COVID-19 has targeted older adults in assisted living facilities and skilled nursing facilities, resulting in high mortality, particularly in SNFs1. Unfortunately, as you undoubtedly know if you are reading this, many challenges exist to managing a COVID-19 outbreak in these two settings, and each has their own unique regulatory, clinical and social factors to consider.

An increasing number of articles and first-hand accounts of outbreaks in these settings shed light on what is needed to prepare for if COVID-19 cases occur in an ALF or SNF2. Here, we describe the eight challenges or issues that leaders and caregivers in these settings need to be aware of once COVID-19 affects residents in a facility.

Take steps to reduce asymptomatic staff transmission.

Asymptomatic staff transmission has been described and is more accepted, as seen in recent articles / editorials3. It is becoming evident that healthcare workers in assisted living and skilled nursing are important vehicles in which the SARS-CoV2 is transmitted to residents and patients. Screening procedures, including questionnaires for common signs and symptoms of COVID-19 and temperature checks, may not capture infected but asymptomatic or presymptomatic staff members.

In addition to the use of masks, we recommend limiting staff contact with residents as much as possible and keeping staff assignments as consistent as possible. Doing so might prevent a larger outbreak if an asymptomatic staff member is spreading SARS-CoV-2. Additionally, limiting staff interactions in group settings such as break rooms or meetings might reduce the spread between healthcare workers.

Loss of key staff increases risk of large outbreak.

In our experience, the loss of a director of nursing, infection prevention nurse and / or director of environmental services early in an outbreak increases the risk of a larger outbreak and more SARS-CoV2 spread between staff and residents. There is a clear need to maintain strong leadership in the facility as much as possible.

We recommend finding an alternative nurse or environmental service staff member who knows the facility well to fill these roles and be available on site. Affected leadership staff working remotely might not be able to provide the same level of guidance and ensure adherence to guidelines as being on-site. Lack of leadership presence might increase the risk of transmission, leading to increase morbidity and mortality in the facility.

Assume the outbreak is coming.

The quicker a facility can act, the better4. One of the biggest areas of risk to a facility is for a facility to think, “This will not happen in my building.”

Develop policies and procedures for cohorting; ensure appropriate personal protective equipment; order more nasopharyngeal testing swabs; obtain dedicated equipment, such as pulse oximeter and thermometers; and create or implement staffing plans and protocols for discontinuing precautions and placement of patients recently discharged from the hospital, etc., now, prior to COVID-19 introduction in the facility. Once the outbreak occurs, interventions need to move quickly and efficiently to limit spread.

It’s never wrong to use more PPE before an outbreak.

Obviously, the expectation is that, at minimum, the current health department guidelines (universal masking, for example) are followed to prevent COVID-19 infection. If enough PPE is available, however, then it never is a bad idea to encourage more widespread use throughout the facility and to use appropriate infectious disease protocols to conserve it5. For example, if you have enough face shields, then use them before an outbreak.

Remember, the only way you will know that a COVID-19 outbreak is occurring in a facility is when multiple residents or patients are infected. At that point, you no longer are preventing infection; you are trying to limit it, which can be a losing battle.

Test often.

As tests have become more widely available, the earlier you can test a resident or staff member, the better.

Because staff members seem to be the most common method of spread in a facility outbreak, the sooner you can isolate them and limit their resident contact, the better. Testing can limit spread by focusing on affected staff and tracing their contacts with other staff members so they can be monitored more closely and potentially tested. Early testing of residents also can help cohorting and can limit the exposure to SARS-CoV2 to COVID-19 negative residents.

To be able to perform rapid testing of your residents and staff, develop relationships with your local laboratory directors and county health department before an outbreak to ensure that these procedures are in place.

Always remember, however, that a negative test today does not imply a negative test in the future. Therefore, repeat testing is appropriate if a staff member is high risk or has a high level of exposure or if more symptomatic residents are being identified.

Assume about 20% to 30% of your staff members will become sick or refuse to come in.

Plan for emergency staffing and for how the facility will manage it, now. If an outbreak occurs, it is possible that multiple staff members will be affected, and developing a backup staffing model in the moment is extremely difficult.

Possible options could include the use of agency staffing, re-deploying staff members from other facilities in the organization, partnering with the state or county to ensure a staffing pool exists, or partnering with local your local hospitals to develop a backup staffing system.

A viable option for SNFs is to use the Center for Medicare & Medicaid Services training waiver for certification of nurse aides6, which can help temporarily certify bedside staff. Another option is to train some of the staff already in the facility (secretaries, front office staff, etc.) to help provide more hands-on care.

Constantly communicate with residents, patients and families.

Constantly communicating, understandably, is very challenging given the scary nature of this illness combined with visitor restrictions in facilities. The more you can communicate with families, however, the better.

Setting up systems to decrease staff burden is ideal. For example, frequently updating the facility website (if there is one), or establishing an automatic call system, possibly could serve this purpose. This service will provide reassurance to families that the facility is actively engaged and involved during an outbreak.

Collaborate with your local community partners.

As COVID-19 has found its way into long-term care, there never has been a better time to collaborate and communicate with community partners in your region.

Many facilities are facing challenges that are difficult to navigate by themselves. Community partnerships, whether they be with other ALFs or SNFs, local health systems, or local county officials, will be essential for facilities to survive this pandemic.

Resources that could be shared across a community include PPE, staff, training and education, and best practices. Establish a regional or community task force with leaders of the health care continuum and county / state department of health that focuses on COVID-19 in long-term care — the further in advance of an outbreak, the better. Doing so will lead to an improved community-wide response when the need arises.

The solutions, proposed ideas and challenges defined in this article are intended to help a long-term care facility reduce spread before it occurs and leverage local community resources to achieve this goal. If these steps are attempted during an outbreak, it often is too late to deal with some of the known barriers or issues, thus leading to further morbidity and mortality. Combining this with the scenario of multiple facilities dealing with outbreaks at the same time further stretches resources and only reiterates the fact that proper planning is warranted. 

*Disclaimer: This information is observational and meant for educational purposes only. It does not replace health department recommendations or Centers for Disease Control recommendations. Health department recommendations always take precedence.


1. Chidambarm, Priya. Henry J Kaiser Family Foundation. State Reporting of Cases and Deaths Due to COVID-19 in Long-Term Care Facilities. Accessed May 12, 2020.

2. Zimmerman S, Sloan PD, Katz PR, Kunze M, O’Neil K, Resnick B. The Need to Include Assisted Living in Responding to the COVID-19 Pandemic. JAMDA. 2020. 21; 572-575.

3. Arons MM, Hatfield KM, Reddy SC, et al. Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility. N Eng J Med. 2020. [ePub ahead of print]

4. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID19). Preparing for COVID-19: Long-term care facilities, nursing homes. Accessed May 15 2020.

5. Livingston E, Desai A, Berkwits M. Sourcing Personal Protective Equipment during the COVID 19 Pandemic. JAMA. 2020; 323 (19): 1912-1914.

6. Centers for Medicare and Medicaid Services. COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers. Accessed May 29, 2020.