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Important update: Healthcare facilities
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Considerations for Preventing Spread of COVID-19 in Assisted Living Facilities

Considerations for Preventing Spread of COVID-19 in Assisted Living Facilities
Updated May 29, 2020

Summary of Recent Changes

As of May 29, 2020

Key Actions
  • Assisted living facility (ALF) owners and administrators should refer to guidance from state and local officials when making decisions about relaxing restrictions (e.g., easing visitor restrictions, allowing group activities, or restoring communal dining)
  • State licensing authorities, which have oversight of ALFs, are encouraged to share this guidance with all ALFs in their jurisdiction. State healthcare-associated infections programs are an important resource to assist ALFs with responding to COVID-19 and implementing recommended practices.

Given their congregate nature and population served, assisted living facilities (ALFs) are at high risk for SARS-CoV-2 spreading among their residents. If infected with SARS-CoV-2, the virus that causes COVID-19, assisted living residents—often older adults with underlying medical conditions—are at increased risk for severe illness. CDC is aware of confirmed cases of COVID-19 among residents of ALFs in multiple states. Experience with outbreaks in nursing homes has demonstrated that residents with COVID-19 may not report common symptoms such as fever or respiratory symptoms; some may not report any symptoms. Unrecognized asymptomatic and pre-symptomatic infections likely contribute to transmission in these settings. Therefore, CDC recommends source control measures for all persons, including when in a healthcare setting.  Detailed recommendations, including when facemasks versus cloth face coverings should be used are in the CDC’s Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings

ALFs should refer to guidance from state and local officials when making decisions about relaxing restrictions (e.g., easing visitor restrictions, allowing group activities, or restoring communal dining).  CMS has created Nursing Home Reopening Recommendations for State and Local Officials pdf icon[180 KB, 11 Pages]external icon.  This guidance was created specifically for nursing homes, but content might also be informative for ALFs.

When relaxing any restrictions, ALFs must remain vigilant for COVID-19 among residents and personnel in order to prevent spread and protect residents and personnel from severe infections, hospitalizations, and death.

Depending on the level of care and services provided in the ALF, recommendations in the following guidance documents may also apply:

To prevent spread of COVID-19 in their facilities, ALFs should take the following actions:

Identify a point of contact at the local health department to facilitate prompt notification as follows:

  • Immediately notify the health department about any of the following:
    • If COVID-19 is suspected or confirmed among residents or facility personnel;
    • If a resident develops severe respiratory infection resulting in hospitalization;
    • If 3 or more residents or facility personnel develop new-onset  respiratory symptoms within 72 hours of each other.

Prompt notification of the health department about residents and personnel with suspected or confirmed COVID-19 is critical.  The health department can help ensure all recommended infection prevention and control measures are in place.  Often, when a new-onset infection is identified, there are others in the facility who are also infected but who do not yet have symptoms. Rapid action to identify, isolate, and test others who might be infected is critical to prevent further spread.

In addition to guidance for health departments addressing case investigation and contact tracing that helps to define who should be considered exposed, CDC has also released SARS-CoV-2 testing guidance for nursing homes, which might be helpful to ALFs.

Educate residents, family members, and personnel about COVID-19:

Have a plan for visitor and personnel restrictions

  • Encourage residents to limit outside visitors; visitor restrictions are to protect them and others in the facility who might have conditions making them more vulnerable to severe illness from COVID-19.
    • In some jurisdictions, a total restriction of visitors might be warranted based on community prevalence of COVID-19 and guidance from local and state officials.
  • Facilitate and encourage alternative methods for visitation pdf icon[440 KB, 1 Page] (e.g., video conferencing) and communication with residents
  • Create or review an inventory of all volunteers and personnel who provide care in the facility, including consultant personnel (e.g., home health personnel, barber, nail care). Use that inventory to determine which personnel are non-essential and whose services can be delayed. This inventory can also be used to notify personnel if COVID-19 is identified in the facility.
    • In some jurisdictions, a total restriction of all volunteers and non-essential personnel including certain consultant services (e.g., barber, nail care) might be warranted based on community prevalence of COVID-19 and guidance from local and state officials.
  • Post signage at all entrances and leave notices for contract service providers at all residences that:
    • Provide information about current visitation policies or restrictions;
    • Remind visitors and personnel not to enter the building if they have fever or symptoms consistent with COVID-19.
  • Consider designating one central point of entry to the facility to facilitate screening (while maintaining social distancing) and establishing visitation hours if visitation is allowed.
  • Designate one or more facility employees to actively screen all visitors and personnel, including essential consultant personnel, for the presence of fever and symptoms consistent with COVID-19 before starting each shift/when they enter the building.
    • Send visitors and personnel home if they have a fever (temperature of 100.0 oF or greater) or symptoms consistent with COVID-19.
  • Implement sick leave policies that are flexible and non-punitive.
  • Personnel with suspected COVID-19 should be prioritized for testing.
  • Create a plan for responding to personnel with COVID-19 who may have worked while ill, which addresses identifying and performing a risk assessment for exposed residents and co-workers.
  • Encourage personnel who work in multiple locations to tell facilities if they have worked in other facilities with recognized COVID-19 cases.

Encourage source control

  • Everyone in the facility should practice source control.
  • Personnel should wear a facemask (or cloth face covering if facemasks are not available or only source control is required) at all times while they are in the facility.
    • When available, facemasks are generally preferred over cloth face coverings for healthcare personnel as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Guidance on extended use and reuse of facemasks is available. Cloth face coverings are not personal protective equipment (PPE) and should NOT be worn instead of a respirator or facemask if more than source control is required.
  • Visitors should wear a cloth face covering while in the facility.
  • Encourage residents to wear a cloth face covering (if tolerated) whenever they are around others, including when they leave their rooms and when they leave the facility (e.g., residents receiving hemodialysis).

Cloth face coverings should not be worn or placed on anyone who has trouble breathing, or anyone who is unconscious, incapacitated, or otherwise unable to remove the mask without assistance.  Additionally, they should not be placed on children under age 2.

Encourage social (physical) distancing

  • Modify or cancel group activities
    • Instead of communal dining, consider delivering meals to rooms, creating a “grab n’ go” option for residents, or staggering mealtimes to accommodate social distancing while dining (e.g., a single person per table).
    • Schedule group activities in a staggered fashion to limit number of residents participating and allow them to remain at least 6 feet apart from each other
    • Remind residents to remain at least 6 feet apart from others when they are outside their room
  • Remind personnel to practice social distancing while in break rooms and common areas, cancel non-essential meetings, and consider alternate methods for essential meetings (e.g., virtual)

Provide access to supplies and implement recommended infection prevention and control practices:

  • Provide access to alcohol-based hand sanitizer with at least 60% alcohol throughout the facility and keep sinks stocked with soap and paper towels.
    • Remind residents, visitors, and personnel to frequently perform hand hygiene
  • Ensure adequate cleaning and disinfection supplies are available. Provide EPA-registered disposable disinfectant wipes so that commonly used surfaces can be wiped down.
    • Routinely (at least once per day) clean and disinfect surfaces and objects that are frequently touched in common areas. This may include cleaning surfaces and objects not ordinarily cleaned daily (e.g., door handles, faucets, toilet handles, light switches, elevator buttons, handrails, handicap access door panels, countertops, chairs, tables, remote controls, shared electronic equipment, and shared exercise equipment).
    • Use regular cleaners, according to the directions on the label. For disinfection, refer to List Nexternal icon on the EPA website for a list of products that are EPA-approved for use against the virus that causes COVID-19. Follow the manufacturer’s instructions for all cleaning and disinfection products (e.g., concentration, application method and contact time).

Rapidly identify and properly respond to residents with suspected or confirmed COVID-19:

  • Designate one or more facility employees to ensure all residents have been asked at least daily about fever and symptoms consistent with COVID-19.
    • Implement a process with a facility point of contact that residents can notify (e.g., call by phone) if they develop symptoms.

Older people with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Identification of symptoms consistent with COVID-19 should prompt isolation and further evaluation for COVID-19.

  • If COVID-19 is identified or suspected in a resident (i.e., resident reports fever or symptoms consistent with COVID-19):
    • Immediately isolate the resident in their room and notify the health department. The resident should be prioritized for testing.
    • Encourage all other residents to self-isolate, if not already doing so, while awaiting assessment to determine if they are also infected or exposed.
    • Maintain social distancing (remaining at least 6 feet apart) between all residents and personnel, while still providing necessary services.
    • For situations where close contact with any (symptomatic or asymptomatic) resident cannot be avoided, personnel should at a minimum, wear:
      • Eye protection (goggles or face shield) and an N95 or higher-level respirator (or a facemask if respirators are not available). Cloth face coverings are not PPE and should not be used when a respirator or facemask is indicated.
      • If personnel have direct contact with a resident, they should also wear gloves. If available, gowns are also recommended but should be prioritized for activities where splashes or sprays are anticipated, or high-contact resident-care activities that provide opportunities for transfer to pathogens to hands and clothing of personnel (e.g., dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care).
    • Personnel who do not interact with residents (e.g., not within 6 feet) and do not clean resident environments or equipment do not need to wear PPE. However, they should wear a cloth face covering or, if PPE supplies are sufficient, a facemask for source control.
    • Personnel who are expected to use PPE should receive training on selection and use of PPE, including demonstrating competency with putting on and removing PPE in a manner to prevent self-contamination.
    • CDC has provided strategies for optimizing personal protective equipment (PPE) supply that describe actions facilities can take to extend their supply if, despite efforts to obtain additional PPE, there are shortages. These include strategies such as extended use or reuse of respirators, facemasks, and disposable eye protection.
  • A resident with COVID-19 might be able to remain in the facility if the resident:
    • Is able to perform their own activities of daily living;
    • Can isolate in their room for the duration of their illness;
    • Can have meals delivered;
    • Can be regularly checked on by staff (e.g., checking in by phone during each shift; visits by home health agency personnel who wear all recommended PPE);
    • Is able to request assistance if needed.
  • It might also be possible for residents with COVID-19 who require more assistance to remain in the facility if they can remain isolated in their room, and on-site or consultant personnel can provide the level of care needed with access to all recommended PPE and training on proper selection and use.
  • If the resident with COVID-19 requires more assistance than can be safely provided by on-site or consultant personnel (e.g., home health agency), they should be transferred (in consultation with public health) to another location (e.g., alternate care site, hospital) that is equipped to adhere to recommended infection prevention and control practices. Transport personnel and the receiving facility should be notified about the suspected diagnosis prior to transfer.
    • While awaiting transfer, residents should be separated from others (e.g., remain in their room with the door closed) and should wear a cloth face covering or facemask (if tolerated) when others are in the room and during transport.
    • Appropriate PPE (as described above) should be used by personnel when coming in contact with the resident.
  • If residents are transferred to the hospital or another care setting, actively follow up with that facility and resident family members to determine if the resident was confirmed or suspected to have COVID-19. This information will inform need for contact tracing or implementation of additional infection prevention and control recommendations.

Report COVID-19 cases, facility staffing, and supply information to the National Healthcare Safety Network (NHSN) Long-term Care Facility (LTCF) COVID-19 module weekly

  • While ALFs do not have the same federal requirement to report to NSHN as nursing homes, their participation is encouraged.
  • CDC’s NHSN provides LTCFs with a customized system to track infections and prevention process measures in a systematic way. ALFs can report into the 4 pathways of the COVID-19 module including:
    • Resident impact and facility capacity;
    • Staff and personnel impact;
    • Supplies and personal protective equipment;
    • Ventilator capacity and supplies.


Source Control: Use of a cloth face covering or facemask to cover a person’s mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing.  Facemasks and cloth face coverings should not be placed on children under age 2, anyone who has trouble breathing, or anyone who is unconscious, incapacitated, or otherwise unable to remove the mask without assistance.

Cloth face covering: Textile (cloth) covers that are intended to keep the person wearing one from spreading respiratory secretions when talking, sneezing, or coughing. They are not PPE, and it is uncertain whether cloth face coverings protect the wearer. Guidance on design, use, and maintenance of cloth face coverings is available.

Facemask: Facemasks are PPE and are often referred to as surgical masks or procedure masks. Use facemasks according to product labeling and local, state, and federal requirements. FDA-cleared surgical masks are designed to protect against splashes and sprays and are prioritized for use when such exposures are anticipated, including surgical procedures. Facemasks that are not regulated by FDA, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays.

Respirator: A respirator is a personal protective device that is worn on the face, covers at least the nose and mouth, and is used to reduce the wearer’s risk of inhaling hazardous airborne particles (including dust particles and infectious agents), gases, or vapors. Respirators are certified by the CDC/NIOSH, including those intended for use in healthcare.