Printer Friendly

Evaluation of five years of nursing home inspection forms: structural and hygiene-related violation trends.


Nursing homes are an important part of today's society because they provide shelter, health care, and a sense of community to over 1.5 million U.S. citizens (Smith et al., 2008). Most nursing home occupants are elderly or sick and are unable to fully provide for themselves (U.S. Department of Health and Human Services [HHS], 2013). In 2050, the number of Americans aged 65 and older is projected to be 88.5 million, more than double the current population (40.2 million) (HHS, 2010). One of every four persons who reaches the age of 65 can be expected to spend part of his or her life in a nursing home (American Medical Association, 1990). An estimated 15,000 nursing homes are currently operating in this country (American Health Care Association, 2011). Ninety percent of nursing home residents are over 65 years of age, and the mean age of residents is over 80 years (Smith et al., 2008). Nursing home residents must rely on nursing home staff and administration for their general welfare, which includes safe and sanitary living conditions. Without sanitary living conditions, elderly nursing home residents are more at risk for various acute illnesses such as pneumonia, urinary tract infections, cold, and flu (Yoshikawa, 2000). It has been noted that compared with other elderly adults, nursing home residents are often more frail, prone to multiple medical problems and symptoms, and are at a higher risk for adverse outcomes from acute illnesses (Hung, Liu, & Boockvar, 2010). More research is needed concerning sanitation conditions at nursing homes because in recent years, the acute illness of nursing home residents has increased (Smith et al., 2008).

The current nursing home inspection process emerged in the mid-1980s, as the U.S. Congress responded to reports of resident abuse and inadequate enforcement of the nursing home regulations. A report on nursing home quality by the Institute of Medicine (1986) found "serious, even shocking inadequacies" in the enforcement of the regulations. As a result of this report and the efforts of advocacy groups and professional organizations, Congress passed a major reform of nursing home regulation as part of the Omnibus Budget Reconciliation Act of 1987 (Institute of Medicine, 2013).

North Carolina nursing homes must be licensed and comply with state and local sanitation regulations (15A NCAC 18A .1300) that follow federal guidelines. Sanitation inspections are conducted by environmental health specialists (EHS) from local health departments in North Carolina to help ensure that nursing homes provide adequate, sanitary living conditions. Sanitation inspections are conducted at least once per year by EHS personnel. Inspection scoring is on a 10-point scale with 90-100 being an A, 80-89 being a B, and 70-79 being a C. During an inspection, EHS conduct a thorough review of the nursing home, documenting code violations and writing descriptive notes on an inspection form. Items are deducted full credit for repeat violations and half credit for nonrepeat violations. Full credit items can range from one to three points and one half credit can range from 0.5 to 1.5 depending on the violation. High-risk violations carry the larger point values and are associated with items such as hands properly washed, vermin excluded, lavatories having mixing faucet with soap, water, and drying device, waste water and solid waste disposed properly, and food supply approved. EHS review the completed inspection reports with the nursing home manager. When a facility poses an imminent threat to health of residents, or the facility fails to maintain a minimum score of a C, the North Carolina state inspector is contacted by the county EHS for further review. Actions may include closure, suspension, or intent to suspend a facility. Nursing homes that have a history of serious problems may be inspected more frequently than once per year.

EHS are trained in risk-based inspection techniques. Recommendations are developed for long-term care infection control programs based on interpretation of currently available evidence (Smith et al., 2008). The recommendations cover the structure and function of the inspection control program, including surveillance, isolation precautions, outbreak control, resident care, and employee health (Smith et al., 2008).

Our study included a review and analysis of nursing home sanitation inspection reports conducted in Pitt County, North Carolina, over a five-year period (2005-2010). The objectives of our study were 1) to determine the most frequently reported violations, 2) to determine which violations (structural related vs. hygiene related) were most common, and 3) to determine if the nursing home sanitation scores were related to age of the nursing home facility.

The hypothesis of our study was that the majority of nursing home inspection report violations are related to structural problems that continually receive point deductions because structures deteriorate with age.

Materials and Methods

Nursing home inspection reports completed in Pitt County, North Carolina, between 2005 and 2010 were reviewed. The inspections were performed at 21 nursing homes by EHS with the Pitt County Health Department. The North Carolina state form for the inspection of hospitals, nursing homes, adult care homes, and other institutions was used during all inspections. The form has a total of 48 variables for multiple or single violations that can total 100 points and a comments section where inspectors can include notes specific to each violation. The forms are based on North Carolina General Statue 15A NCAC 18A.1300. Only paper inspection forms were evaluated to eliminate omission errors from computer-generated reports.

Pitt County nursing home inspection reports were analyzed for the frequency of violations, structural violations, hygiene-related violations, and sanitation scores. The violations and corresponding comments were reviewed on each inspection form. Reported violations were categorized into structural and hygiene-related violations. Structural violations were defined as facility changes that were needed to correct the issues through repair or replacement including replacing carpet, repairing walls, replacing furniture, or design issues. Hygiene-related violations were associated with cleaning, practice-related, or risk-based items that could contribute to illness, such as misuse of disinfectants, general cleanliness, improper hand-washing techniques, or poor food-handling procedures. Some violations were marked for both categories when the violation was for repair and cleanliness. The frequency of specific code violations over the five-year period was calculated for each nursing home. The total number of structural violations was compared to the total number of hygiene-related violations to determine which category was more common. When a nursing home had the same violation in sequence, it was recorded as a repeat violation.

The age and history of the facility were determined via interviews with current management. Nursing homes were assigned to age categories based on their age at the beginning of the study period (2005). The nursing homes were bracketed into three categories based on age to avoiding overlapping data into the different age categories as facilities became older during the five-year study period. The three age brackets included 0-14 years, 15-29 years, and 30-45 years. Six nursing homes were each in the 0-14 and 30-45 years age categories, and nine nursing homes were in the 15-29 year category. Spearman's rank correlation analysis for nursing home age, total violations, and repeat violations were performed using SPSS v. 19.


Overall Trends

Twenty-one nursing homes and 131 corresponding inspection forms were evaluated over the five-year evaluation period. An average of 6.4 inspections occurred per facility, and the inspection rate was 1.29 inspections per year. The inspection frequency met the minimum of one inspection per year for the federal and state mandates. The average nursing home age in Pitt County was 25 years. A total of 525 violations were recorded for the five-year period. Three hundred ninety-seven (81%) were nonrepeat violations while 127 (19%) were repeat violations. The average number of repeat violations per facility was 6.0. The facility with the most repeat violations was 13 years old, with 13 violations over the five-year period. The average percentage of nursing homes marked for violations in this study (92.6%) was similar to the national average (91.9%) reported by the U.S. Department of Health and Human Services (2008). A significant correlation occurred between the age of the facility and total number of violations (p = .003), and between the number of total violations and repeat violations (p = .000).

Structural and Hygiene Violations

Two hundred ten structural violations were reported (40% of all violations) and 315 hygiene-related violations were reported (60% of all violations). The most frequent structural violation (n = 32) was "facilities conveniently located, clean, and in good repair" (Table 1). The age group of facilities that had the most structural violations was the 0-14 year category, followed by the 15-29, and 30-45 year categories (Table 1). The age group with the highest average rate of structural violations per nursing home was 0-14 years (2.6/yr.), followed by 30-45 years (2.1/yr.), and 15-29 years (1.5/yr.).

The most frequent hygiene-related violation (n = 37) was associated with "walls and ceilings cleanable, clean, and in good repair (Table 2)." Other common violations were clean floors, carpet, and walls; clean patient contact items; and clean furniture. The age group of facilities that had the most hygiene-related violations was the 15-29 year category, followed by the 30-45 and 0-14 year categories (Table 2). The age group with the highest average rate of hygiene-related violations per nursing home was 30-45 years (3.7/yr.), followed by 15-29 years (3/yr.) and 0-14 years (2.3/yr.). Hygiene-related violations accounted for 359.5 total points over the course of 115 nursing home inspections, for an average of 3.1 points deducted per inspection. Approximately three hygiene-related violations occurred per inspection.


The data did not show more structural than hygiene-related violations as hypothesized. More hygiene-related inspection items (31; 64.5% of total) occurred, however, than structural inspection items (17; 35.5% of total) on the inspection forms. Hygiene-related violations accounted for 60% while structural violations accounted for 40% of the violations reported. This should raise some concern because hygiene-related violations are usually a more significant health risk to patients than minor structural violations, and research has shown that people tend to change their routines under observation or overreport desired practices during such inspections (Biran et al., 2008). Despite any possible attempts to "deceive" nursing home inspectors, the results show that more hygiene-related violations were present than structural violations. An average of 3.1 points was deducted per inspection for hygiene-related violations in Pitt County nursing homes. Most of the hygiene-related violations reported in our study could be easily remedied by cleaning walls and surfaces with soap, water, and a U.S. Environmental Protection Agency-approved disinfectant that provides antimicrobial activity with minimal additional cost or work (Madeo, 2011).

The age bracket with the most violations over the five-year period was 15-29 years (204 violations), but this bracket also had the most nursing homes (nine). When evaluating the average violation rate for each category, the 15-29 year bracket had the lowest violation rate (4.5 violations/yr.), followed by the 0-14 bracket (4.9 violations/yr.), and the 30-46 year bracket (5.8 violations/yr.). Therefore, the oldest nursing home group did have the highest average violation rates, and a significant correlation occurred between the age of the facility and the number of total violations. The lowest violation rate, however, was for the middle bracket. This may be because those nursing homes were maintained and managed better.

Overall, hygiene-related violations were more common than structural violations. Hygiene-related violations are of importance because they can directly influence the health of nursing home residents. For example, Huang and Wu (2008) showed that the infection rate of nursing home residents was significantly decreased after nursing assistants implemented a hygiene program in Taiwan. Providing a health care environment that is aesthetically pleasing, clean, and microbiologically safe remains a key component to combating the spread of health care-associated infections (Madeo, 2011). Swanson and Jeanes (2011) stated that the key components of infection prevention and control that are common to all health care delivery include hygiene-related practices such as routine and proper hand washing, using personal protective equipment, sharps management, decontamination of equipment, identification of infection, surveillance, and education and training. Education is very important because research has shown that inconspicuous items such as laminated menus can harbor potentially pathogenic microorganisms, and thus should be sanitized frequently (Sirsat, Choi, & Neal, 2013). Nursing home assistants may not be aware of these potential hazards if they are not involved in the inspection process.

While EHS reviewed the nursing home inspection reports with the nursing home managers, it is unknown if the results were communicated from nursing home managers to the nursing assistants who provide most of the direct care to residents. If the inspection report information was not communicated to the nursing home staff and care providers, it is unlikely significant corrective changes would be made to improve sanitation and the inspection scores. Bowers and Becker (1992) found that rules and regulations relating to nursing home care were not communicated to the nursing assistants and suggest that nursing assistants need to be more involved in the development of the nursing home protocols. A study by Bowers and co-authors (2003) indicated that many nursing assistants felt the administrators were dismissive when they discussed organization policies with them. Chung (2012) concludes that nursing assistants should be more involved in the inspection process to help reduce the chasm between administrators--"them"--and assistants--"us." Therefore, it may be beneficial for the staff to participate in the inspection review with the nursing home managers and EHS to ensure the messages are communicated to the assistants.

Pitt County EHS work in different territories of the county and are assigned nursing homes within their territory. It is possible that subjectivity played a role in the nursing home inspection process and grades. Each EHS, however, was authorized by the state of North Carolina pertaining to nursing home regulations and inspection protocols. Furthermore, Pitt County uses several quality control and quality assurance steps to ensure consistency among EHS, including regular "ride-along" exercises by the EHS supervisor with inspectors, departmental review of inspection grading sheets, the scheduling of routine staff meetings to discuss inspection report grading, and participation in professional development workshops.


Health inspections are important for nursing home residents because they aim to ensure a safe and healthy environment. Without sanitary living conditions, nursing home residences are more at risk for various acute illnesses such as pneumonia, urinary tract infections, cold, and flu. Data indicated a higher frequency of hygiene-related violations, which are relatively inexpensive for a facility to correct in comparison to structural defects. With improved sanitation practices, the mean nursing home inspection score could increase by more than three points. It is important for facilities to eliminate hygiene-related violations to lower nursing home residents' risk for acute illnesses.

Corresponding Author: Charles Humphrey, Assistant Professor, Environmental Health Sciences, East Carolina University, 3408 Carol Belk, Greenville, NC 27858.


American Health Care Association. (2011). Oscar data reports: Nursing facility total, average and median number of patients per facility, and ADL dependence. Retrieved from data/oscar_data/Nursing%20Facility%20Operational%20 Characteristics/OperationalCharacteristicsReport_Jun2011.pdf

American Medical Association. (1990). American Medical Association white paper on elderly health: Report of the council on scientific affairs. Archives of Internal Medicine, 150(12), 2459-2472.

Biran, A., Rabie, T., Schmidt, W., Juvekar, S., Hirve, S., & Curtis, V (2008). Comparing the performance of indicators of handwashing practices in rural Indian households. Tropical Medicine International Health, 13(2), 278-285.

Bowers, B.J., & Becker, M. (1992). Nurse's aides in nursing homes: The relationship between organization and quality. The Gerontologist, 32(3), 360-366.

Bowers, B.J., Esmond, S., & Jacobson, N. (2003). Turnover reinterpreted: CNAs talk about why they leave. Journal of Gerontological Nursing, 29(3), 36-43.

Chung, G. (2012). Nursing assistant views on nursing home regulatory inspection: Knowledge and attitudes regarding the state nursing home survey. Journal of Applied Gerontology, 31(3), 336-353.

Huang, T.T., & Wu, S.C. (2008). Evaluation of a training programme on knowledge and compliance of nursing assistants' hand hygiene in nursing homes. Journal of Hospital Infection, 68(2), 164-170.

Hung, W.W., Liu, S., & Boockvar, K.S. (2010). A prospective study of symptoms, function, and medication use during acute illness in nursing home residents: Design, rationale, and cohort description. BMC Geriatrics, 10, 47.

Institute of Medicine. (1986). Improving the quality of care in nursing homes. Washington, DC: National Academies Press.

Institute of Medicine. (2013). Actions taken as a result of the report "Improving the quality of care in nursing homes." Retrieved from

Madeo, M. (2011). Cleaning the hospital environment--a focus on Difficil-S. British Journal of Nursing, 20(11), 688-693.

Sirsat, S.A., Choi, J.K., & Neal, J.A. (2013). Persistence of Salmonella and E. coli on the surface of restaurant menus. Journal of Environmental Health, 75(7), 8-14.

Smith, P.W., Bennett, G., Bradley, S., Drinka, P, Lautenbach, E., Marx, J., Mody, L., Nicolle, L., & Stevenson, K. (2008). Shea/ apic guideline: Infection prevention and control in the long-term care facility. Infection Control and Hospital Epidemiology, 29(9), 785-814.

Swanson, J., & Jeanes, A. (2011). Infection control in the community: A pragmatic approach. British Journal of Community Nursing, 16(6), 282-288.

U.S. Department of Health and Human Services, Administration on Aging. (2010). Aging statistics. Retrieved from http://www.aoa. gov/AoARoot/Aging_Statistics/index.aspx

U.S. Department of Health and Human Services, Administration on Aging. (2013). Aging into the 21st century, health, nursing home usage. Retrieved from Statistics/future_growth/aging21/health.aspx#Nursing

U.S. Department of Health and Human Services, Office of Inspector General. (2008). Trends in nursing home deficiencies and complaints. Retrieved from

Yoshikawa, T.T. (2000). Epidemiology and unique aspects of aging and infectious diseases. Clinical Infectious Diseases, 30(6), 931-933.

Chris Avery, MS, REHS

Charles Humphrey, MS, PhD, REHS

Jo Anne Balany, MS, PhD, CIH

Environmental Health Sciences Program East Carolina University

Nursing Home Structural Violations by Facility Age

Items Inspected                           Facility               Total
                                          Age (yrs.)

                                          0-14   15-29   30-46

Floors easy to clean, no obstacles,        2       2       2       6
  drains where needed
Floors clean, carpet clean, dry,           4       6       5      15
  odor free
Walls and ceilings cleanable,              11      8      11      30
  clean, in good repair
Lighting at least 10 foot candles          3       1       1       5
  30 inches above floor
Facilities conveniently located,           13     11       8      32
  clean, in good repair
Toilet rooms free of storage,              7       3       4      14
  hand wash signs posted
Hand sinks used only for                   0       0       2       2
  intended purpose
Lavatories have mixing faucet or           2       3       2       7
  tempered water, soap, hand towel
  or drying device
Lavatory and bathing hot water between     5       4       4      13
  100[degrees]F and 116[degrees]F
Water fountains clean, good repair,        2       1       1       4
  properly regulated
Ice protected, dispensed, equipment        2       2       2       6
  clean, in good repair
Vermin excluded                            1       0       1       2
Adequate storage, area clean,              4       9       5      18
  items properly stored
Medication carts clean, sharps             1       1       0       2
  containers affixed, food and
  utensils handled properly
Furniture clean and in good repair,        8       8       7      23
  mattresses clean, dry, odor free
Patient contact items in good              9       9       8      26
  repair, properly stored, cleaned,
  and disinfected
Approved utensils and equipment,           3       1       1       5
  cleaned and sanitized
Total                                      77     69      64      210


Nursing Home Hygiene-Related Violations by Facility Age

Items Inspected                         Facility               Total
                                        Age (yrs.)

                                        0-14   15-29   30-46

Floors clean, carpet clean,              5       6       8      19
  dry, odor free
Walls and ceilings cleanable,            8      12      17      37
  clean, in good repair
Ambient air temperature 65[degrees]F     1       2       2       5
  to 85[degrees]F, equipment clean
No evidence of microbial growth          3       2       5      10
Indoor smoking limited to dedicated      0       0       0       0
  smoking rooms
Facilities conveniently located,         9      11       9      29
  clean, in good repair
Bedpans, urinals, bedside commodes,      8      11       8      27
  and emesis basins properly cleaned
Hand sinks used only for intended        0       4       0       4
Lavatories have mixing faucet or         1       4       2       7
  tempered water, soap, hand towel
  or drying device
Disinfectant accessible,                 0       5       3       8
  properly used
Approved water supply, no                0       1       0       1
  cross connections
Water fountains clean, good              0       8       2      10
  repair, properly regulated
Drinking utensils properly handled       1       8       2      11
Ice protected, dispensed, equipment      1       6       5      12
  clean, in good repair
Solid waste stored properly, areas       1       0       1       2
  clean, facilities for cleaning
Solid waste disposed of frequently,      1       0       2       3
  no insect breeding or nuisance
Medical wastes handled and disposed      0       2       0       2
  of properly
Vermin excluded                          1       1       0       2
Approved pesticides properly stored      1       1       0       2
  and handled
Premises clean, no breeding places       0       2       1       3
  rodent harborage
Adequate storage, area clean,            4       4       7      15
  items properly stored
Medication carts clean, sharps           2       9       9      20
  containers affixed, food and
  utensils handled properly
Feeding syringes and oral suction        0       0       1       1
  catheters handled properly,
  tube-feeding bags changed
Furniture clean and in good repair,      3       9       8      20
  mattresses clean, dry, odor free
Linen changed when soiled, soiled        0       9       4      13
  linen handled properly
Laundry area and equipment clean,        11      5       5      21
  linen disinfected, clean laundry
  stored and handled separately
Patient contact items in good            5       8       7      20
  repair, properly stored, cleaned,
  and disinfected
Approved utensils and equipment,         0       1       1       2
  cleaned and sanitized
Food brought by employees or             2       1       0       3
  visitors handled properly
Food protected, potentially              2       2       1       5
  hazardous food maintained at
  45[degrees]F or 140[degrees]F,
  consumed or discarded in two hours
Hands properly washed or                 0       1       0       1
Total                                    70     135     110     315
COPYRIGHT 2014 National Environmental Health Association
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2014 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Author:Avery, Chris; Humphrey, Charles; Balany, Jo Anne
Publication:Journal of Environmental Health
Geographic Code:1U5NC
Date:Nov 1, 2014
Previous Article:Promoting safe hygiene practices in public restrooms: a pilot study.
Next Article:Sanitation in classroom and food preparation areas in child-care facilities in North Carolina and South Carolina.

Terms of use | Privacy policy | Copyright © 2019 Farlex, Inc. | Feedback | For webmasters