Why Some Long-Term Care Facilities Fail: When Leadership, Culture, and Accountability Break Down

A long-term care facility rarely fails because of one bad day, one difficult employee, or one regulatory survey. More often, facility decline is the result of multiple leadership and operational problems that are allowed to continue without effective intervention.

When leadership is misaligned, accountability becomes inconsistent, departments begin operating independently, negative behaviors become normalized, strong employees become frustrated, and turnover increases. Eventually, the organization may experience declining quality outcomes, regulatory deficiencies, staffing instability, financial pressure, and repeated changes in facility leadership.

At Kay Consulting Group, we believe one of the most important questions leaders should ask is:

The Administrator Cannot Be Expected to Succeed Without Leadership Alignment

The Nursing Home Administrator is responsible for the overall operation of the facility. However, accountability for facility performance does not mean the Administrator should operate without meaningful support from regional and corporate leadership.

A strong Regional Director of Operations (RDO) should function as a strategic partner, coach, resource, and accountability leader. The RDO should support the Administrator while also ensuring that the Administrator is held accountable for measurable outcomes.

Support + Accountability + Alignment + Communication = Stronger Leadership

Problems arise when regional leadership communicates one expectation to the Administrator while allowing department leaders or staff to operate under another.

For example, if an Administrator establishes an operational expectation and a department leader disagrees, the appropriate response is not for the department leader to bypass the Administrator and seek regional approval simply to avoid accountability.

Instead, the leadership team should address the disagreement, evaluate the facts, make a decision, and communicate a unified expectation.

When this does not happen repeatedly, the organization can unintentionally create a culture in which employees learn that going around the Administrator is easier than working through the established chain of command.

That is a dangerous leadership pattern.

When Department Leaders Become Empowered to Undermine Leadership

Employee empowerment is generally a positive concept. However, empowerment without accountability can become organizational dysfunction.

There is a significant difference between:

• Empowering employees to speak up
• Empowering employees to disregard leadership accountability

Healthy organizations encourage employees to raise concerns, report safety issues, provide feedback, and participate in problem-solving.

But once a culture develops in which employees can:

• Ignore established leadership expectations
• Refuse reasonable accountability
• Bypass the Administrator
• Create competing chains of command
• Undermine department-to-department collaboration
• Publicly challenge leadership without constructive resolution
• Receive different answers from different levels of management

the organization begins losing leadership consistency. The result can be confusion, conflict, disengagement, and eventually turnover.

Administrator Turnover Is a Warning Signal

One of the most overlooked indicators of organizational instability is repeated Administrator turnover.

CMS recognizes administrator turnover as an important staffing measure and reports that lower administrator turnover may contribute to greater leadership stability, direction, and operational consistency (Centers for Medicare & Medicaid Services).

Research has also identified an association between Administrator turnover and nursing home quality. A longitudinal study examining nearly 20,000 nursing homes found that Administrator turnover is an important organizational factor connected to quality outcomes (PubMed).

This does not mean that every Administrator departure indicates organizational dysfunction. Administrators leave organizations for many legitimate reasons.

However, when an organization repeatedly loses Administrators from the same facility, region, or leadership structure, leadership should stop asking only:

“Why can't we keep our Administrators?”

and begin asking:

“What is happening in our leadership system that may be contributing to Administrator turnover?”

That question requires courage.

The Culture Problem: What Leadership Allows Becomes the Culture

Culture is not created by a mission statement hanging on the wall. Culture is created by what leaders consistently reward, tolerate, address, and ignore.

• If a department leader repeatedly demonstrates disrespect toward the Administrator and leadership does nothing, the organization has communicated that the behavior is acceptable.
• If employees bypass their supervisor and leadership consistently accommodates the behavior, the organization has created an alternative chain of command.
• If strong employees raise concerns about a dysfunctional culture and leadership dismisses those concerns, employees eventually learn that speaking up does not lead to meaningful change.

And when good employees leave, organizations often describe the problem as: “We just can't find good staff.”

Sometimes the more important question is: “Why are good employees leaving?”

Leadership and Staff Empowerment Must Be Balanced

Research supports the importance of effective leadership and appropriate staff empowerment. A study of U.S. nursing homes found that greater leadership and staff empowerment were associated with higher nursing-assistant retention (ScienceDirect).

Another study found that nursing homes with stronger leadership commitment to worker safety, health, and well-being had approximately 10% lower nurse turnover than facilities with weaker leadership commitment (ScienceDirect).

The lesson is not that leaders should control every decision. The lesson is that empowerment works best when it exists within a clear leadership structure.

• Employees should have a voice.
• Department leaders should have authority within their scope.
• Administrators should have operational authority.
• Regional leaders should provide support, resources, coaching, and accountability.
• And everyone should understand the boundaries of their role.

Why Some Facilities Fail

There is rarely one reason. Facilities may struggle because of a combination of:

1. Leadership instability: Frequent changes in Administrators, DONs, department heads, or regional leaders can create uncertainty and inconsistent expectations.
2. Lack of regional support: An Administrator who is held accountable for results but is not given adequate resources, authority, staffing, or leadership support is placed in an impossible position.
3. Competing leadership structures: When employees receive conflicting direction from the Administrator, RDO, DON, corporate leadership, or department heads, accountability becomes unclear.
4. Negative workplace culture: A culture of blame, favoritism, disrespect, intimidation, or poor communication can drive away high-performing employees.
5. Failure to address toxic behaviors: Problems rarely improve when leadership continually says, “That's just how that department is.” Unaddressed behavior becomes normalized behavior.
6. Poor communication: When leadership does not communicate consistently, employees fill the information gap themselves. Rumors replace facts, departments become divided, and trust declines.
7. Reactive rather than proactive management: Some organizations wait until there is a serious complaint, survey deficiency, staffing crisis, resident incident, leadership resignation, or financial problem before addressing underlying issues. Effective organizations identify risk before it becomes a crisis.
8. Failure to listen to frontline employees: Direct-care employees often know where operational problems exist long before senior leadership does. Ignoring their feedback results in missed opportunities for early intervention.
9. Lack of accountability: Accountability must apply to everyone—from frontline staff to senior leadership. An organization cannot expect employees to follow standards that leaders themselves do not consistently enforce.
10. Focusing on blame instead of systems: When a facility struggles, it is tempting to identify an individual as the problem. Sometimes an individual does need corrective action. But leaders should also ask: What process allowed this problem to continue? Who knew about it? What was done? Was the intervention effective? Was accountability consistent? What will prevent recurrence?

That is the foundation of effective quality improvement.

The Administrator Should Not Be the Organizational Scapegoat

One of the most damaging leadership patterns occurs when an organization repeatedly changes Administrators without addressing the conditions surrounding those Administrators.

Replacing the Administrator may temporarily change the face of the facility. It does not necessarily change the system.

If the same:

• Leadership conflicts
• Department dysfunction
• Staffing challenges
• Communication problems
• Accountability gaps
• Regional leadership practices
• Cultural issues

remain in place, the next Administrator may experience the same outcome. Changing the person without changing the system is not necessarily improvement.

What Should Organizations Do Differently?

At Kay Consulting Group, we encourage organizations to examine the entire leadership ecosystem.

1. Conduct a Leadership Culture Assessment

Ask critical questions:

• Do Administrators feel supported by regional leadership?
• Do Administrators have appropriate decision-making authority?
• Are department heads aligned with the Administrator?
• Are employees comfortable reporting concerns?
• Are complaints addressed consistently?
• Are leaders held accountable for their own behavior?
• Is there a clear chain of command?
• Are leadership disagreements resolved privately and professionally?
• Are high-performing employees being retained?
• Why have previous Administrators left?

2. Analyze Turnover Patterns

Don't look only at the percentage. Look at who is leaving. If an organization repeatedly loses:

• Administrators
• DONs
• Nurse managers
• MDS leaders
• Social workers
• Strong CNAs

that pattern deserves investigation. CMS makes nursing-home staffing and turnover information available through its Care Compare system, emphasizing the importance of staffing stability to quality and resident outcomes (Centers for Medicare & Medicaid Services).

3. Establish Leadership Alignment

The Administrator, DON, RDO, and department leaders should clearly understand:

• Who makes the decision?
• Who is accountable?
• Who provides support?
• How are disagreements resolved?
• How is the decision communicated to staff?

This does not eliminate healthy disagreement. It creates a professional process for managing disagreement.

The Goal Is Not a Perfect Facility

Every facility will experience challenges. There will be staffing shortages, difficult employees, resident complaints, survey deficiencies, and leadership disagreements.

The difference between a struggling facility and a resilient facility is often how leadership responds to those challenges. Strong organizations don't pretend problems don't exist. They identify them, investigate them, communicate about them, hold people accountable, measure improvement, and continuously ask: “What can we do better?”

A Message to Regional and Corporate Leaders

If your organization has experienced repeated Administrator turnover, don't automatically assume that the solution is another Administrator. Look at the environment in which the Administrator was expected to lead.

Ask yourself:

• Did we provide the Administrator with the authority necessary to do the job?
• Did we consistently support the Administrator when difficult decisions had to be made?
• Did we hold department leaders accountable for behaviors that undermined facility leadership?
• Did we listen when the Administrator raised concerns?
• Did we address cultural problems early?
• Did we create alignment between regional and facility leadership?

Those questions may reveal more about organizational performance than another recruitment campaign ever will.

The Kay Consulting Group Perspective

At Kay Consulting Group, LLC, we believe sustainable long-term care performance requires more than regulatory compliance. It requires strong leadership, operational discipline, accountability, culture development, quality improvement, and strategic alignment.

Our approach is simple:

A facility should not have to repeatedly lose strong leaders before an organization recognizes that something is wrong. Leadership turnover is not merely an HR metric. It can be an organizational warning signal.

When leaders are supported, employees understand expectations, accountability is consistent, and departments work together toward a common mission, facilities are better positioned to provide stable, safe, resident-centered care.

Final Thoughts

If the same problem keeps occurring after the person responsible has changed, perhaps the person was never the entire problem.

Sometimes the real opportunity for improvement is not replacing the leader. It is fixing the leadership system around the leader.

References

• Centers for Medicare & Medicaid Services. Nursing Home Staff Turnover and Weekend Staffing Levels. CMS.
• Centers for Medicare & Medicaid Services. CMS Enhances Nursing Home Rating System with Staffing and Turnover Data. CMS.
• Centers for Medicare & Medicaid Services. Provider Data Catalog: Nursing Home Quality Measures. CMS.
• Berridge, C., Tyler, D. A., & Miller, S. C. (2024). Can Better Leadership Reduce Nursing Home Staff Turnover? Journal of the American Medical Directors Association, 25(3), 403–407.e1. (ScienceDirect)
• Banaszak-Holl, J., Castle, N. G., Lin, M. K., & Spreitzer, G. (2015). The Role of Organizational Culture in Retaining Nursing Workforce. The Gerontologist. (PubMed Central)
• Donoghue, C. (2009). Leadership Styles of Nursing Home Administrators and Their Association With Staff Turnover. The Gerontologist, 49(2), 166–174. (OUP Academic)
• Chu, C. H., Wodchis, W. P., & McGilton, K. S. (2014). Turnover of Regulated Nurses in Long-Term Care Facilities. Journal of Nursing Management, 22, 553–562. (Wiley Online Library)
• Pradhan, R., Ghiasi, A., & Weech-Maldonado, R. (2024). Leadership Matters: Nursing Home Administrator Turnover and Quality. The Gerontologist. (PubMed)
• Centers for Medicare & Medicaid Services (CMS). The Nursing Home Staffing Study Comprehensive Report. U.S. Department of Health and Human Services.