1-19-23 This SNF Guidance is currently being updated to remove certain requirements that were put in place for extra protection during the winter surge. As of 1-18-23:
Please note that the guidelines below have not yet been updated to reflect these changes.
These guidelines outline actions that Skilled Nursing Facilities (SNFs) should take to help prevent and manage COVID-19, based on the current status of and trends in community transmission in LA County.
The current CDC COVID-19 Community Level for Los Angeles County is High as of Dec 8, 2022.
Case: A case is defined as an individual with a positive viral test (e.g., PCR/NAAT or antigen test) regardless of symptoms unless a confirmatory PCR/NAAT test is negative for an asymptomatic individual with a positive antigen test.
The separation of persons with COVID-19 from persons without COVID-19. Isolation measures in SNFs include restricting the resident to their room, infected residents wearing well-fitting masks when not in their rooms, and staff donning full PPE prior to providing care or entering rooms where there are infected persons (i.e., placing on transmission based precautions). Please see “Isolation and Quarantine” section below for more details.
Quarantine keeps asymptomatic persons who might have been exposed to SARS-CoV-2 away from others to see if they become infected. Quarantine in SNFs, when required, involves restricting the resident to their room as much as possible, exposed residents wearing well-fitting masks when not in their rooms, and staff donning full PPE prior to providing care or entering rooms where there are exposed persons (i.e., placing on transmission-based precautions). Residents in quarantine should be managed in-place; avoid movement of residents to different rooms that could lead to new exposures. Please see “Isolation and Quarantine” section below for more details.
An individual is considered up to date with COVID-19 vaccines when they have received all recommended doses in the primary series and the most recent booster dose recommended for them by the CDC.
Essential visitors include the following:
Staying up to date with COVID-19 vaccines including recommended boosters is critical to protecting both residents and staff in SNFs. The latest COVID-19 vaccine clinical recommendations are located on CDC’s website: Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the US. Below are key COVID-19 vaccine guidance and resources for SNFs in LA County.
The updated (bivalent) boosters are recommended for everyone ages 5 and older if it has been at least 2 months after the last COVID-19 vaccine dose. These boosters have been updated to target the most recent Omicron subvariants (BA.4/BA.5) as well as the original COVID-19 virus. The BA.4/BA.5 subvariants are more contagious than earlier strains of Omicron. The updated boosters can help restore protection against COVID-19 that has decreased over time and provide broader protection against newer variants. Keeping everyone up to date with their COVID-19 vaccines, including the updated booster can help significantly protect SNF residents and staff from transmission and severe outcomes like hospitalizations and deaths related to COVID-19.
Visit the LAC DPH COVID-19 Vaccine Schedule website for more information including color-coded vaccine schedules in English and Spanish. Additional vaccine resources from are located on the DPH vaccine resources page.
Track, Increase, and Maintain COVID-19 Vaccination & Booster Coverage
*Please read the full orders for description of who is included in “workers”.
Outpatient COVID-19 Treatment: Oral Antivirals
There are highly effective outpatient COVID-19 treatments to prevent severe outcomes, including hospitalizations and death, among high-risk individuals infected with COVID-19 including nursing home residents. The preferred outpatient treatment is ritonavir-boosted nirmatrelvir (Paxlovid), an oral antiviral, or intravenous remdesivir. Molnupiravir (Lagevrio) is an alternative if these preferred treatments are not appropriate or accessible. Because they need to be started within five (5) days of symptom onset, it is crucial to initiate the process of assessing residents with confirmed COVID-19 as soon as they test positive. Per LAC DPH’s Order of the Health Officer on Prevention of COVID-19 Transmission in SNFs and CDPH AFL 20-22 (COVID-19 Treatment Resources for SNFs), all residents with a positive SARS-CoV-2 viral test must be immediately assessed by their healthcare provider for any symptoms of COVID-19. Outpatient COVID-19 treatment, specifically ritonavir-boosted nirmatrelvir or molnupiravir, should be initiated at the facility within 5 days of symptom onset if clinically appropriate, i.e., they have mild or moderate symptoms and there are no contraindications or drug-drug interactions. Facilities should not transfer residents to hospitals solely for treatment of mild or moderate COVID-19. Residents should be treated at their SNF.
To ensure facilities are meeting the requirements set forth in LAC DPH’s SNF Health Officer Order and CDPH AFL 20-22, facilities should:
Residents with confirmed COVID-19 may also be assessed for and offered IV remdesivir. For more information please see LAC DPH’s COVID-19 Outpatient Therapeutics page and NIH’s Therapeutic Management of Nonhospitalized Adults with COVID-19 for the most up to date information.
Residents should also be evaluated by their healthcare providers for eligibility for pre-exposure prophylaxis. Residents are eligible if they have moderate to severe immune compromise and/or have not received any available COVID-19 vaccine due to a true medical contraindication (e.g., severe allergic reaction) AND they are neither currently infected nor recently exposed (i.e., not in quarantine or isolating in the Red Cohort). Currently, tixagevimab/cilgavimab (Evusheld) has emergency use authorization (EUA) for pre-exposure prophylaxis and can be administered via intramuscular injection. Please bookmark and refer to LAC DPH’s COVID-19 Outpatient Therapeutics page for the most up to date information.
Below are general and COVID-19 specific recommendations. For more information on infection control basics and the difference between standard and transmission-based precautions, visit https://www.cdc.gov/infectioncontrol/basics/index.html.
Hand Hygiene (HH)
Respiratory Hygiene/Cough Etiquette:
Transmission Based Precautions and Personal Protective Equipment (PPE)
HCP should follow transmission-based precautions for residents in isolation including standard precautions as summarized in figure 1 and detailed below.
Figure 1. PPE for COVID-19
Ventilation, Filtration, and Air Quality: Effective ventilation is one of the most important ways to control small aerosol transmission. Facilities should consult with professionals (facilities engineers, mechanical engineers, indoor air quality or industrial hygiene consultants, etc.) to perform comprehensive evaluations of their HVAC (Heating, Ventilation, and Air Conditioning) systems and indoor air quality and obtain permits or approvals from any applicable regulatory bodies as necessary prior to implementing changes. Facilities should not rely on any single solution to effectively improve the ventilation and air quality of their buildings. Importantly, ventilation and other indoor air quality improvements are additions to and not replacements for infection prevention and control including any applicable state or local directives. Please carefully review in full the following guidance from CDPH, Department of Health Care Access and Information (HCAI) formerly OSHPD, and Cal/OSHA: Interim Guidance for Ventilation, Filtration, and Air Quality in Indoor Environments.
Please note SNFs have a second opportunity to apply for Civil Money Penalty (CMP) Reinvestment funds to purchase portable fans and portable room air cleaners with high-efficiency particulate air (HEPA, H-13 or -14) filters to increase air exchange or improve air quality. Facilities should only use portable air cleaners with the involvement of professionals and following the Interim Guidance for Ventilation, Filtration, and Air Quality in Indoor Environments. Placement of portable air cleaners must be carefully considered to avoid blowing air from one person to another especially in multi-occupancy rooms and communal areas and should not be placed in corners of rooms or beneath tables where they will not effectively clean the air. Do not create tripping hazards with these devices or associated electrical cords that increase fall risk for SNF residents. Finally, please note LAC DPH does not necessarily endorse the usage of portable air cleaners as the most effective or only strategy to improve ventilation and indoor air quality in SNFs, but recommend SNFs to consult with professionals on a comprehensive evaluation and plan.
In addition to CDC guidelines, the recommendations below are referenced from the California Department of Public Health AFL for Environmental Infection Control for the Coronavirus Disease 2019 (COVID-19).
The following recommendations for communal dining, group activities, and visitation are based upon the most recent CDPH All Facility Letter (AFL) and CMS Quality Safety & Oversight memo (QSO):
The purpose of these guidelines is to help each facility develop resident-centered visitation, communal dining, and group activity policies that balances the need to protect staff and residents from COVID-19 transmission with the need to provide timely care that optimizes residents’ physical and psychological health in alignment with state and federal requirements.
Facilities may not restrict visitation or suspend communal dining and group activities without a reasonable clinical or safety cause, consistent with resident rights in the federal regulation Title 42 CFR section 483.10(f)(4)(v) as stated in CDPH AFL 22-07 and CMS QSO 20-39-NH-Revised. Residents have the right to make choices about aspects of his or her life in the facility that are significant to the resident as long as it does not impose on the rights of other residents. Furthermore, residents or their designated representative when the resident does not have capacity, should be involved, and have their preferences prioritized. To mitigate risks to other, visitation, communal dining, and group activities should be conducted adhering to the “Core Principles of COVID-19 Infection Prevention” by following the guidance in this section and the rest of this guidance including but not limited to the “Infection Prevention and Control Guidance” section. Failure to facilitate resident rights, without adequate reason related to clinical necessity or resident safety, would constitute a potential violation of this federal regulation, and the facility would be subject to citation and enforcement actions.
Communal Dining and Group Activities
Communal dining and group activities should be permitted for residents who are not in isolation (suspect isolating in-place or confirmed isolation in the Red Cohort), not a close contact, nor undergoing testing as a part of broad-based response testing. These activities may take place indoors or outdoors regardless of the facility’s outbreak status and regardless of the resident’s vaccination status. Facilities must continue to follow all infection prevention and control measures to conduct communal dining and group activities safely.
The facility should adhere to the following measures for all communal dining and activities:
Table 1. Resident Masking Requirements During Communal Dining and Group Activities
|Active outbreak or within 14 days of outbreak closure||No outbreak for 14 days or more|
|CDC Community Level: Low||Well-fitting face masks are required* when not actively eating or drinking, regardless of vaccination status||Well-fitting face masks are optional^ but recommended when not actively eating or drinking, regardless of vaccination status|
|CDC Community Level: Medium to High||Well-fitting face masks are required* when not actively eating or drinking, regardless of vaccination status||Well-fitting face masks are required* when not actively eating or drinking, regardless of vaccination status|
*When safe and practical. Please see contraindications under source control for residents.
^Exception: Residents who are new admissions, re-admissions, or have returned after leaving the facility more than 24 hrs must wear face masks for 10 days.
If there is a COVID-19 outbreak in the facility, then the following applies:
Visitation should be supported by the facility in a manner that is consistent with resident rights in the federal regulation Title 42 CFR section 483.10(f)(4)(v).
|Table 2. Infection Prevention & Control Requirements for Visitation|
|Residents Not in Isolation or Quarantine||Residents in Isolation (Red Cohort or in-place)|
|Face Masks||All visitors must wear well-fitting mask with good filtration (N95, KF94, KN95, or surgical masks are preferred over cloth face coverings) throughout the visit when indoors or in-room when not actively eating/drinking. Residents should also wear well-fitting face mask if safe and practical when not actively eating/drinking.||All visitors must wear N95 respirator or higher throughout the visit and perform a seal check. Residents should also wear well-fitted face masks if safe and practical.|
|PPE||Visitors are required to properly don and doff any additional PPE (eye protection, gowns, gloves) required per COVID-19 transmission based precautions according to instruction by facility staff.|
|Physical Distancing||There is no recommendation to physically distance or avoid physical contact (e.g., hugs, holding hands) between a resident and their visitor(s), regardless of vaccination status. However, physical distancing should be maintained between other resident-visitor groups both indoors and outdoors.|
|Location of Visit||
Below are recommendations for testing in SNFs based upon California Department of Public Health (CDPH) requirements outlined in recent CDPH AFLs:
NOTE: Interpretation of COVID-19 viral test results does not change after an individual has received COVID-19 vaccination.
Testing of Symptomatic Residents or Staff.
Post-exposure and Response Testing. If a single positive COVID-19 case is identified among either staff or residents, the SNF must immediately conduct contact tracing to identify all residents who may have had close contact with the case(s) and all staff who may have had higher-risk exposures with case(s). Post-exposure and response testing should occur depending on the level of the exposure or ability to contact trace as described in figure 2 and detailed below.
Figure 2. Post-exposure and Response Testing
Routine Screening Testing. Routine screening testing must be conducted according to the LA County Health Officer Order as described below. Please note when there are differences in testing requirements, the most conservative testing guidance must be followed. Routine screening testing is resumed when no new cases are identified from two sequential weeks of response testing.
New Admission and Re-admission Testing. Residents who are asymptomatic and newly admitted or re-admitted to a facility should undergo serial testing on days 0, 3, and 5 after admission (day 0). New admissions and re-admissions do not need to quarantine. New admissions and re-admissions who are asymptomatic, not close contacts, and within 90 days of a prior COVID-19 infection do not need to undergo testing. If a new admission or re-admission tests positive by a PCR/NAAT test, then they should be immediately isolated following guidance in the “Isolation and Quarantine” section. If a new admission or re-admission who is asymptomatic tests positive by antigen testing, then they should be isolated in place pending confirmatory PCR/NAAT test results. The results of the PCR/NAAT test will determine whether the resident should be isolated in the Red Cohort or if isolation can be discontinued.
Residents who have returned after leaving the facility for 24 hours or longer should be managed as an admission.
Figure 3. Testing Schematic
Retesting Previously Positive Staff/Residents
Refusal of Testing
Isolation Area (Red Cohort): This designated, physically separate area is only for residents who have confirmed COVID-19 with or without symptoms.
Isolation in place of suspect cases: Residents with COVID-19 signs or symptoms who are pending test results or who refuse to test should isolate in place. Additionally, asymptomatic residents with a positive test pending confirmatory PCR/NAAT testing results should also isolate in place. If SARS-CoV-2 infection is confirmed, then residents should be moved into the Red Cohort to complete the remainder of their isolation.
Quarantine: Quarantine is no longer required for asymptomatic residents who have known or possible exposures to COVID-19. However, in an outbreak, Public Health may direct facilities to quarantine the following resident groups in order to mitigate transmission: asymptomatic residents who are close contacts, included in group-level or facility-wide post-exposure and response testing, new admissions, re-admissions, or returning after leaving the facility >24 hours.
Regardless of decision to quarantine, residents in these above groups should:
If quarantine is required:
Table 3. Summary of Testing and Infection Control Guidance for Residents
|Testing||Who||Infection Control Measures|
|Testing of Symptomatic Residents: One antigen test immediately and if negative, one PCR/NAAT test collected 48 hrs later;
One PCR/NAAT test immediately
|Residents with symptoms of COVID-19, regardless of vaccination status||Immediately isolate in place** (avoid movement of residents that could lead to new exposures) and place on COVID-19 transmission based precautions while pending clinical evaluation and testing results.
Isolation duration (see “Isolation and Quarantine” section for more details):
|Close Contacts Post-exposure and Response Testing: Serially testing 3 times on days 1, 3, and 5 after the last exposure (day 0).
Antigen tests or PCR/NAAT tests (if TAT is <48 hrs) may be utilized.
If a resident recently recovered from a COVID-19 infection 31-90 days ago, then antigen testing is preferred over PCR/NAAT testing.
|Residents who are close contacts identified via contact tracing, regardless of vaccination status||
|Group-level and Facility-wide Post-exposure and Response Testing: Start by serially testing on days 1, 3, and 5 after the last exposure (day 0); subsequent serial re-testing should be every 3-7 days for PCR/NAAT tests (if TAT <48 hrs) or at least twice per week or every 3 days for antigen tests.
Any asymptomatic residents with positive antigen test results should be immediately followed up with PCR/NAAT testing.
|Group-level testing: Residents in the same group* (unit, wing, nursing station area, etc.) where a positive case was identified regardless of vaccination status; OR
Facility-wide testing: All residents in the facility*, regardless of vaccination status
|Routine screening testing: Generally not required or recommended for residents.
Exception: Once weekly screening testing of residents who frequently leave the facility is recommended, regardless of vaccination status, when the CDC Community Level is Medium to High.
|Residents who are asymptomatic, not a new admission or re-admission, has not left facility ≥24 hours, not a close contact, and when there is no facility-wide or group-level post-exposure and response testing. Regardless of vaccination status.||
|New Admission and Re-Admission Testing: serially test a total of 3 times on days 0, 3, and 5 after admission (day 0).
Antigen tests or PCR/NAAT tests (if TAT is <48 hrs) may be utilized.
|Residents who are new admission, re-admissions, or returning after leaving the facility >24 hrs*, regardless of vaccination status.||
*Residents who are asymptomatic, not close contacts, and recently recovered from a prior COVID-19 infection within the last 90 days are exempt from routine screening testing (if applicable), group-level and facility-wide post-exposure and response testing, and new admission/re-admission testing requirements, regardless of vaccination status.
**Quarantine involves 1) restricting the resident to their room; 2) resident wearing well-fitting face masks when not in their rooms; and 2) staff wearing full PPE per COVID transmission based precautions when providing care or entering a room where the resident is (resident room, shower room, rehab gym, etc.). Residents in quarantine should be managed in-place; avoid movement of residents that could lead to new exposures.
All HCP should routinely self-monitor for symptoms of possible COVID-19 and the facility should screen all HCP for symptoms of COVID-19 prior to the start of shifts as per the LAC DPH COVID-19 Infection Prevention Guidance for Healthcare Personnel. For return to work for HCP refer to the following sections:
Facilities are required to follow transfer and home discharge rules as listed on the LAC DPH website (http://publichealth.lacounty.gov/acd/NCorona2019/InterfacilityTransferRules.htm).
Facilities are required to report all positive test results from point-of-care SARS-CoV-2 antigen tests, any suspected COVID-19 outbreak*, and all fatalities associated with COVID-19 within 24 hours including out of facility/hospital deaths of presumed cases and all deaths that occurred during an active COVID-19 outbreak, regardless of testing.
*Please note that the current COVID-19 outbreak definition for SNFs in Los Angeles County is at least one PCR/NAAT laboratory confirmed case of COVID-19 (symptomatic or asymptomatic) OR at least one symptomatic case with a positive SARS-CoV-2 antigen result in a SNF resident who has been at the facility for at least 7 days.
For more details, please see the LAC DPH COVID-19 Case Reporting Protocol for SNFs flowchart.
Reliable sources of information about COVID-19 infection prevention/control and vaccination in SNFs: