Administrator Turnover and Quality of Care in Nursing Homes : Page 2 of 2

April 16, 2013

Our Findings 
Our study sought to further understand the relationship between administrator turnover and deficiencies reported to Iowa state surveyors. We found that a high rate of administrator turnover was associated with a high number of reported deficiencies in Iowa nursing homes. Other facility characteristics, such as size and location, also affected turnover, with larger facilities reporting an increased number of deficiencies as compared with smaller facilities. These larger nursing homes were located in more urban areas. This is most likely because more densely populated areas have a greater need for nursing home beds. Because larger facilities have a greater number of residents and workers, the finding that an increased number of beds is related to an increased number of deficiencies is fairly logical.

Urban areas also tend to have more facilities within close proximity to one another. We speculate this characteristic may promote administrator turnover in urban areas. When facilities are in close proximity to one another, administrators may be more inclined to leave a position when they become dissatisfied because they have a greater opportunity to find similar positions without having to relocate.

In our study, ownership of the facility was not found to be significant in determining the number of deficiencies. Due to the impact administrators have on managing direct care employees and on care practices, and the determination that reported deficiencies are an accepted way to monitor care quality, our findings support the hypothesis that administrator turnover does adversely affect care quality in LTC facilities.

These findings are in agreement with one previous research study in which administrator turnover was associated with an increased number of health and safety deficiencies.11 This correlation may be due to a multitude of factors, including the leadership role provided by the administrator. As with all occupations, a learning curve is present when new administrators start at a particular facility. Time is needed to understand the culture of the facility and the role that past leadership filled before any changes can be implemented. During this time of transition, direct care staff may become lax due to limited leadership and policy enforcement. Poor quality of care may itself lead to administrator turnover, which in turn leads to even poorer care quality, and the cycle continues, as was suggested by Castle and Lin,13 who reported a multicausal relationship between these two factors.

Nationwide implications and the need for future research. Given that our study is based on data from a single state, a legitimate question is how generalizable the results are to nursing homes in other states. Although the empirical model results pertain only to the conditions in Iowa, it is logical to extend the results to institutions in other parts of the country because US nursing homes share a number of common structural factors that shape their operations. For example, nursing homes in all states are subject to the standards set forth by the Nursing Home Reform Act, part of the
Omnibus Budget Reconciliation Act of 1987, which created a national set of standards of care for residents of certified nursing facilities.14 In addition, nursing homes nationwide face similar socioeconomic environments and market forces, and they have similar staffing characteristics, with direct care and indirect care staff having similar responsibilities. Based on these similarities, one can surmise that the relationship between administrative turnover and the quality of care may demonstrate parallel results in other states.

Future studies are needed to empirically examine the relationships between administrative turnover and nursing home care quality at a national level, and to understand the causes behind administrator turnover. Conceptual models may assist with determining more characteristics to consider.10,13 Implementing retention strategies could help secure administrators for longer tenure (eg, tenure-graded benefits packages). If the administrator is not performing effectively though, turnover may be beneficial.6 In any case, determining what personal and facility characteristics create the most job satisfaction for administrators is important to improving the quality of care at LTC facilities nationwide.


We found that the level of care quality at LTC facilities can be predicted by turnover, and that administrative turnover is also more predictive of care quality than structural characteristics, such as facility size and location. Based on our findings, it appears that prior studies that focused exclusively on direct care staffing characteristics have been missing an important piece of the puzzle: administrators. These individuals clearly have a tremendous impact on the quality of care at LTC facilities. We encourage future researchers to include administrative turnover when they model the structural determinants of nursing home quality. Obviously, our model does not tell the whole story, as it explains only a small proportion of the variations in quality. It does, however, make the important point that models that try to explain the variations in quality should include both direct and indirect care staffing characteristics of a facility. In addition, further research is needed to understand the causes behind administrator turnover.


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7.     Iowa Department of Inspection and Appeals. Health Facilities Division. Accessed January 7, 2013.

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13.   Castle NG, Lin M. Top management turnover and quality in nursing homes. Health Care Manage Rev. 2010;35(2):161-174.

14.   Hawes C, Mor V, Phillips CD, et al. The OBRA-87 nursing home regulations and implementation of the Resident Assessment Instrument: effects on process quality. J Am Geriatr Soc. 1997;45(8):977-985.



The authors report no relevant financial relationships.  


Address correspondence to:

Simon Geletta, PhD

Department of Public Health

Des Moines University

3200 Grand Ave

Des Moines, IA 50312