25 and COVID-19 cases nursing homes (protective factors)
26
27
Footnote: CA = California; CO = Colorado; CT = Connecticut; DE = Delaware; FL = Florida; MD = Maryland; WV = West
28 Virginia; KY = Kentucky; GA = Georgia; IL = Illinois; MA = Massachusetts; NJ = New Jersey; PA = Pennsylvania; WI =
29 Wisconsin; AR = Arkansas; MI = Michigan; NM = New Mexico; UT = Utah; VT = Vermont; ND = North Dakota; SC = South
30 Carolina; VA = Virginia; TN = Tennessee; NC = North Carolina; MS = Mississippi; AL = Alabama; AZ = Arizona; WA =
31 Washington; NV = Nevada; TX = Texas.
32
33
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Gerontology and Geriatric Medicine

Nursing Home Residents' COVID-19 Infections in the United

Journal: Gerontology and Geriatric Medicine

Keywords: Nursing, Aging, Prevention, Systematic Review

2022. Inclusion criteria were studies reported on nursing home COVID-

Running head: COMMUNITY SPREAD INFECTIONS RISKS

30 12 vulnerability for prevention intervention.

37 15 OR "2019-ncov" OR "cov-19" OR "sars-cov-2") AND ("residents") AND ("factors" OR "causes"

30 12 characteristics, staffing, resident’s characteristics, and COVID-19 vaccination status).

15 percentage of the total Africa Americans or Hispanic population in counties, percentage of

30 12 healthcare expenditures by avoiding overlapping services or unneeded expansion (National

37 15 Limitations of the review and suggestions for further research

33 14 Mortality Weekly Report, 70(11), 396-401.

24 10 Association, 324(11), 1103-1105.

24 10 March–June 2020. Morbidity and Mortality Weekly Report, 69(32), 1095.

24 10 Control & Hospital Epidemiology, 42(7), 1-880.

24 10 Quarterly, 82(2), 227-256. https://doi.org/10.1111/j.0887-378X.2004.00309.x

33 14 BioNTech and Moderna vaccines in preventing SARS-CoV-2 infection among nursing

24 10 COVID-19 additional primary or booster vaccine dose in preventing SARS-CoV-2

33 14 (2021). Mapping community-level determinants of COVID-19 transmission in nursing

33 14 COVID-19 infections. Sustainable Communities Review, 14(1).

33 27 (n = 79) homes (n = 13)

42 Studies included in review

24 changing role of facility quality over time

30 2021 older adults at long-term care facilities in COVID-19 infections

37 Occupational Therapists: A Qualitative

30 COVID‐19 outcomes nursing homes

37 coverage among health care personnel care facilities rather than

24 Tobolowsky et Signs, symptoms, and comorbidities Article is irrelated to factors

40 ②Yin et al., 2021 ②Kim et al., 2022

32 Evidence from the opinion of

 Proportion of short-stay residents and organizational

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