Term of Award

Spring 2022

Degree Name

Doctor of Public Health in Public Health Leadership (Dr.P.H.)

Document Type and Release Option

Dissertation (open access)

Copyright Statement / License for Reuse

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 License.


Jiann-Ping Hsu College of Public Health

Committee Chair

Bettye Apenteng

Committee Member 1

Andrew Hansen

Committee Member 2

Helen Bland


Introduction: This study examined the impact of organizational and market factors on the quality of nutritional care in nursing home facilities certified by the Centers for Medicare and Medicaid Services (CMS), using deficiency citations recorded between 2014 through 2019. The rationale was to identify nutritional care gaps in nursing home facilities that may negatively impact the health and quality of life of the elderly resident. Methods: An analysis of secondary health data was conducted to assess trends in nutritional care problems and to determine the contextual correlates of poor nutritional care quality in nursing homes. Datasets were downloaded from multiple data repositories, including LTCFocus Brown School of Public Health, U.S. Census Bureau, County Health Rankings, and U.S. Department of Commerce. A mixed-effects logistic regression model was employed to examine the association between the nursing home market and organizational factors, and nutrition-related deficiencies. Subsequently, mixed-effects ordinal regression analysis was used to determine the correlation between the nursing home market and organizational factors and nutritional-related deficiencies’ scope and severity score. Results: Deficiencies relating to the procurement of foods from approved sources and the storage, preparation, distribution, and service of food in accordance with professional standards were the most frequently cited nutritional deficiencies in nursing homes in the United States over the study period. Market factors that were significantly associated with the presence of a nutrition citation and the severity of the cited nutritional deficiency in nursing homes, included geographic location. Nursing home organizational factors, such as the facility’s ownership type, number of certified beds, and nursing staff hours, were significantly associated with the receipt of a nutrition citation. Among nursing homes with nutrition citations, factors that affected the severity of the deficiencies included the food environment index and the number of certified beds. The scope of the deficiencies was impacted by the number of certified beds and the average case-mix index. Conclusion: This study's identified nutrition care gap in the nursing home to be shaped by both market and organizational contextual factors. Such factors should be considered when planning and allocating health resources, as this could be a strategic process improvement opportunity.

Research Data and Supplementary Material


Available for download on Tuesday, April 20, 2027