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OSHA is committed to protecting the health and safety of 

America’s workers. This guidance is designed specifically for 

nursing homes, assisted living, and other long-term care facilities 

(LTCFs) (e.g., skilled nursing facilities, inpatient hospice, convalescent homes, and group homes with nursing care). LTCFs are 

different than other healthcare settings because they assist residents and clients with tasks of daily living in addition to providing 

skilled nursing care. 

While this guidance focuses on protecting workers from 

occupational exposure to SARS-CoV-2 (the virus that causes 

COVID-19 disease) by the use of respirators, primary reliance 

on engineering and administrative controls for controlling 

exposure is consistent with good industrial hygiene practice and 

with OSHA’s traditional adherence to a “hierarchy of controls.”1

Under this hierarchy, engineering and administrative controls are 

preferred to personal protective equipment (PPE). Therefore, 

employers should always reassess their engineering controls 

(e.g., ventilation) and administrative controls (e.g., hand hygiene, 

physical distancing, cleaning/disinfection of surfaces ) to identify 

any changes they can make to avoid over-reliance on respirators 

and other PPE (see CDC’s COVID-19 webpage on Nursing Homes 

and Long-Term Care Facilities). This is especially vital considering 

the current supply chain demand for N95 filtering facepiece 

1 More information about the hierarchy of controls can be found at: 

https://www.osha.gov/shpguidelines/hazard-prevention.html.

RESPIRATORY PROTECTION GUIDANCE 

for the Employers of Those Working in Nursing 

Homes, Assisted Living, and Other Long-Term Care 

Facilities During the COVID-19 Pandemic
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respirators (FFRs). Additional control strategies for preventing exposure 

to SARS-CoV-2 in LTCFs can be found in OSHA’s COVID-19 Guidance for 

Nursing Home and Long-Term Care Facility Workers and CDC’s Nursing 

Homes and Long-Term Care Facilities. 

Even when control strategies are in place, PPE, including respirators, 

will be needed for workers when close contact with someone who is 

known or suspected of having COVID-19 cannot be avoided. Whenever 

respirators are required, employers must implement a written, 

worksite-specific respiratory protection program (RPP), including 

medical evaluation, fit testing,2 training, and other elements, as 

specified in OSHA’s Respiratory Protection standard (29 CFR 

1910.134). OSHA requirements for other PPE (e.g., eye protection, 

protective clothing) can be found in OSHA’s General PPE standard (29 

CFR 1910.132) and Eye and Face Protection standard (29 CFR 1910.133).

Face Coverings, Facemasks Authorized for Use as Source Control by the FDA, 

FDA-cleared or Authorized Surgical Masks, and Respirators

There are multiple products/devices that can be used during the COVID-19 pandemic to cover a wearer’s 

mouth and nose, and it is important to select the right one for the situation. These products/devices 

can provide source control, and some of them are also considered PPE that will protect the wearer as 

well. Source control refers to the use of a product/device to cover a person’s mouth and nose to reduce 

the spread of respiratory secretions and aerosols when that person is breathing, talking, sneezing, or 

coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control 

measures are currently recommended for everyone in healthcare facilities, including in LTCFs, even if they 

do not have symptoms of COVID-19. Healthcare providers should wear source control products/devices 

at all times while they are in a LTCF, including in breakrooms or other spaces where they might encounter 

other people, including co-workers. The source control product/device should be appropriate for the 

anticipated exposure(s). These products/devices include: 

 Cloth Face Coverings: These are homemade or commercially available products made of cloth that 

cover the nose and mouth. Cloth face coverings should NOT be worn instead of an FDA-cleared or 

authorized surgical mask if protection against exposure to splashes and sprays of infectious material 

from others is needed. Cloth face coverings do not provide effective respiratory protection for workers 

2 Note: In its March 14, 2020, memo (https://www.osha.gov/memos/2020-03-14/temporary-enforcement-guidance-healthcare-respiratoryprotection-annual-fit), OSHA has articulated a temporary policy under which OSHA will exercise enforcement discretion with respect to the annual 

fit testing requirements in paragraph (f)(2) of 29 CFR § 1910.134 for FFRs used in healthcare, as long as the employer conducts initial fit tests 

for each healthcare professional with the same model, style, and size respirator that the worker will be required to wear for protection against 

SARS-CoV-2. Initial fit testing is essential to determine if the respirator properly fits the worker and is capable of providing the expected level of 

protection. 
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when protection against airborne hazards is needed, and do not fall under OSHA’s Respiratory 

Protection standard. They are not considered PPE for the wearer, but can assist in source control. LTCF 

patients and visitors should wear their own cloth face covering upon arrival at and throughout their 

stay in a LTCF for source control.3 If they do not have a cloth face covering, they should be offered a 

facemask, surgical mask, or cloth face covering by the LTCF, as supplies allow. 

 Facemasks: These products look similar to, and are often mistaken for, surgical masks, but do not 

provide fluid resistance. They do not provide effective respiratory protection for workers when protection against airborne hazards is needed, and do not fall under OSHA’s Respiratory Protection standard. 

They are not considered PPE for the wearer, but can assist in source control. The FDA has authorized 

the emergency use of facemasks, including cloth face coverings, that meet certain criteria for use as 

source control by the general public and healthcare personnel in accordance with CDC recommendations during the COVID-19 public health emergency. An example of this type of product would be a 

KN95 respirator with ear loops instead of head straps and that has not undergone rigorous fit testing 

to demonstrate a proper fit/effective seal to the wearer’s face.

 FDA-cleared or authorized surgical masks: Surgical masks 

are cleared, or are authorized for emergency use, by the FDA 

and are jointly regulated by OSHA under the PPE standard

(29 CFR 1910.132) and the Bloodborne Pathogens standard

(29 CFR 1910.1030). When available, FDA-cleared or authorized surgical masks are preferred over cloth face coverings 

for healthcare workers, as they offer both source control 

and protection for the wearer against exposure to splashes 

and sprays of infectious material from others. They are 

loose-fitting devices that do not provide effective respiratory 

protection for workers when the wearer might be exposed to 

airborne hazards, and do not fall under OSHA’s Respiratory 

Protection standard. 

 Respirators (including FDA-cleared or authorized surgical 

N95 FFRs): Healthcare providers who are in close contact with an LTCF resident with suspected or 

confirmed SARS-CoV-2 infection must use a NIOSH-approved N95 FFR or equivalent or higher-level 

respirator (29 CFR 1910.134). When protection against exposure to splashes and sprays of infectious 

material from others is also needed, an FDA-cleared or authorized surgical N95 FFR must be worn by 

healthcare workers (29 CFR 1910.134 and 29 CFR 1910.1030). Surgical N95 respirators provide the same 

level of respiratory protection as a N95 respirator; however, a surgical N95 respirator meets the FDA 

requirements for fluid penetration, flammability, and biocompatibility (see 21 CFR 878.4040(b)(1)). 

OSHA regulates respirators under the Respiratory Protection standard (29 CFR 1910.134). In order for 

3 CDC’s most up-to-date recommendations for the general public (vs. healthcare workers) on how to select, wear, and clean a face covering can be 

found at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html).

N95 respirators and surgical masks
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a respirator to provide the expected level of protection, it must be used in the context of a respiratory 

protection program (29 CFR 1910.134).

For additional information see CDC’s Interim Infection Prevention and Control Recommendations for 

Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic.

Respiratory Protection Program (RPP)

Employers can refer to OSHA’s Small Entity Compliance Guide for the 

Respiratory Protection Standard for a better understanding of OSHA’s 

Respiratory Protection standard. The guide includes step-by-step instructions for compliance with the standard, checklists, and commonly-asked 

questions, as well as a sample written RPP. The key elements of an RPP that 

employers must implement when any of their staff are required to wear 

respirators include the following:

 Assign a suitably trained program administrator to oversee all elements 

of the RPP. This can be an infection prevention and control practitioner 

or a nurse administrator. If there are no staff members suitably trained to 

be the program administrator, consider hiring a local industrial hygiene 

consulting service to help establish a RPP or contact OSHA’s On-Site Consultation Program.

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 Implement and maintain a written RPP that details worksite-specific procedures and elements for 

required respirator use (e.g., medical evaluation, fit testing, training, maintenance, etc.). Certain 

program elements may also be required by OSHA for voluntary respirator use in order to prevent 

potential hazards associated with the use of a respirator.

 Conduct a risk assessment to identify which workers are at risk of exposure to any airborne hazards 

(e.g., SARS-CoV-2, tuberculosis [TB], Legionella, certain hazardous chemicals). Such workers could 

include: any staff (whether clinical or not) in close contact (less than 6 feet) with residents with 

confirmed or suspected COVID-19 (e.g., during bathing, dressing, toileting, and direct clinical care); 

clinical staff performing aerosol-generating procedures5 (e.g., respiratory therapy, open suctioning of 

airways, BiPaP and CPAP); cleaning staff; maintenance staff; and visiting practitioners (e.g., physicians 

or physical therapists who do not normally work at that facility). Note: For classifying exposure risk to 

SARS-CoV-2, OSHA has divided job tasks into four risk exposure levels, as depicted in the occupational 

risk pyramid for COVID-19.

4 OSHA’s On-Site Consultation Program offers no-cost and confidential occupational safety and health services to small- and medium-sized 

businesses in all 50 states, the District of Columbia, and several U.S. territories, with priority given to high-hazard worksites. On-Site Consultation 

services are separate from enforcement and do not result in penalties or citations. Consultants from state agencies or universities work with 

employers to identify workplace hazards, provide advice for compliance with OSHA standards, and assist in establishing and improving safety and 

health programs.

5 See “Which Procedures Are Considered Aerosol Generating Procedures in Healthcare Settings?” at: https://www.cdc.gov/coronavirus/2019-ncov/

hcp/faq.html
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 Implement procedures for selecting the appropriate type of respirator(s) for the hazard, whether it 

be an infectious agent (e.g., SARS-CoV-2) and/or a hazardous chemical. The program administrator 

is responsible for identifying which type(s) of respirator is suitable based on the hazard(s), workplace 

factors, and user factors. OSHA’s Small Entity Compliance Guide for the Respiratory Protection Standard

can be a useful tool for assisting in general respirator selection.

 Select from NIOSH-approved respirators and be cautious of counterfeit respirators, which often come 

to the commercial market during pandemics. Employers can access NIOSH’s NIOSH-Approved N95 

Particulate Filtering Facepiece Respirators and Counterfeit Respirators / Misrepresentation of NIOSHApproval to determine if the respirator model they are considering is NIOSH-approved. 

 During times like the present pandemic, when there are increased demands on the supply chain 

for N95 FFRs, consider alternatives to N95 FFRs, including other FFRs (e.g., P100s, N99s), reusable 

elastomeric (rubber) respirators, and powered air purifying respirators (PAPRs). While the initial 

investment for elastomeric respirators and PAPRs may be greater than for N95 FFRs, purchasing these 

types of respirators can often lead to cost savings over the long-term since they are reusable and can 

also help reduce the impact of supply chain disruptions. In addition, loose-fitting PAPRs do not require 

fit testing, which can lead to further cost and time savings for employers. For additional information on 

the advantages and limitations of using elastomeric respirators and PAPRs during COVID-19, refer to 

CDC’s Elastomeric Respirators: Strategies During Conventional and Surge Demand Situations and CDC’s 

Considerations for Optimizing the Supply of Powered Air-Purifying Respirators (PAPRs).

 Choose eye and face protection that can be worn safely together with the type of respirator being 

used, meaning that care must be taken to ensure that the eye or face protection will not interfere with 

the seal of the respirator. 

 Implement procedures for performing medical evaluations of workers required to use respirators 

to determine their ability to safely wear a respirator prior to needing to wear one in the workplace. 

Identify a physician or other licensed healthcare professional to conduct the medical evaluations and 

maintain confidentiality.

 Ensure that any worker using a tight-fitting respirator (e.g., N95 FFR) is fit-tested prior to initial use of 

the respirator, whenever a different respirator size, style, model or make is used, and at least annually 

thereafter. Passing a fit-test is important because it ensures that the size, make, and model of the 

respirator can provide a proper facial seal to offer the expected level of protection to the wearer. 

 Ensure that only OSHA-approved fit test protocols (which can be found in 29 CFR 1910.134, Appendix 

A) are used for fit testing.2 If you are having difficulty obtaining commercially available fit-testing 

solutions required for some qualitative fit tests due to limited commercial supplies, refer to OSHA’s/

NIOSH’s guidance for Preparing Solutions for Qualitative Fit Testing from Available Chemicals, or consider switching to a quantitative fit test protocol or contracting with a reputable occupational health 

clinic that provides fit-testing services.
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 Establish procedures and schedules for the maintenance and 

storage of any respirators used for more than a single use (e.g., 

procedures for cleaning, disinfecting, storing, repairing, discarding). 

Note that while N95 FFRs are meant to be discarded after each 

use, CDC has developed contingency and crisis strategies, including 

reuse and decontamination of N95 FFRs, to help healthcare facilities conserve their supplies in the face of shortages. For additional 

information, refer to CDC’s Implementing Filtering Facepiece 

Respirator (FFR) Reuse, Including Reuse after Decontamination, 

When There Are Known Shortages of N95 Respirators and CDC’s 

Elastomeric Respirators: Strategies During Conventional and Surge 

Demand Situations.

 Provide effective training to workers required to wear respirators. Training must be conducted in a 

manner that is understandable to workers, meaning that your training program should be tailored to 

the education level and language background of your workers.

 Train workers who wear respirators on: how to properly put them on and take them off; how to conduct 

proper user seal checks; how to recognize respiratory hazards in their workplace; the limitations and 

capabilities of respirators; and how to recognize the medical signs and symptoms that may prevent or 

limit effective respirator use. Ensure that they can demonstrate the knowledge to safely and correctly 

use their respirators.

 Conduct periodic evaluations of the workplace to ensure that your written RPP is being properly implemented and is up-to-date, and to ensure that workers are using their respirators properly. Solicit input 

from workers (and union representatives, if applicable) to provide feedback on the program.

Temporary Enforcement Discretion Related to the Respiratory Protection 

Standard During COVID-19

In light of the essential need for adequate supplies of respirators during the COVID-19 pandemic, OSHA 

has temporarily allowed for some enforcement flexibility regarding respirators - including certain fit testing 

provisions,2 the use of respirators that are beyond their manufacturer’s recommended shelf life, extended 

use and reuse of respirators, the use of alternative respirators certified under standards of certain other 

countries and jurisdictions, and decontamination of respirators - as is described in detail in various temporary enforcement memoranda, which can be found on OSHA’s COVID-19 webpage. In order for OSHA 

to exercise enforcement discretion, employers must demonstrate and document good-faith efforts to 

comply with OSHA standards, as outlined in the same memoranda and summarized in Understanding 

Compliance with OSHA’s Respiratory Standard During the Coronavirus Disease (COVID-19) Pandemic. 

OSHA’s temporary enforcement memoranda are time-limited to the current COVID-19 crisis and are 

aligned with CDC’s Strategies for Optimizing the Supply of N95 Respirators, which recommend a variety 
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of conventional, contingency, and crisis capacity control strategies. Enforcement discretion applies only 

after an employer has considered and taken all possible steps to comply with measures in a particular 

control strategy. LTCF employers should periodically refer to OSHA’s COVID- 19 webpage for the most 

up-to-date interim/temporary enforcement discretion memoranda and guidance. 

Additional Resources

 OSHA’s Guidance on Preparing Workplaces for 

COVID-19 (https://www.osha.gov/Publications/

OSHA3990.pdf)

 OSHA’s Respiratory Protection Training Videos

(https://www.osha.gov/respiratory-protection/

training)

 NIOSH’s Healthcare Respiratory Protection 

Resources (https://www.cdc.gov/niosh/npptl/

hospresptoolkit/default.html)

 NIOSH’s & OSHA’s Hospital Respiratory 

Protection Program Toolkit (https://www.cdc.

gov/niosh/docs/2015-117/default.html)

 OSHA’s Inspection Procedures for the 

Respiratory Protection Standard (https://www.

osha.gov/sites/default/files/enforcement/

directives/CPL_02-00-158.pdf)

 FDA’s Decontamination Systems for 

Personal Protective Equipment EUAs

(https://www.fda.gov/medical-devices/

coronavirus-disease-2019-covid-19-

emergency-use-authorizations-medicaldevices/decontamination-systems-personal-protective-equipment-euas)

 The Joint Commission’s Implementing Hospital 

Respiratory Protection Programs: Strategies 

from the Field

(https://www.jointcommission.org/resources/

patient-safety-topics/infection-preventionand-control/respiratory-protection/) 

 NIOSH’s Respirator Trusted-Source Information

(https://www.cdc.gov/niosh/npptl/topics/

respirators/disp_part/respsource3surgicaln95.

html)

 NIOSH’s National Personal Protective 

Technology Laboratory (https://www.cdc.gov/

niosh/npptl/default.html)

 NIOSH’s Education and Research Centers

(https://www.cdc.gov/niosh/oep/ercportfolio.

html)

 National Institute for Environmental Health 

Sciences’ Worker Training Program (https://

www.niehs.nih.gov/careers/hazmat/awardees/

index.cfm)

 Professional industrial hygiene and occupational health associations (e.g., AIHA)

 Certified industrial hygienists/health and safety 

consultants

 Local or state Departments of Health/Public 

Health 

 Respirator manufacturers

This document does not have the force and effect of law and is not meant to bind the public in any way. This document is 

intended only to provide clarity to the public regarding existing requirements under the law or agency policies.

DOL-OSHA-OOC-2020-103