TABLE 2.

Administrators reported challenges associated with governmental policies.

Concept	Representative quote, nursing home characteristics
Confusing and conflicting policies	“It gets a little confusing in that [state] Department of Public Health regulations may be a little bit different than the CMS regulations, so even though where the confusion comes in is if some [state] regulations are not as stringent as the CMS regulations, we are supposed to follow the CMS regulations.” S2N2.3, April 2021, Northeast, 151+ beds, Star rating 5, For profit
Insufficient time to implement policies properly	“The biggest disconnect is that often the guidance gets released to the public or like a governor spews it out in a press conference prior to the nursing homes being made aware, or we get to find out at the same time. And then everybody still has that sense of urgency to scurry around and update their practices so we are being compliant and that still feels chaotic.” S6N1.4admin2, June 2021, South, 126–150 beds, Star rating 4, Not for profit
Perception that policymakers did not have current nursing home experience	“We have that state call every…Wednesday at 11:00. They talk about changes and they talk about how things should be, but none of them have a clue what it's like to really work in COVID….Because they are all working from home when they are on the Zoom call. They're all in their living rooms or their bedrooms. [laughs] It's kind of hard to know what's going on in the real world when you sit in your home all the time.” S3N4.1, January 2021, South, <100 beds, Star rating 3, For profit
Regulators more punitive than collaborative	“And I think that's been the frustration all along is, all we hear from the Department of Health is how we are here to support you, but they are not. They come in here and do not tell us anything and then try to write tags about it.” S4N4.2, January 2021, Midwest, 151+ beds, Star rating 3, Not for profit
Difficult to communicate policy changes	“Updating policies almost weekly, daily, monopolizes our time, because then we have to turn around and write letters to families and send that out. And then the next week we are like, ‘Oh, my god, this has changed,’ and then we send that out to families that there's another change. Nobody can keep up, and family members get upset with us…. it does make our relationships with family members really strained and adversarial. It's created quite a wedge between the relationships we used to have with families and residents…and it's going to take a while to repair that.” S6N1.3admin2, March 2021, South, 126–150 beds, Star rating 4, Not for profit
Corporations helped interpret policy changes	“We just have one person for the company that takes the time to [join the weekly calls with the Department of Health] and then disseminates it to us instead of every facility being consumed for that 2 h, and multiple people from the facility, and that has really helped‐ It takes the noise out of it. Or I interpret it one way and my director of nursing interprets is another. It stopped that.” S4N3.1, October 2020, Midwest, 100–125 beds, Star rating 1, For profit