A randomized trial of 85 very preterm infants found no difference in death or neurodevelopmental impairment at 36 months between single-family room and open-bay NICU care. Despite the lack of primary endpoint separation, mortality and infection rates were lower with private rooms. The results update the evidence base for facility design decisions, suggesting that benefits may show up in infectious outcomes even when long-term neurodevelopmental metrics do not diverge. For NICUs facing ongoing staffing and infrastructure constraints, the data provide a more nuanced justification for private-room investments. While the trial’s sample size limits subgroup conclusions, the study remains a landmark dataset for architects, hospital administrators, and neonatal clinicians deciding how to structure physical care environments.