Infection Control in Assisted Living: Approaches to Keeping Residents Safe

      Assisted living (AL) communities are very different state by state and even community by community. Each must adhere to their state-based requirements, which can vary based on the size of the community. AL communities can range from a few beds to a thousand beds, and the residents may have their own rooms, or small apartments, or may share a room with one or more individuals. Given these differences, infection control practices can also vary — but there are some practices that communities can engage in that help keep their residents safe.

      Infection Control Programs

      The COVID-19 pandemic has raised awareness about what should be included in infection control programs in AL communities. It is currently recommended that communities have policies and procedures that address surveillance of infections and that they collect information about residents’ exposure to and contraction of a particular communicable disease.
      Likewise, the community should complete an annual risk assessment, as recommended by the Centers for Disease Control and Prevention (CDC) (“Infection Control Assessment Tools,” Oct. 15, 2019,, provide staff and resident education, and require immunizations for staff and residents that are consistent with the recommendations for adults/older adults. Communities should also establish basic adherence to environment cleaning on a daily basis.
      All AL communities need to adhere to standard precautions, which were first established in 1991 from the Bloodborne Pathogen Standard directed by the U.S. Occupational Safety and Health Administration (OSHA). These precautions are provided in Table 1.

      Infection Outbreaks

      Infection outbreaks occur in AL communities due to a lack of adherence to the basic principles of infection control, insufficient immunizations among staff and residents, infections brought into communities by staff and visitors, contamination in devices used or food sources, and residents who bring in infections from interactions with others outside of the community.
      When an outbreak occurs, the delegating nurse or the nurse in a leadership role in the AL community must report the outbreak to the state after reviewing the medical records of the residents involved. He or she should then develop a plan to manage the outbreak (see Table 2 for an example). The staff should be monitored to ensure that they are maintaining contact precautions and using personal protective equipment (PPE) appropriately.
      Further, it is helpful to keep the staff on set units to avoid spread across units. For small communities, the ideal scenario for infection control is when the staff actually live within the community with the residents.

      Considerations for AL Residents

      Each resident is different. Some are negatively impacted by having to be isolated in their rooms during an outbreak of an infection; others may be quite content. It is often impossible to keep some individuals isolated. Gentle redirection or allowing for distance activities may be more appropriate for those negatively affected by isolation.
      Further, it may be challenging to have residents, particularly those with memory impairment, adhere to wearing masks or even observing good hand hygiene. In these cases, physical distancing can be encouraged by placing chairs in open areas at least three to six feet apart and having a sufficient number of tables for socially-distant dining. Alternatively, residents who are all affected by the same infectious disease can be cohorted to eat, visit, or engage in activities together.
      Although not specific to AL, the CDC Infection Preventionist Training Program is one of the available resources for the delegating nurse or nurse leader to create an effective training program for staff (

      Reward Staff

      We have learned much from COVID-19, and one thing to remember is to make sure your AL community adheres to good infection control practices — reward the staff for wearing and using PPE appropriately, make it fun by providing colorful masks and gloves intermittently, and have contests for innovative approaches to implement good infection control practices while maintaining resident safety.
      Dr. Resnick is the Sonya Ziporkin Gershowitz Chair in Gerontology at the University of Maryland School of Nursing and a member of the Editorial Advisory Board for Caring for the Ages.
      Ms. Kaes is ANCC Board Certified in Gerontological Nursing, has worked in long-term care for 37 years, including 18 years as Vice President of Clinical Services for Chelsea Senior Living, and is a Board Member of the Center for Excellence in Assisted Living (CEAL).
      Tabled 1Table 1. Standard Infection Control Precautions
      Hand Hygiene

      • May use an alcohol-based hand rub when hands are not visibly soiled.

      • Complete the hand hygiene before donning gloves and perform it again after removal of gloves and between procedures.
      Use of Personal Protective Equipment (PPE)

      • Use gloves, gowns, masks, eye protection, or face shields depending on anticipated exposure.

      • Don PPE before entering a resident’s room, and doff (remove) PPE before leaving the resident’s room.
      Respiratory Hygiene

      • Cover the mouth and nose during coughing and sneezing with a tissue or offer a surgical mask to a coughing resident; discard the mask or tissue appropriately and perform hand hygiene.

      • Keep residents a safe 3 to 6 feet away from others if they are coughing and can’t engage in respiratory hygiene. A safety shield placed in front of the individual is another option to keep others safe while the resident is able to be out of his or her room.
      Contact Precautions

      • PPE: Gown and glove. Always do hand hygiene with glove changes. Again, hand hygiene and regloving are necessary between procedures.

      • Environment: Clean daily with a focus on high-touch areas, resident bathrooms, and areas close to the resident.
      Droplet Precautions

      • Ideally keep residents in private rooms if infected or keep 3 to 6 feet apart.

      • PPE: Continue to wear gloves and masks during all interactions.

      • Environment: Clean daily as noted above.
      Airborne Precautions

      • PPE: Ideally use a fit-tested National Institute for Occupational Safety and Health (NIOSH)–approved N95 respirator. This face mask will remove, by filtration, airborne particles in the range of 1–5 μm

      • Remove a resident from the facility if he or she is positive for tuberculosis or certain other diseases if no negative pressure room is available.
      Staff Safety Precautions

      • Do not allow immunocompromised and/or pregnant staff to care for residents who are known or suspected to have measles (rubella), chickenpox or disseminated zoster (varicella zoster virus), or smallpox.
      Staff Zero Tolerance Regarding Illness

      • Require that staff stay home when sick, and adhere to that policy.
      Tabled 1Table 2. Example of a Management Plan After an Infection Outbreak
      • Identify case(s).

      • Identify the mode of transmission: Where and how did this start?

      • Create a cleaning schedule, especially for contact precaution–related illnesses.

      • Keep residents in their apartments/rooms, and provide meals, plan one-to-one activities, and close the dining rooms or distance the residents if possible. Alternatively, in small communities where family-style home eating together may be the only option, practice good hand and respiratory hygiene, and have staff or those not eating use personal protective equipment (PPE).

      • Report new and resolved cases to the health department as required.

      • Review the list of symptoms with all staff to provide for early symptom reporting response and treatment.

      • Monitor the residents and staff daily to prevent or identify further cases. Ensure that the staff stay home when sick by having a zero-tolerance policy.

      • Review and oversee adherence to hand hygiene, standard precautions, and other necessary precautions with staff, residents, and family/visitors.

      • Provide staff with appropriate and adequate supplies of PPE.

      • Post notices on community doors alerting visitors and vendors of the outbreak, and restrict visitors at this time, except for compassionate care.

      • Communicate with administration, families, and staff daily to advise on the progress and results of the outbreak investigation.