ResearchPosted on rand.org Jul 20, 2026Published in: Journal of the American Medical Directors Association, Volume 27, Issue 8, 106343 (August 2026). DOI: 10.1016/j.jamda.2026.106343
California conducts audits of skilled nursing facilities (SNFs) to ensure required staffing levels. We examined facility characteristics associated with failing these staffing audits, trends before and during the COVID-19 pandemic, and the impact of waiver policies.
Longitudinal repeated cross-sectional, multivariate logistic regression with a difference-in-differences framework. Setting and Participants: Three thousand nine hundred sixty-four staffing audit observations of the Centers for Medicare and Medicaid Services–certified California SNFs from July 2018 to June 2022.
We merged California Department of Public Health data to federal data sources. We analyzed associations between audit outcomes, facility characteristics (eg, waiver status [applied for, approved, and denied], ownership, chain affiliation, size, average occupancy rate, share of residents enrolled in Medicaid, and resident racial/ethnic composition) before, during, and after the COVID-waiver periods.
Audit failures increased from 7% in fiscal year 2019 to 55% in fiscal year 2021. The odds of failing rose over time (Q1-Q14; adjusted odds ratio [aOR], 1.581; 95% CI, 1.480-1.690). Odds differed significantly in the pre-COVID, COVID-waiver, and post–COVID-waiver periods. In multivariable regression, failure was associated with for-profit, chain-affiliation facilities vs nonprofit, independent facilities (aOR, 2.634; 95% CI, 1.757-3.947), rural location (aOR, 3.237; 95% CI, 1.925-5.443), and Medicaid share (aOR, 1.178; 95% CI, 1.079-1.285). Waivers lowered the odds of failure, but SNF applicants denied workforce shortage waivers were not more likely to fail. SNFs with higher proportions of Asian residents had lower failure odds (aOR, 0.853; 95% CI, 0.780-0.933), whereas SNFs with more Black residents had higher odds (aOR, 1.101; 95% CI, 1.015-1.195).
While the audit failure rate was climbing before the pandemic, the shallower failure trajectory post–COVID waivers reflects a new, rather than continuing, trend. As workforce shortage waiver denials were not associated with audit failure, the California Department of Public Health policy effectively determined SNFs that did not need a waiver. Associations between SNF racial composition and audit failure, controlling for other characteristics, warrant further study.
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