1. Introduction
Many skilled nursing facility administrators in the United States struggle to meet state and federal care standards while balancing operational costs and rising patient expectations. As the base of younger taxpayers shrinks and the baby boomer population expands, the trajectory of healthcare spending in the United States remains unsustainable (Miyawaki et al., 2020). Under the existing legislation, national health spending is projected to grow at an average annual rate of 5.6% from 2017 to 2025 (Keehan et al., 2017). With rising life expectancy among the elderly population, demand for nursing home services is increasing (Brent, 2021). The largest share of this population is baby boomers, who have raised their expectations for patient-centered healthcare and want a voice in their treatment (Clark, 2022). This prompted the Centers for Medicare & Medicaid Services (CMS) to adjust the payment mechanism for nursing home services in order to increase the value of spending on skilled nursing facilities (Baldwin, 2018). New compliance regulations and the increased demand for excellent service delivery have prompted a significant transformation in the nursing home industry. Nursing homes that accept Medicare or Medicaid beneficiaries need to obtain a “certification of compliance” with federal participation requirements (Baldwin, 2018). They are now frequently subject to regular inspections and fines for noncompliance. Regulatory oversight establishes a baseline for care quality; however, those facilities often fail to meet benchmarks, risk financial penalties, or face license revocation (Baldwin, 2018). Nursing homes lacking effective strategies will struggle financially and be inefficient, unable to deliver quality care. The specific financial outcome is to reduce penalties and ensure that all health and safety standards are met, and avoid actions that could lead to civil monetary penalties.
2. Methods
The researchers conducted a qualitative pragmatic inquiry to identify strategies for financial stability for nursing homes. The research approach centered on developing practical, actionable insights for nurse home leaders. Therefore, the research focused on identifying and exploring the effective strategies nursing home leaders used to implement regulatory compliance practices that enhanced financial sustainability. The researchers used Drucker’s (1954) Management by Objective theory (MBO) as the lens through which to view the business problem, to help answer the research project’s question. The core constructs of the MBO framework are implemented through a five-step process: (a) define organizational objectives, (b) translate objectives to employees, (c) monitor performance, (d) evaluate progress, and (e) reward achievement. The MBO framework applies to the research project because it enables managers and employees to work collaboratively in establishing organizational goals, thereby fostering teamwork. This approach incorporates structured methods that encourage employee involvement in planning, aiming to enhance efficiency, boost motivation and dedication, and develop strategies to achieve results. The implementation of MBO requires both managers and their staff to set objectives together, regularly assess progress towards these goals, evaluate outcomes, and distribute rewards based on achievements. Objectives should be (a) prioritized according to significance, (b) quantified whenever feasible, (c) realistic, (d) aligned with the organization’s policies, and (e) compatible with other existing objectives (Drucker, 1954). Drawing on Drucker’s MBO theory, I explored effective practices employed by nursing home leaders to improve compliance with state and federal regulations, reduce potential deficiencies and associated penalties, and promote financial sustainability. MBO entails a structured approach aimed at enhancing efficiency while fostering employee involvement in planning to boost motivation and dedication towards achieving specific outcomes. This approach involves a collaborative effort between managers and their team members to establish goals, periodically review progress toward these objectives, assess outcomes, and allocate rewards based on the progress achieved (Drucker, 1954). According to Chitpin (2020), the successful implementation of MBO requires managers at all tiers to gather for 1 or 2 days every 6 months to engage in open discussions about any challenges facing the organization.
The researchers used purposive sampling to select night nursing home leaders in the contiguous United States who had developed and used effective strategies to implement regulatory compliance practices that increased financial sustainability performance. The researchers recruited participants through social media, personal connections, and professional networks. Data saturation was reached after seven interviews, with one additional interview conducted for confirmation. Regulatory compliance practices are defined as policies and procedures that organizations implement laws, regulations, and industry standards. The participant roles consisted of Administrator, Department of Nursing leads, and compliance lead. The facilities used were both for-profit and non-profit, and higher quality ratings can attract more residents and improve financial performance.
The primary data collection process for this project involved semistructured interviews, with the researchers serving as the primary instrument for data collection. This method facilitated the systematic collection of rich, in-depth data, allowing flexibility to probe emergent themes aligned with the project’s objectives. A standardized interview protocol guided each session to ensure consistency across interviews while allowing for adaptive follow-up questions to explore participant responses more deeply. All interviews were audio recorded with participant consent and transcribed verbatim to preserve the accuracy and integrity of the data. The researchers maintained notes on each interview and created analytic memos to elicit contextual insights from participants’ responses and to support ongoing reflection throughout the interview process.
The researchers used thematic analysis to identify patterns and meanings within the dataset. This adaptable approach is widely used, making it suitable for a range of qualitative research frameworks. The researchers used a six-step process outlined by Naeem et al. (2023), which includes (a) familiarizing yourself with the data, (b) generating initial codes, (c) searching for themes, (d) reviewing themes, (e) defining and naming themes; and (f) reviewed the interviews and converted them into a Microsoft Word document for analysis. The process involved transcribing interviews, developing codes to categorize data, identifying recurring themes, and consolidating findings to reduce redundancy. In my research project, I organized all interview data in a question-by-question format, using audio recordings and notes taken during the interviews. I also formatted the data obtained from the NHC website using Microsoft Excel. To ensure participant confidentiality, it is essential to assign codes to identifiable information, such as names and addresses, and store this data separately (Belmont Report, 1979).
Each participant was assigned a unique code beginning with Nursing Home Leader. Furthermore, I maintained a Microsoft Word document that linked participants’ names to their corresponding codes. This system has proven valuable in the analysis process, generating vivid, clear visual representations that enhance productivity and methodological transparency. I employed probing questions and member checking to verify that my interpretations of participants’ responses were accurate. Member checking permitted nursing home leader participants to clarify my interpretations for any biases and to contribute additional information, ensuring comprehensive data saturation. I employed a structured interview protocol to guide the process.
Reflexivity was applied throughout the analysis to mitigate potential bias stemming from the researcher’s professional experience. To ensure accuracy and systematic tracking, all data were stored in labeled, password-protected files and supported with research logs and interview transcripts. The analysis further correlated emergent themes with existing literature and the conceptual framework. The themes that emerged from the data analysis revealed three key themes from the data collected: (a) developing a knowledgeable workforce to enhance employee performance, (b) improving communication between residents and staff, and (c) fostering innovation for continuous quality improvement. Before delving into these emerging themes, recent literature has identified various approaches to address them effectively, thereby reinforcing the foundational concepts of theoretical frameworks.
To enhance reliability and validity, the researchers employed member-checking by allowing participants to review both their transcripts and the researchers’ interpretations of their responses. This process ensured accuracy, alignment with participants’ professional experiences, and greater resonance of the findings. Consistency was maintained by adhering strictly to the interview protocol throughout data collection.
My analysis focused on how individual domain ratings influence the overall star ratings of these five-star facilities. It provided insights into effective strategies nursing home leaders used to implement regulatory compliance practices that increase financial sustainability. Methodological triangulation was achieved by comparing data from my interview technique with documentation sourced from Medicare’s NHC website.
3. Literature Review
3.1. Centers for Medicare & Medicaid Services (CMS) Five-Star Quality Rating System
Providing information on the quality of care in nursing homes is essential. In 1998, the CMS launched the Nursing Home Compare (NHC) website, which publicly discloses quality metrics by detailing the characteristics of nursing facilities, staffing levels, performance measures, and survey outcomes for every Medicare and Medicaid-certified facility (Chen et al., 2024). To aid individuals in comparing and selecting nearby nursing homes, CMS introduced the Five-Star Quality Rating System on the NHC platform in 2008 (Miller et al., 2023). This system rates certified nursing homes on a scale of 1 to 5 stars. Konetzka et al. (2021) stated that nursing homes rated 1 or 2 stars are considered below average in quality, while those rated 4 or 5 stars are considered above average. The overall star rating is derived from a composite evaluation across three domains: health inspections, staffing levels, and quality measures, with each domain receiving an individual five-star rating. The calculation begins with the health inspection score; if a nursing home’s staffing rating is four or more and exceeds its health inspection score, one star is added—similarly, a one-star staffing rating results in a one-star deduction. Additionally, a five-star quality measure rating adds one star, while a one-star quality measure rating subtracts one star. Ultimately, the overall star rating must remain within the one to five-star range (Konetzka et al., 2021).
CMS continuously updates the data for the Five-Star Quality Rating System. Inspection data is refreshed monthly on the NHC website, while information regarding quality measures and staffing levels is updated quarterly (Brunt & Bowblis, 2023). The star ratings are based on health inspection results from standard and complaint surveys conducted over the past 3 years, evaluating compliance with minimum quality standards set by Medicaid and Medicare. Staffing calculations reflect the average daily hours of nursing care provided per resident. Quality measures assess clinical and physical criteria to evaluate the effectiveness of staff care for residents in nursing homes (Konetzka et al., 2021). These measures rely on data collected over the past four quarters, with total quality scores reflecting equally weighted assessments adjusted for differences in prevalence (Miller et al., 2023). The Minimum Data Set (MDS) assessment tool captures functional and health-related information about residents in nursing facilities to calculate these quality measures, including the percentages of residents who develop new or worsening pressure sores, experience moderate to severe pain, or sustain significant injuries from falls (Konetzka et al., 2021). Surveyors utilize MDS data to ensure compliance with the quality expectations outlined in CMS’s Five-Star Quality Rating System. This is how successful financial sustainability/compliance performance was determined.
3.2. Management by Objectives Theory: Increasing Financial Stability in Nursing Homes
Drucker’s (1954) Management by Objectives (MBO) theory serves as a lens through which to view the business problem, helping researchers answer the project’s research question: What effective strategies do nursing home leaders use to implement regulatory compliance to improve financial sustainability? The core constructs of the MBO framework are implemented through a five-step process: (a) define organizational objectives, (b) translate objectives to employees, (c) monitor performance, (d) evaluate progress, and (e) reward achievement. The MBO framework applies to the research project because it enables managers and employees to work collaboratively in establishing organizational goals, thereby fostering teamwork. This approach incorporates structured methods that encourage employee involvement in planning, aiming to enhance efficiency, boost motivation and dedication, and develop strategies to achieve results. The implementation of MBO requires managers and their staff to set objectives together, regularly assess progress toward these goals, evaluate outcomes, and distribute rewards based on achievement. Objectives should be (a) prioritized according to significance, (b) quantified whenever feasible, (c) realistic, (d) aligned with the organization’s policies, and (e) compatible with other existing objectives (Drucker, 1954). Drawing on Drucker’s MBO theory, I explored effective practices employed by nursing home leaders to improve compliance with state and federal regulations, reduce potential deficiencies and associated penalties, and promote financial sustainability. MBO provides a basis for understanding effective strategies nursing home leaders can implement to encourage employee involvement. This participation is crucial for fostering collaboration to modify nursing home practices, thereby enhancing compliance with state and federal regulations, reducing the risk of deficiencies and associated penalties, and supporting the financial viability of these facilities. Alanazi et al.’s (2024) research project on the influence of managerial effectiveness on organizational performance supports Drucker’s management theory by asserting that effective leadership, sound decision-making, and ethical conduct should serve as core objectives guiding all managerial decisions. Alanazi et al. emphasized that organizations grounded in these principles demonstrate sustained productivity, employee engagement, and long-term strategic success.
Successful managers understand that effective leadership practices in a given setting are key to success, as they create goals in every domain of the business, linking sustainable performance and outcomes to performance (Drucker, 2001). This research project is relevant to my research purpose: to identify successful strategies used by nursing home leaders to implement changes that help them meet state and federal regulations and maximize the financial sustainability of nursing homes. Nursing homes typically serve two main client segments: elderly citizens who need help with non-medical tasks, and post-acute patients who seek physiotherapy and nursing care after being hospitalized for acute medical conditions (Werner et al., 2023). As noted by the Centers for Disease Control and Prevention (CDC), in 2020, there were 15,600 nursing homes across the United States with 1.7 million licensed beds, which were home to about 1.4 million people (Miyawaki et al., 2020). The average nursing home has 106 beds. About 19% of these homes are sub60, compared with nearly 30% with over 120 beds overall (Miller et al., 2023).
Individuals residing in nursing homes define quality care as the fulfillment of their needs and expectations through personal interactions within an environment that resembles home. Nursing facilities are subject to stringent regulations imposed by state and federal authorities, requiring caregivers to balance resident preferences with safety measures and quality-of-care standards (McGarry & Grabowski, 2021). The combination of stricter compliance requirements and an increasing demand for services from a discerning baby boomer demographic has underscored the importance of care providers being extensively trained to meet regulatory obligations while also addressing residents’ heightened expectations for quality care.
Quality care involves performing the appropriate actions at the right moment to attain optimal outcomes (Duffy, 2022). Staff in nursing homes deliver quality care to residents by ensuring that all treatments and services adhere to recognized professional practice standards, respect residents’ preferences, and align with the comprehensive, resident-centered care plan (Grabowski, 2022). Providing reliable and high-quality care should be the primary objective for all staff members in a nursing facility. The CMS mandates that residents must receive the necessary care and services to attain or preserve their optimal level of physical, mental, and psychosocial functioning and overall well-being (Grabowski, 2022). The quality of care hinges on a nursing home’s capacity to fulfill the care and service requirements and expectations of its residents. Achieving consistent high-quality care has been an ongoing challenge and concern for individuals residing in U.S. nursing homes (McGarry & Grabowski, 2021).
The 1987 Omnibus Budget Reconciliation Act (OBRA) initiated regulatory reforms designed to improve the quality of care within the nursing home sector. Nevertheless, the quality of care remains inadequate (Gaugler, 2016). The Affordable Care Act (ACA) built upon the care quality standards set forth by OBRA. It was incorporated into the Nursing Home Transparency and Improvement Act, which sought to simplify ownership, management, and financial frameworks that hindered surveillants’ efforts to ensure compliance with federal nursing home regulations (Harrington et al., 2021). Further initiatives were introduced to establish new policies that foster compliance with nursing home regulations and enhance quality. Enrollment in Medicare and Medicaid now depends on the execution of a Quality Assurance Performance Improvement (QAPI) program (Mannethodi & Nashwan, 2025).
QAPI combines two methodologies for quality enhancement: Quality Assurance (QA) and Performance Improvement (PI) (Lane, 2024). QA is a reactive approach that nursing home leaders use to identify unmet quality benchmarks and formulate plans to ensure acceptable care and regulatory compliance. In contrast, PI is an ongoing, proactive strategy aimed at improving processes in nursing homes to prevent or minimize noncompliance by addressing the root causes of issues, thereby enhancing care quality and residents’ overall well-being (Mannethodi & Nashwan, 2025).
In 2016, CMS introduced the Nursing Home Action Plan for 2016/2017, which aimed to enhance the quality of life, health, and safety of nursing home residents through five practical strategies (Harrington et al., 2021). The first strategy focuses on increasing consumer awareness and support by ensuring access to relevant, timely information on the NHC website, enabling consumers to effectively manage their care while holding the healthcare system accountable for its services and the level of care provided (Grabowski, 2022). The second strategy aims to improve survey processes, standards, and enforcement measures by refining annual nursing home surveys and swiftly addressing consumer or family member complaints (Grabowski, 2022). The third strategy enhances enforcement activities by emphasizing resident-centered health quality within an enforcement framework that guarantees both safety and compliance with federal regulations (Grabowski, 2022). The fourth strategy promotes improved quality through cultural transformation and personalized care, leveraging quality improvement initiatives focused on critical issues such as minimizing physical restraints, preventing pressure ulcers, and reducing antipsychotic medication use (Grabowski, 2022). Finally, the fifth strategy adopts a collaborative approach to develop strategic plans that integrate diverse stakeholders’ efforts and coordinate resources effectively (Grabowski, 2022).
In 2017, CMS collaborated with Quality Innovation Network-Quality Improvement Organizations to engage leaders and direct care personnel from high-performing nursing homes throughout the United States (Linkletter, 2024). This involved questioning and observing them to uncover their methods for maintaining quality and for implementing effective practices that enhance care standards. The findings revealed key themes and successful strategies, which were then formulated into actionable items, change concepts, and strategies that nursing home leaders can adopt. According to Linkletter (2024), these initiatives are designed to improve systems that affect both the quality of care provided and residents’ overall well-being by establishing performance-enhancing practices that aim to eliminate adverse conditions in healthcare settings while enhancing resident satisfaction in nursing homes.
According to Braun et al. (2024), some of the strategies nursing home leadership can develop for improving their systems are (a) lead their teams with a clear purpose and high standards (strong mission and values), and build an organizational culture that values acceptance over punishment; (b) recruit and retain employees: qualified, compassionate employees who understand the mission, values, and cultural framework of the organization are required to provide good quality care; (c) resident-centered: when we focus on meeting residents where they are, that means respecting their wishes and meeting them in meaningful context as part of the activities of their lives within the home; (d) teamwork: fostering respect, communication, and teamwork between staff and residents is essential; ensuring access to information throughout the facility helps to achieve a goal by everyone working for the same objectives; (e) a lifelong-learning culture: organizations need to promote a climate of learning, whereby staff are equipped to adapt by utilizing data for performance improvement while also leveraging resources effectively in a connected environment; (f) holistic clinical care provisioning: understanding the residents will deliver the best possible care for them; anticipating their health status to proactively address their health condition whilst also preventing complications related to the healthcare field; and (g) robust business practices development: establish sound business principles aligned with operational success, including managing finances prudently while maintaining integrity focused on resident welfare alongside investing in necessary supplies and equipment for delivering high-quality care within a comfortable home-like atmosphere (Brunt, 2023).
The MBO applied to the researcher’s project provided a foundation for understanding the successful strategies nurse home leaders used to elicit employee participation and promote working together to facilitate changes in nursing home procedures that improve compliance with state and federal regulations, mitigate potential deficiencies and associated fines, and promote financial sustainability.
3.3. Stakeholder Theory in Increasing Financial Stability in Nursing Homes
Drucker’s MBO theory provides a foundation for understanding the successful strategies nurse home leaders may use to elicit employee participation and promote working together to facilitate changes in nursing home procedures that improve compliance with state and federal regulations, mitigate potential deficiencies and associated fines, and promote financial sustainability. In fact, Pradhan et al. (2025) identified intricate relationships among leadership, decision-making, and ethical behavior through a comprehensive study comprising two surveys: the Authentic Leadership Questionnaire and the Moral Potency Questionnaire. These surveys were administered to 98 retail business leaders in the southwestern United States. The research was grounded in Drucker’s management theory, providing a relevant framework for analyzing how managerial actions influence ethics, leadership, and decision-making variables as captured by the survey instruments. The theoretical model developed in the study suggested that ethical behavior could be predicted based on these interrelated factors. Business ethics refers to the guidelines or moral codes that guide organizations toward appropriate conduct (Quezado et al., 2022). These findings illustrated Drucker’s assertion that effective management practices, including leadership style, decision-making processes, and adherence to ethical standards, should be prioritized within organizational strategies. Competent managers understand that employing impactful leadership techniques and setting clear objectives across all operational facets are essential for achieving sustainability (Drucker, 2001). At its core, the researchers found this particularly relevant to the project based on the effective approaches used by nurse home leaders to ensure compliance with state and federal regulations while enhancing the financial viability of the nursing homes they oversee.
Taranekar (2021) found that MBO strategies facilitated alignment with managerial expectations, enabling organizations to adapt to the challenges posed by the Affordable Care Act implementation efforts aimed at bolstering financial stability amid rising healthcare costs driven by reform measures. As an established planning tool introduced by Drucker in 1954, MBO enhanced organizations’ ability to navigate obstacles effectively by setting strategic objectives, thereby improving operational processes. This inquiry aligned with the researchers’ work on identifying the tactics nurse home leaders used to address regulatory compliance issues imposed at both federal and state levels while maintaining fiscal health.
Mbodj and Laye (2025) examined how poverty rates and effective management could mitigate the mismanagement of funds affecting the U.S. economy. The findings indicated that institutional improvements depend on greater adoption of ethical benchmarks, effective governance, and addressing corruption-induced barriers that hinder economic progress. A significant correlation was identified, indicating that higher poverty levels adversely affect funding integrity, leading to variations in overall efficiency across different management styles. Successful managers excel at navigating the complexities of challenges and determining optimal solutions through specific methodologies (Drucker, 1954).
Drucker’s principles were instrumental in guiding the development of frameworks tailored specifically to governmental organizations, where clearly defined targets facilitate desired outcomes (Mbodj & Laye, 2025). These findings draw relevant parallels to the researchers’ examination of how MBO theory can enhance understanding of the effective strategies employed by nurse home leaders. These strategies aim to promote behavioral shifts that improve staff adherence to regulations, mitigate potential deficiencies, safeguard against fines, and ultimately foster long-term sustainability.
4. Results and Discussion
4.1. Theme 1: Development of Knowledgeable Staff
The first emergent theme was the development of knowledgeable staff. The percentage responses that contributed to this theme was 32%. The successful strategy derived from this emergent theme was to develop knowledgeable staff who promote regulatory compliance. A sustainable nursing home management team is willing to learn, open to change, and provides interpersonal quality care to residents (Shiundu, 2024). Staffing themes expressed by nursing home leader participants (Table 1).
Developing knowledgeable staff supports Drucker’s MBO theory by enhancing organizational performance by clarifying employee roles and ensuring their contributions align with the organization’s objectives. Developing knowledgeable staff emerged as a critical factor in maintaining a skilled workforce, especially among nurse home leaders (Drucker, 2001). The scholarly literature identified various strategies for effectively retaining employees. Shiundu (2024) suggested giving nurse home leaders greater involvement in organizational decision-making to increase the value of developing knowledgeable staff. Ahmed (2025) emphasized the importance of developing knowledgeable staff by creating a positive work environment, with organizations providing mentorship programs, employee compensation, perks, and wellness offerings. Each of the nine participants confirmed that the importance of creating a positive work environment is balancing the needs of employee morale, while offering competitive salaries is suitable for the market; developing leaders in mentorship programs to stay knowledgeable about state and regulatory compliance helps leaders grow and helps make companies increase their financial sustainability. For example, Nurse Home Leader 5 shared, “As a leader, it is necessary to know a little about everything and then know who to contact when expertise is needed. We leverage our internal network of colleagues and their specialized expertise. It’s not just about what you know; it’s also about who you know. I actively seek out individuals with in-depth knowledge in specific fields, so I can consult them when necessary. You don’t have to have all the answers; you just need to know where to find them”. Nurse Home Leader 5 supported this sentiment by stating, “I believe it is essential for any leader to acknowledge that complete knowledge is ultimately unattainable. The recent regulations encompass 698 pages, supplemented by an additional 80 pages focused on emergency preparedness. Navigating these extensive requirements can be daunting at any time”.
Table 1. Staffing themes.
Theme |
n |
% |
Develop knowledgeable staff |
13 |
32.5 |
Competencies and expectations |
9 |
22.5 |
Hold staff accountable |
4 |
10 |
Be a coach |
2 |
5 |
Ensure adequate staffing |
12 |
30 |
Note: n = number of frequency a strategy was stated and % = percentage of frequency a strategy was stated.
The development of knowledgeable staff supports Drucker’s MBO theory, which seeks to enhance organizational performance by clarifying employee roles and ensuring their contributions align with the organization’s objectives. This methodology encompasses establishing goals, formulating action plans, tracking advancements, delivering feedback, and evaluating outcomes. By aligning individual performance with the organization’s overarching aims, MBO cultivates an environment of accountability, responsibility, and dedication to shared objectives. Kwon et al. (2024) further stated that regular training develops knowledgeable staff by providing sessions to ensure employees are fully equipped with the latest skills and knowledge. This can include formal training, workshops, and hands-on experiences that reinforce learning. The sessions should also include promoting a culture of continuous learning by encouraging employees to participate in ongoing development programs that enhance adaptability and skill development. These findings support the theme of developing knowledgeable staff by implementing strategies that can significantly improve an organization’s employee development, which enhances overall success and competitiveness in the marketplace.
Shiundu (2024) observed that managers can promote sustainability by motivating employees and implementing changes, ensuring that the right people receive appropriate training and education to develop knowledgeable staff. Ru and Jamil (2024) found that strategies for developing knowledgeable staff include fostering a well-informed workforce. Tomas et al. (2023) found that organizations can implement a variety of strategies that focus on skill enhancement, career development, and lifelong learning. Several approaches include mentorship programs that pair less experienced employees with seasoned professionals to provide guidance and support. These relationships can be informal yet yield valuable insights and foster a culture of knowledge sharing. Kwon et al. (2024) further stated that regular training develops knowledgeable staff by providing sessions to ensure employees are fully equipped with the latest skills and knowledge. This can include formal training, workshops, and hands-on experiences that reinforce learning. The sessions should also promote a culture of continuous learning by encouraging employees to participate in ongoing development programs that enhance adaptability and skills. These findings support the theme of developing knowledgeable staff by implementing strategies that can significantly improve an organization’s employee development, which enhances overall success and competitiveness in the marketplace.
4.2. Theme 2: Enhance Communication with Residents and Staff
The second emergent theme was to enhance communication with residents and staff. The percentage responses that contributed to this theme was 37%. The successful strategy derived from this emergent theme was to enhance communication with residents and staff, thereby mitigating Department of Health (DoH) complaint surveys. Communication themes expressed by nurse home leaders (Table 2).
Table 2. Communication themes.
Theme |
n |
% |
Enhance communication with residents and staff |
18 |
37.5 |
Solve problems |
9 |
18.75 |
Ensure satisfaction |
5 |
10.42 |
Staff meetings |
16 |
33.33 |
Ensure adequate staffing |
12 |
30 |
Note: n = number of frequency a strategy was stated and % = percentage of frequency a strategy was stated.
There is an urgent need to provide exceptional, resident-centered care and customer service in nursing homes. When staff deliver high-quality, individualized care that prioritizes residents’ needs, complaints tend to decrease. This reduction in complaints not only leads to fewer complaint surveys but also minimizes deficiencies and the potential for fines from the DoH. All nine nursing home leaders emphasized that maintaining open lines of communication between staff and residents is one of the most effective strategies for preventing DoH complaint inspections while simultaneously enhancing satisfaction for both employees and residents.
Nurse Home Leader 5 highlighted that fostering open dialogue can help prevent complaints by allowing residents to approach management directly with their concerns, rather than escalating issues to state authorities. In fact, Nurse Home Leader 5 stated, “You can mitigate many issues and reduce calls to the state by resolving their problems internally”. Additionally, Nurse Home Leader 7 shared how you can mitigate complaints and said, “Creating a dialogue so they feel that they can come to you with any issues versus going to the state. Because you’ll mitigate many issues and calls to the state if you can resolve them internally”. Nurse Home Leader 9 shared strategies to mitigate deficiencies and derivative fines and stated, “Having staff and department heads who are engaged with family and resident satisfaction. Have people check on the residents daily. Often, you’ll get a lot of the complaints resolved that way, through starting a dialogue from the moment one”.
Enhancing communication with residents and staff supports Drucker’s MBO theory as it necessitates direct, honest communication between employees. It requires managers to evaluate themselves, their peers, and their subordinates to help the organization reach its objectives with residents and staff (Drucker, 1954). MBO requires managers on all levels to meet for 1 to 2 days every 6 months and openly communicate any concerns facing the company (Drucker, 2001). Serang et al. (2024) examined whether leadership, communication, decision-making, and ethical behavior were correlated. The research project used two surveys (the Authentic Leadership Questionnaire and the Moral Potency Questionnaire) on 98 retail business leaders in the southwestern United States. The researchers chose Drucker’s theory of management as the theoretical framework because it complemented the effects of managerial actions on ethical behavior, leadership, communication, and decision-making variables, as measured by the research project’s survey tools. The model predicted that communication would increase alongside ethical behavior if leadership engagement remained constant. Business ethics are rules, codes of morality, or organizational expectations of ethical behavior that steer an organization toward doing what is right (Quezado et al, 2022).
Lapatoura’s (2025) findings support Drucker’s theory that successful management practices (leadership, decision making, and ethical behavior) should function as principal objectives in decision making. Successful managers realize that the key to success is to use influential leadership practices and set objectives in every area of business where performance and results affect sustainability (Drucker, 2001). Lapatoura’s research aligns with the researcher’s project to determine the effective strategies that nurse home leaders use to effect changes that promote compliance with state and federal regulations and enhance the financial sustainability of the nursing homes they manage.
4.3. Theme 3: Promote Innovation for Continuous Quality Improvement
The third emergent theme was promoting innovation for continuous quality improvement. The percentage responses that contributed to this theme was 42%. The successful strategy derived from this emergent theme was promoting innovation for continuous quality improvement, ensuring regulatory compliance, and promoting sustainability. Compliance themes expressed by nurse home leader participants (Table 3).
Table 3. Compliance themes.
Theme |
n |
% |
Innovative strategies |
12 |
31.58 |
Quality improvement |
16 |
42.1 |
Audit for compliance |
4 |
10.53 |
Improve survey inspections |
6 |
15.79 |
Note: n = number of frequency a strategy was stated and % = percentage of frequency a strategy was stated.
Nursing home leaders can drive innovation aimed at continuous quality improvement by implementing creative strategies to attract new clients and retain or expand their existing business. When residents of nursing homes express high satisfaction with the care and services they receive, they are likely to share these positive experiences within their communities. This favorable word of mouth serves as free advertising, enhancing client retention and attracting new clients, ultimately contributing to the sustainability of nursing homes. As the costs of nursing home care continue to rise, it becomes crucial for nursing home leaders to identify additional revenue streams to maintain income levels and profitability (Pradhan et al., 2024). Managers are encouraged to adopt innovative approaches that transform their organization’s business model, optimizing limited resources while strengthening their competitive advantage (Zhang et al., 2025).
Six out of nine nurse home leaders identified increased competition and reduced reimbursement rates as significant challenges to sustainability. They shared a variety of innovative tactics to improve service quality while generating income to enhance sustainability. Nurse Home Leader 6 highlighted the importance of creativity in promoting innovation for continuous quality improvement by stating, “We are very creative in our initiatives. We explore ways to comply with regulations while streamlining processes. Shorter lengths of stay, combined with lower reimbursement rates, necessitate closer alignment with other healthcare providers to achieve financial stability”.
One recommended approach is to form alliances with provider organizations that offer mutual benefits. The nurse home leaders provided insights into the methods they employed to build such partnerships that effectively promote sustainability. Nursing Home Leader 8 described collaboration involving post-acute care management, promoting innovation for continuous quality improvement by stating, “We function collaboratively as a unit; we engage directly with patients rather than strictly adhering to day-seven discharge protocols; and we offer extensions when appropriate to enhance continuous quality improvement for patients”.
Promoting innovation for continuous quality improvement supports Drucker’s MBO theory, which consists of systematic procedures to improve efficiency, and it elicits employee participation in the planning process to promote motivation and commitment to achieve desired results. The MBO process involves managers and subordinates determining objectives, periodically reviewing progress toward them, evaluating end results, and allocating rewards based on progress (Drucker, 1954).
5. Professional Practice and Implications for Social Change
Implementing focused, evidence-informed strategies to assist nurse home leaders can greatly improve organizational financial sustainability, spur innovation, and enhance talent retention. This approach also establishes a benchmark for professional practices across the wider business sector. Research has highlighted that customized work arrangements, such as training guides, task division, and personalized checklists aligned with individual development and communication, can promote innovation for continuous quality improvement to implement regulatory compliance practices that increase financial sustainability.
Modular training initiatives within organizations play a vital role in embedding sustainability concepts into everyday operations and decision-making processes. Training enhances both technical and interpersonal skills, increasing employee adaptability and efficiency (Yertas, 2024). Tools for digital transformation, like e-learning and virtual simulations, improve the scalability and applicability of training initiatives. Furthermore, a nurturing organizational culture magnifies the effects of training, while active leadership involvement guarantees that these programs align with strategic objectives. Key components highlight a direct link between productivity gains and financial outcomes, including cost-effectiveness, revenue growth, and operational resilience (Harrington et al., 2024). Key components that promote the integration of these strategies include daily activities, such as enhancing practical skills, offering scenario-based learning experiences, and facilitating peer-to-peer collaboration. By adopting these strategies, company leaders can create impactful sustainability training programs that empower employees to embrace sustainable practices, ultimately fostering a workplace that is both environmentally and socially responsible.
Equally important for the successful application of these strategies is the creation of safe, structured work environments that enable communication and foster employee flourishing. Creating a secure workplace involves more than just compliance with legal standards; it is a fundamental aspect of employee well-being and productivity (Almarashdah, 2024). A safe environment minimizes risks and potential hazards, allowing employees to focus on their tasks without fear. This sense of safety is crucial for nurturing a positive company culture and enhancing employee satisfaction. Inclusive communication practices, including clear and consistent instructions provided in multimodal formats, along with active listening, have been shown to facilitate understanding and effective task execution, thereby increasing productivity and financial sustainability (Yertas, 2024). When organizational leaders adopt these communication strategies alongside change management techniques, they not only enhance employees’ sense of belonging and self-efficacy but also develop scalable models for sustainable inclusion that are applicable across sectors.
Utilizing external support systems is essential for nursing home leaders to navigate challenges effectively and promote their staff’s well-being. Local organizations and hospitals serve as important community-based resources for independent nursing homes, offering necessary support and opportunities for collaboration (Noghrehchi et al., 2024). Independent nursing homes often depend on state agencies for assistance, which is crucial to their compliance with state and federal regulations. State agencies are crucial for overseeing compliance with regulations and verifying that nursing homes meet quality-of-care and safety standards (Ghanouni & Raphael, 2022). This reliance on state oversight is fundamental to upholding standards and ensuring that nursing facilities operate within legal and ethical parameters. Collaborative methods complement strategies by ensuring workplace adaptations resonate with the broader support ecosystem for staff and residents, helping them flourish. Integrating personalized work structures with inclusive communication practices, while fostering external support systems, aligns with current research and can promote innovation to support continuous quality improvement and regulatory compliance, thereby increasing financial sustainability. By embedding these principles into organizational policies and everyday operations, businesses can harness the unique potential of nursing home leaders’ talent while establishing a replicable model for inclusive innovation across industries (Braganza et al., 2022).
The implications for positive social change from this research include identifying successful strategies to improve nursing homes’ compliance with state and federal regulations to prevent or remediate deficiencies and associated fines, thereby promoting and maintaining nursing homes’ financial sustainability. Nursing homes that comply with state and federal regulations provide better care for nursing home residents. Providing higher-quality care improves the quality of life for nursing home residents. Furthermore, this project provides several benefits to residents and their families, people living in communities with nursing homes, the U.S. health care industry, and leaders from organizations in other industries who could consider implementing these successful strategies. CMS’s Five-Star Quality Rating System allows people to choose a nursing home based on the quality of care information available on Medicare’s NHC website. Public reporting of quality-of-care information increases competition among residents, reducing private-pay costs and improving the quality of care provided. Families receive the benefit of no longer bearing the burden of providing care or worrying about nursing home care quality.
Furthermore, this research project offers multiple benefits not only for residents but also for their families, surrounding communities, and the broader U.S. healthcare system. The insights gained can lead to improved healthcare experiences for residents due to better service delivery. The CMS uses a Five-Star Quality Rating System, which allows individuals to select facilities based on publicly available information about care quality on Medicare’s Nursing Home Compare website. This transparency fosters competition among facilities vying for residents’ attention, which, in turn, helps lower out-of-pocket costs while raising the standard of care. Families also benefit from reduced anxiety regarding caregiving responsibilities and concerns about the quality of service in nursing homes. Communities experience growth in job opportunities as increased demand, driven by higher standards in nursing home operations, creates new employment prospects. Additionally, areas that host five-star-rated facilities often become more desirable places to live, attracting new residents seeking high-quality long-term care options. This research underscores recurring themes focused on practical strategies that can enhance the financial stability of U.S.-based healthcare establishments. Such insights can inspire meaningful social transformation, supporting economic sustainability across the American healthcare sector while improving overall patient outcomes.
6. Directions for Further Research
Future researchers should examine the significance of the star rating system for prospective consumers and their families when evaluating nursing home services. Conducting a detailed analysis of individual star ratings would help assess their impact on the quality of care provided to residents. Additionally, researchers could examine whether the 5-star rating system improves care quality and influences potential residents’ decisions when selecting a facility. Theoretically, if consumers are using the 5-star rating system as intended, we would expect facilities rated 4 or 5 stars to have higher occupancy rates than those rated 1 or 2 stars. Furthermore, future researchers should investigate any correlation between star ratings and the level of care nursing home residents receive. Poh et al. (2021) highlighted that regulations governing nursing homes aim to establish a fundamental standard of care; however, there is a notable absence of research examining the costs of enforcing these regulations. Additionally, studies investigating the relationship between increased state minimum nurse staffing ratios and their impact on care quality and financial stability are limited.
During the research, the researchers faced several methodological limitations, including a small sample size, the use of only participants who consented to take part in nursing homes, the use of only a few data collection points, and biases, which may limit the generalizability and validity of my findings. To address these issues, future researchers should expand sample diversity across sectors, organizational sizes, and geographic locations to ensure representativeness. Incorporating both quantitative and qualitative methodologies, such as surveys, interviews, and behavioral observations, alongside a longitudinal approach, would yield richer, multidimensional insights into the experiences of nurse home leaders. Additionally, examining emerging factors such as digital transformation, remote work, and the dynamics of cross-cultural teams could reveal further mechanisms that influence inclusion and retention in contemporary workplaces.
Focusing on these areas will enable future studies to deepen our understanding of staffing, communication, and compliance strategies for nurse home leaders. Exploring the long-term impacts of staffing, communication, and compliance programs will yield valuable insights for organizations striving to implement regulatory compliance practices that increase financial sustainability. These expanded research pathways can equip organizations with effective strategies to enhance engagement and performance among nurse home leaders while promoting compliance and financial productivity. Ultimately, these initiatives will help businesses tackle challenges within diverse organizational contexts and strengthen their commitment to social responsibility, inclusivity, and lasting success.
7. Conclusion
Noncompliance with state and federal regulations can significantly threaten the financial stability of nursing homes. Since nurse home leaders cannot always be present at their facilities, managers and direct care staff must receive comprehensive training on the policies and procedures that ensure regulatory compliance. The foundation of sustainability in the nursing home sector rests on staff’s ability to maintain seamless operations while achieving financial success by adhering to regulatory standards.
To enhance care quality and attain financial stability, nurse home leaders must prioritize adaptation and innovation within the industry. By implementing effective strategies to improve compliance with state and federal regulations, nursing home leaders can help prevent potential deficiencies and the penalties that accompany them. Ensuring that staff adhere to these requirements not only strengthens financial sustainability but also meets the expectations of the aging baby boomer population for high-quality care. Nursing homes that successfully fulfill regulatory obligations while excelling in service delivery are more likely to attract this demographic, thereby increasing demand for their services as a beneficial outcome for long-term financial health.
To remain financially viable, nursing home leaders need effective strategies to enhance care quality while ensuring regulatory compliance across all operational levels. Insights from surveys revealed several successful approaches: (a) cultivating a knowledgeable workforce enhances regulatory adherence, (b) improving communication between residents and staff minimizes issues during Department of Health complaint surveys; and (c) encouraging innovative practices focused on continuous improvement supports both compliance efforts and overall operational sustainability. All team members need to collaborate effectively in delivering exceptional, resident-centered care while keeping organizational finances in focus. Staff must commit to evolving practices to better meet changing client needs and navigate the challenges of maintaining fiscal responsibility.