Nursing home design shapes resident safety in ways researchers can measure. How many people share a bedroom, how far a resident sits from the nearest caregiver, and how an exit door behaves under pressure can affect infection exposure, injury risk, and the likelihood of a resident leaving unnoticed. A study of 618 Ontario nursing homes published in JAMA Internal Medicine found COVID-19 infection rates of 9.7% in the most crowded homes and 4.5% in the least crowded. Its authors estimated that converting every four-bed room to a two-bed room would have prevented about 19% of cases.
Buildings do not cause neglect on their own. Understaffing, poor training, and weak oversight can contribute to it. But a floor plan affects how visible a missed check, an unwatched door, or a resident on the floor will be, and how quickly staff can respond. That puts resident safety in the architectural brief, not only the operations manual.
What Does Nursing Home Neglect Have to Do With Architecture?
Federal investigators have found much of the harm in long-term care to be preventable. A 2014 HHS Office of Inspector General report estimated that 22% of Medicare beneficiaries experienced an adverse event during a skilled nursing facility stay, and another 11% experienced temporary harm. Physician reviewers judged 59% of those events clearly or likely preventable.
The Nursing Home Abuse Center, a U.S. resource on abuse and neglect in long-term care, describes nursing home neglect as a facility’s failure to provide the basic care residents depend on, and identifies understaffing and weak oversight as recurring causes. Many failures that fit that definition play out in physical space: a corridor too long to supervise, a stair door no one can see, a bedroom shared by four people.
The Centers for Medicare & Medicaid Services (CMS) cites nursing homes under tag F689 when the environment is not free of accident hazards or supervision falls short. Many of those citations read like post-occupancy evaluations of a floor plan.
How Does Unit Size Affect Supervision?
The number of residents assigned to a nursing unit influences how staff organize care, monitor shared spaces, and respond to emergencies. Larger units often require caregivers to cover longer distances and supervise rooms spread across multiple corridors. Smaller units can bring residents and staff closer together, making everyday interactions and changes in resident condition easier to observe.
The limits of the corridor model
The traditional American nursing home borrowed its plan from the hospital: a central nurses’ station, long double-loaded corridors, and shared rooms on either side. Supplies and charting stay centralized, but residents at the far end of a wing sit a long walk from help. A fall in a distant room can go unnoticed until the next scheduled round.
The household alternative
The household model shrinks the unit so supervision can happen through daily life rather than patrols. Architect Gaius Nelson helped pioneer the U.S. skilled nursing household model at Evergreen Retirement Community in 1987. The Green House Project builds homes of 10 to 12 residents, each with a private bedroom and bathroom arranged around a shared kitchen, dining, and living space where staff spend much of the day.
De Hogeweyk in Weesp, the Netherlands, applied the same idea at neighborhood scale when it opened in 2009. Today about 188 residents with advanced dementia live in 27 houses of six or seven people, inside a secure village with streets, a square, and a supermarket. Similar dementia villages have since opened in Norway, France, and Canada.
| Design factor | Institutional corridor model | Household / small-house model |
| Residents per unit | Dozens per wing | 10–12 (Green House); 6–7 per house (De Hogeweyk) |
| Staff visibility | Central station; many rooms out of view | Open kitchen-living core facing bedroom doors |
| Travel distance to help | Long, especially at corridor ends | Short; bedrooms open onto shared space |
| Room occupancy | Often shared bedrooms and bathrooms | Private bedroom and bathroom |
| Infection control | Large shared cohorts and dining | Small resident and staff cohorts |
Why Do Exit Doors Fail Residents With Dementia?
On May 30, 2026, a man with dementia living on the secured memory care floor of an Indianapolis assisted living community was found lying in a neighboring restaurant’s parking lot, complaining of head and hip pain. He was taken to the hospital.
The Indiana state survey that followed recorded repeated exit-seeking in his care records, no cameras or wander-alert system, and a stairwell door that opened after 15 to 20 seconds of sustained pushing. No alarm sounded the day he left. During the inspection, surveyors watched staff ignore a loud door alarm, which one employee dismissed as “just a resident.” The state cited the community for neglect.
The failure was as much spatial as human. NFPA 101 Life Safety Code permits certain delayed-egress locks to release after 15 seconds, or 30 seconds with approval from the authority having jurisdiction, once the release is activated. The delay helps preserve emergency egress while giving staff time to respond. It cannot supervise anyone, and an alarm on a stair door outside staff view may become background noise if staff repeatedly disregard it.
Federal nursing home inspection reports, searchable through ProPublica’s Nursing Home Inspect database, document failures to supervise residents at risk of wandering and to maintain exit safeguards. Those findings put part of the responsibility on design: where the exits and alarms go, and which zones staff can actually supervise.
The National Institute on Aging advises drawing attention away from doors and giving people who wander a safe place to walk. At facility scale, that means exits inside staff sightlines, looped walking paths rather than routes that lead residents toward stairwells, and a secure garden they can use with appropriate oversight.
How Do Room Typologies Change Infection Risk?
The Ontario study in JAMA Internal Medicine measured crowding as the average number of residents per bedroom and bathroom. Researchers found no significant difference in whether COVID-19 entered high- or low-crowding homes. Once it did, however, more crowded homes experienced more cases: mortality reached 2.7% in high-crowding homes against 1.3% in low-crowding homes.
A 2021 study in the Journal of the American Medical Directors Association found lower COVID-19 incidence and mortality in Green House and other small homes than in traditional nursing homes, including those with fewer than 50 beds. The authors noted that the small homes also had fewer for-profit operators and fewer high-risk residents. The building is not the only factor.
Standards have moved anyway. According to the chairs of the committee that wrote it, the 2026 FGI Code for Planning and Design of Residential Care and Support Settings calls for at least 90% of resident rooms in newly constructed nursing homes to be single-resident rooms, which would put roughly 80% of residents in a private room if the remaining rooms are doubles. Authorities having jurisdiction can approve a lower share when a need is demonstrated. Its requirements apply where the code is adopted and do not automatically require existing multi-bed homes to convert.
Where Do Falls Begin in the Floor Plan?
The Falls Management Program from the Agency for Healthcare Research and Quality (AHRQ) reports that about half of nursing facility residents fall each year, and one in 10 who fall suffers a serious injury. AHRQ traces most falls to a mix of factors within the resident and factors in the environment. The environmental side is where design can help.
A common fall-risk point is the nighttime walk from bed to toilet. A conveniently placed toilet, a continuous grab rail along the path, and low motion-activated lighting can make that trip easier to navigate. Matte, slip-resistant flooring can reduce glare, and contrast at thresholds helps residents with low vision judge edges. RTF’s checklist for designing old-age homes and nursing homes covers related circulation and accessibility basics.
The Nursing Home Abuse Center lists falls that follow missing supervision or mobility help among common forms of safety neglect. A bedroom door that opens onto shared living space, rather than an empty corridor, may make that supervision easier to deliver.
A Design-to-Risk Map for Facility Planners
- Falls: short bed-to-toilet paths, continuous handrails, night lighting, matte flooring, seating along walking routes.
- Elopement: exits within staff sightlines, looped circulation, secure gardens, less visually prominent stair doors only where life-safety and accessibility codes permit.
- Infection: single-resident rooms with private bathrooms, small household cohorts, hand-hygiene stations where staff move between rooms.
- Missed care: decentralized staff work areas, short walks from staff to every bedroom, bedroom doors that open onto shared living space.
Designing for the Moment Care Breaks Down
No floor plan replaces enough trained staff. What a plan can do is influence whether a lapse in care stays hidden or is noticed in time. A resident on the floor of a room that opens onto a shared living area may be seen sooner than one at the end of a long corridor. A stair door within staff sightlines is easier to monitor than one around a corner with an alarm people have learned to ignore.
The 2026 FGI Code moves new construction toward single rooms where its requirements are adopted, but it does not automatically require existing multi-bed homes to convert. That leaves much of the work to renovation. Relocated exits, shorter paths to the toilet, and staff work areas moved out of a central station and into the places residents actually spend their day can all be considered within an existing building, subject to applicable codes and feasibility.
For architects and operators, the useful question is not whether a building looks safe on paper. It is how quickly the plan shows staff when something has gone wrong.
Frequently Asked Questions
How does nursing home design affect resident safety?
Nursing home design influences how easily staff can supervise residents, respond to emergencies, and prevent accidents. Shorter corridors, accessible bathrooms, clear sightlines, and appropriately positioned staff work areas can reduce environmental hazards and improve supervision. However, good design must work alongside adequate staffing, training, and care procedures to protect residents.
Are smaller nursing home units safer than traditional facilities?
Smaller household-style nursing homes can offer advantages in supervision, resident privacy, and infection control. Models such as the Green House Project typically accommodate 10 to 12 residents in a shared household setting. Research has associated smaller facilities with better outcomes in some areas, although staffing levels, resident health, and operational practices also influence safety.
Why are private bedrooms important for infection control in nursing homes?
Private bedrooms and bathrooms reduce close contact between residents and can help limit the spread of infectious diseases. A study of 618 Ontario nursing homes found higher COVID-19 infection and mortality rates in more crowded facilities. Private rooms also provide greater flexibility for isolating sick residents without disrupting care throughout the building.
How can nursing home design help prevent residents with dementia from wandering away?
Facilities can reduce elopement risks by placing exits within staff sightlines, providing secure outdoor spaces, and designing continuous walking paths that allow residents to move safely. Door alarms and access controls can provide additional protection, but they require reliable staff responses. Exit systems must also comply with applicable fire and life safety requirements.
What architectural features help prevent falls in nursing homes?
Important features include short, unobstructed routes between beds and bathrooms, continuous handrails, slip-resistant flooring, adequate nighttime lighting, and clearly marked changes in floor level. Accessible bathroom layouts and strategically positioned seating also help residents with limited mobility. These measures complement individual fall-risk assessments and staff assistance.
Can an existing nursing home be renovated to improve resident safety?
Yes. Older facilities can often improve safety without complete reconstruction. Potential upgrades include repositioning staff work areas, improving bathroom accessibility, adding handrails and lighting, strengthening exit monitoring, and reducing shared-room occupancy where feasible. Renovation priorities should reflect the building’s existing hazards, resident needs, and applicable regulatory requirements.
Can poor nursing home design contribute to neglect?
Poor design can make neglect harder to detect or increase the consequences of missed care. Long corridors, obstructed sightlines, and poorly monitored exits may delay staff responses to falls, wandering, or other emergencies. However, architectural shortcomings do not automatically constitute neglect. Resident safety depends on both the physical environment and a facility’s ability to provide appropriate supervision and care.
