Nursing Home Leadership Turnover and Its Association With Star Ratings and Consumer Satisfaction

Objective: Nursing home administrator (NHA) and director of nursing (DON) are the 2 key leadership positions in nursing homes (NHs) and play an important role in delivering high-quality long-term care services. However, the impact of DON turnover has not been well investigated compared with that of NHA. This study aims to investigate the association of NHA/DON turnover with 5-star ratings and consumer satisfaction. Design: A cross-sectional analysis of Ohio NHs. Setting and Participants: An NH-level data set of Ohio NHs was constructed, containing 5-star ratings, consumer satisfaction scores, and NH characteristics. Six data sets were merged from the 2017 Nursing Home Compare Archive, 2017 Ohio Nursing Home Resident Satisfaction Survey, 2018 Ohio Nursing Home Family Satisfaction Survey, the Certification and Survey Provider Enhanced Reports, Payroll-Based Journal, and the 2017 Ohio Biennial Survey of Long-Term Care Facilities. Methods: Logistic and linear regressions were performed, controlling for other NH characteristics. Results: Multivariable regressions indicate that DON turnover is consistently associated with lower star ratings by 2.9%-11.5% points and lower consumer satisfaction scores by 0.4%-1.5% points. NHA turnover is associated with lower overall and health inspection star ratings and family satisfaction score, but the effect sizes of NHA turnover diminish when accounting for DON turnover. Conclusions and Implications: The Centers for Medicare & Medicaid Services incorporates a specific measure for NHA turnover into the staffing star rating. However, DON turnover is only reported as a part of the turnover of total nursing staff or registered nurse turnover rates. Given its impact on quality outcomes, DON turnover should be incorporated as a standalone measure to enhance accountability and transparency within the NH industry.