What Are the CDC COVID Guidelines for Nursing Homes?

The CDC’s COVID guidelines for nursing homes require every facility to run an infection prevention and control program that covers masking during active transmission, prompt testing of symptomatic and exposed people, isolation of residents who test positive, staff work restrictions, outbreak response, antiviral treatment, open visitor access, and case reporting to the federal government. These CDC recommendations sit inside a regulatory frame set by the Centers for Medicare and Medicaid Services under 42 CFR § 483.80, which makes an infection-control program a condition of participating in Medicare and Medicaid.¹ State and local health departments can add requirements on top, so a facility’s actual practice reflects all three tiers.

When Masking Is Required

After the federal Public Health Emergency ended in May 2023, the CDC retired the Community Transmission levels metric that used to trigger facility-wide masking. Facilities now pick their own local indicators of respiratory virus activity and decide when to expand masking.²

Some situations call for a mask regardless of local conditions. Anyone in the building with respiratory symptoms or a confirmed COVID-19 infection should be masked. Visitors and residents who had close contact with a confirmed case should mask for 10 days after the exposure. And when active transmission is occurring inside the facility, universal masking should be in place on the affected units or throughout the building.²

Testing Residents and Staff

Any resident or staff member who develops new respiratory symptoms should be tested. At a minimum the test should cover both SARS-CoV-2 and influenza, and the CDC prefers multiplex tests that screen for several viruses at once because the result guides both treatment and infection-control choices.³

After a Close Contact

When an asymptomatic resident or staff member has been in close contact with a confirmed case, the CDC recommends three viral tests over five days. The first test is done no earlier than 24 hours after the exposure (Day 1, counting the exposure as Day 0). If it’s negative, another test follows 48 hours later on Day 3, and a third 48 hours after that on Day 5.²

During an Outbreak

Universal routine screening of asymptomatic staff is no longer a blanket CDC recommendation, though a facility or state health department can still require it. Once transmission is active, the CDC recommends broad testing across affected units or the whole facility rather than relying only on close-contact tracing, which tends to miss silent infections in a congregate setting. Outbreak testing should continue every three to seven days until no new cases appear for 14 consecutive days.²

Isolating Residents Who Test Positive

A resident who tests positive should be placed in a single-person room or grouped with other confirmed-positive residents. The CDC’s healthcare isolation timeline is longer than the shortened general-public guidance issued in 2024. For a resident with mild to moderate illness who is not significantly immunocompromised, isolation lasts at least 10 days from the day symptoms first appeared, and the resident must also have been fever-free for 24 hours without fever-reducing medication with symptoms improving.² If the resident never develops symptoms, the 10 days run from the date of the first positive test.

Residents who are moderately to severely immunocompromised stay infectious longer. The CDC recommends isolating them for at least 10 days and up to 20, with the actual length set through serial testing and input from an infectious disease specialist. Some patients remain contagious past 20 days, so clinical judgment carries real weight here.²

Federal regulations require that any isolation be the least restrictive arrangement the situation allows.¹ A positive test does not suspend a resident’s rights to dignity, to communication with family, or to participation in decisions about their own care. Facilities should provide phone or video access to family and keep isolated residents engaged.

Staff Exclusion and Return to Work

Staff who test positive are kept out of work. For healthcare personnel with mild to moderate illness who are not significantly immunocompromised, the CDC’s standard paths back are:

With a negative viral test taken within 48 hours before returning, at least 7 days from symptom onset (or from the positive test date if asymptomatic), fever-free for 24 hours without medication, and symptoms improving.
Without testing, at least 10 days from symptom onset, with the same fever and symptom criteria.
For severe illness, at least 10 days and up to 20 days from symptom onset, plus fever and symptom resolution.⁴

Staff who were exposed but stay asymptomatic are not automatically pulled from work. They must wear a mask in the facility and complete the three-test post-exposure series.⁴

When a facility can’t keep enough staff on the floor using the standard timeline, the CDC allows two fallback tiers. Under contingency capacity, staff with mild to moderate illness who are not significantly immunocompromised can return after five days from symptom onset if they’ve been fever-free for 24 hours and symptoms are improving, with clearance confirmed by a negative molecular test or two negative antigen tests 48 hours apart. Under crisis capacity, a genuine last resort, staff can work before meeting even the contingency criteria, but they should be kept away from moderately to severely immunocompromised residents.⁵

Responding to an Outbreak

A single new case among staff or residents triggers an investigation. The facility has to figure out who else was exposed and choose between traditional close-contact tracing and a broader unit-wide or facility-wide response. The CDC favors the broad approach in nursing homes because close contacts in a shared living setting are hard to pin down precisely, and missing one chain lets the virus keep spreading.²

When first steps fail to stop the spread, facilities should apply universal masking on affected units, put exposed residents on transmission-based precautions, and restrict exposed staff from work. Testing continues every three to seven days across affected areas until no new cases appear for 14 days. Facilities must also notify their local public health authority and follow any state or local outbreak guidance layered on top.²

Antiviral Treatment After a Positive Test

The CDC’s nursing home toolkit uses a “test and treat” approach: when a resident tests positive, the clinical team should evaluate immediately whether antiviral therapy is appropriate.³ Treatment has to start within five days of symptom onset, and each hour of delay reduces effectiveness.

Nirmatrelvir-ritonavir (Paxlovid) is the primary oral antiviral, taken twice daily for five days. The CDC identifies nursing home residents as a higher-risk population for severe outcomes based on age, vaccination status, and the congregate living environment itself.⁶ Drug interactions matter in this population because most residents take several medications, so facilities should have pharmacy connections in place before an outbreak rather than after.

Visitor Access

Federal guidance on visits is direct: nursing homes must allow indoor visitation for all residents at all times. Facilities cannot limit how often or how long visitors come, cap the number of visitors, or require advance scheduling. A facility that restricts visitation without a reasonable clinical or safety justification risks citation and enforcement for violating resident rights under 42 CFR § 483.10(f)(4).⁷

CMS has stated that no COVID-19 scenario now justifies limiting visitation, other than moving the visit to the resident’s room rather than a common area. During active transmission, visitors should be informed of the risk and counseled to wear a mask, but the visit itself cannot be denied as long as the resident or their representative accepts the risk and the visit doesn’t endanger others.⁷ When community respiratory virus levels are elevated, facilities should ask all visitors to mask throughout the visit, and any visitor who has had close contact with a confirmed case should mask for the entire visit.⁸

Vaccination Rules Today

The federal staff vaccination mandate CMS imposed in late 2021 has expired.⁹ Facilities are no longer required under federal law to make sure all staff are vaccinated for COVID-19 as a condition of Medicare and Medicaid participation. States or individual employers can still impose their own vaccination requirements, so staff should check local rules.

Residents keep the right to accept or refuse a COVID-19 vaccine. The CDC continues to recommend that facilities offer updated vaccines to residents and staff, and vaccination status remains a data point facilities have to track and report.

Reporting to the CDC

Nursing homes report surveillance data to the CDC through the National Healthcare Safety Network. Starting January 1, 2025, the reporting scope expanded past COVID-19. Facilities now electronically report data on COVID-19, influenza, and RSV, including facility census, resident vaccination status for all three viruses, confirmed cases broken down by vaccination status, and hospitalizations linked to confirmed infections.¹⁰ Facilities that fail to report required data face civil money penalties from CMS, which treats reporting as an ongoing condition of participation.

If a Facility Isn’t Following the Guidelines

Residents and families who see infection-control failures or unjustified visitor restrictions have concrete options. The main step is filing a complaint with the State Survey Agency, usually part of the state health department, which inspects nursing homes and can act on what it finds. Complaints can be filed anonymously.¹¹

Every state also has a Long-Term Care Ombudsman program, established under the Older Americans Act, whose role is to protect residents’ health, safety, and rights. Ombudsman representatives can investigate complaints, advocate for a resident, and communicate by phone or video when in-person access is limited. Nursing homes are required to facilitate resident contact with the Ombudsman program regardless of the resident’s isolation status.¹² For help working through the complaint process, call Medicare at 1-800-633-4227.

1
eCFR. 42 CFR 483.80 – Infection Control
2
Centers for Disease Control and Prevention. Infection Control Guidance: SARS-CoV-2
3
Centers for Disease Control and Prevention. Viral Respiratory Pathogens Toolkit for Nursing Homes
4
Centers for Disease Control and Prevention. Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2
5
Centers for Disease Control and Prevention. Strategies to Mitigate Healthcare Personnel Staffing Shortages
6
Centers for Disease Control and Prevention. COVID-19 Treatment Clinical Care for Outpatients
7
Centers for Medicare & Medicaid Services. Nursing Home Visitation – COVID-19 (REVISED) QSO-20-39-NH
8
Centers for Disease Control and Prevention. Viral Respiratory Pathogens Toolkit for Nursing Homes (PDF)
9
Centers for Medicare & Medicaid Services. Interim Final Rule – COVID-19 Vaccine Immunization Requirements for Residents and Staff EXPIRED
10
Centers for Medicare & Medicaid Services. QSO-25-11-NH
11
Medicare.gov. Filing a Complaint
12
Administration for Community Living. Long-Term Care Ombudsman Program and COVID-19