Americans are living longer, and the population is rapidly graying. Baby Boomers, who currently make up 21% of the US population, will be 65 or older by 2030. As a result, the number of persons living in nursing homes is expected to double. For the first time ever in this country, there will be more older adults than children. Most of these older adults will need long-term care (LTC) services at some point in their lives.1,2,3

Currently, about 8.3 million people live in the country’s nearly 66,000 regulated LTC facilities.4 These residents are at high risk for infection due to their frailty, waning immune systems, multiple chronic conditions, prolonged healthcare stays, and over-exposure to antibiotics.5 Compounding this risk is the congregate nature of LTC living with shared rooms and common spaces. Unfortunately, there is no requirement to report healthcare-associated infections (HAIs) in LTC settings — at least not yet. Without this data, it is unclear just how many HAIs occur in this setting, but it estimated to be somewhere between 1 to 3 million per year.6 The environment is an important reservoir for HAI-causing pathogens – many of which can survive for prolonged periods in the environment where they can be picked up on the hands of healthcare workers and then transmitted to residents. However, cleaning and disinfection can stop transmission as shown in Figure 1. Part 1 of this 2-part blog will highlight some of the challenges in regards to cleaning and disinfection that LTC facilities face. Part 2 will provide actionable solutions.

Figure 1. Cleaning and Disinfection Stops Transmission.

Challenges to Cleaning & Disinfection in LTC Settings

Long-term care is different as compared to acute care settings and here are some reasons why. First, hand hygiene alone, while important, is insufficient to control the spread of pathogens. Effective and consistent cleaning and disinfection is essential to reducing HAI incidence. While the same sanitation principles apply, simply adopting acute care environmental cleaning and disinfection protocols and practices does not address the challenges that LTC facilities face as shown in Table 1.

Table 1. Acute Care vs LTC Setting Differences that Impact Cleaning and Disinfection.

Some of the setting differences include:

  • Milieu or Environment: The hospital is a more “sterile” environment, while the LTC facility is the resident’s home, often including personal furnishings and many belongings.
  • Length of Stay (LOS): Residents tend to stay indefinitely and for long periods of time, whereas the LOS in the hospital is more on the order of a couple of days.
  • Congregate Setting: In the hospital, patients tend to stay in their room with the exception of diagnostic procedures. The opposite is true in LTC which is very much a congregate and social setting. Residents dine together, gather for activities, and even spend their days together visiting or hanging out in the TV room. The more people gather, the higher the risk of pathogen sharing and disease transmission.
  • Isolation Precautions: In the hospital, patients harboring epidemiologically important pathogens are placed in isolation precautions. This is a little trickier in the LTC setting. Isolation is often impractical. Additionally, the Centers for Medicare and Medicaid Services (CMS) requires use of the least restrictive precautions possible. Resident’s safety must be balanced with quality of life. The CDC’s new enhanced barrier precautions helps LTCs find the right balance.
  • Budget and Resources: LTC tends to lean-in to more generic products and dilutable disinfectants but the trade-off can be efficacy, efficiency, and surface compatibility. Concerns with dilutable products include the risk of dilution error, product contamination, and the need to clean, disinfect, and dry buckets and spray bottles after use. Any remaining diluted product must be discarded at the end of each shift which can be wasteful.

In addition to setting differences, a recent study found that residents touch surfaces in shared areas on average 12 times per hour and staff contact these surfaces 26 times per hour.7 Consider this in light of another new study that found that 90% of surfaces across 11 LTC facilities tested positive for fecal pathogens.8 Not surprisingly, multidrug-resistant organisms (MDROS) are highly prevalent in LTC facilities. Studies show that over half of residents are colonized with an MDRO. The cases we see – the active infections – are only the tip of the iceberg. Asymptomatic carriage contributes to silent spread. Several studies have reported that 93%-100% of surfaces in LTC facilities are contaminated with MDROs.9-11 It’s vital to prevent MDRO transmission as treatment options are limited.

As if these challenges are not enough, there are staffing issues. The new CMS regulatory requirement calls for LTC facilities to have a designated and trained IP.12 This coupled with the Great Resignation, has resulted in many new IPs in this setting. On average, these IPs spend less than 9% of their time on cleaning and disinfection which makes becoming proficient in this area a challenge.13 IPs are not the only ones who are under-staffed. There are shortages in nursing and environmental care staff (EVS) as well. While turn-over has always been high in the LTC sector, the pandemic has dramatically exacerbated the issue. With so many new hires, it can be difficult to ensure that everyone is cleaning in a standardized way.

Another challenge that LTC facilities face are disparities in their environmental cleaning and disinfection programs. A recent CMS pilot project found that 80% of LTC facilities had the following gaps:14

  • A lack of training and documented competency,
  • Failure to adhere to disinfectant instructions for use (IFUs),
  • Failure to audit cleaning practices, and
  • A lack of policies for cleaning medical equipment, particularly between residents.

Cleaning Failures: Improper cleaning contributes to pathogen transmission. Studies show that we miss more than half of surfaces that should be cleaned. Additionally, researchers have identified a significant increase in risk to the next patient to occupy a room previously occupied by an infected patient to acquiring that pathogen. Environmental surfaces, objects, and medical devices can serve as reservoirs for pathogens that can be transmitted by the hands of healthcare workers to patients. In fact, hands have been implicated in 20–40% of HAIs. This failure rate of both hand and environmental surfaces cleaning leaves much room for improvement. Figure 2 is a nice infographic that summarizes this section on cleaning failures.15-18

Figure 2. Improper Cleaning Contributes to Transmission of Pathogens.

In closing, the LTC setting has its own unique challenges to cleaning and disinfection but these can be overcome with a robust cleaning and disinfection program. This brings us to Part 2 of this blog: Solutions to Cleaning and Disinfection Challenges in LTC Settings.


1. The Checkup. Long-Term Care Statistics 2022. [Internet]. [Cited 2022 May 20]. Available from
2. US Census Bureau. Older People Projected to Outnumber Children for First Time in US History. [Internet]. [Cited 2022 May 20]. Available from,decade%20for%20the%20U.S.%20population.
3. NIH. Supporting Older Patients with Chronic Conditions. [Internet]. [Cited 2022 May 20]. Available from
4. Consumer Affairs. Long-term care statistics [Internet]. [Cited 2022 Mar 20]. Available from,people%20in%20assisted%20living%20facilities
5. Infection Prevention Guide to Long-Term Care. 2nd ed. Arlington, VA: APIC; 2019
6. CDC. HAI Data Portal, 2021. Available from
7. Pineles L, Perencevich E, Roghmann M, Gupta K, Cadena, J, Barocco G, et al. Frequency of Nursing Home Resident Contact with Staff, other Residents, and the Environment outside Resident Rooms. Infection Control & Hospital Epidemiology. 2019;1-3.
8. Cannon JL, Park GW, Anderson B, Leone C, Chao M, Vinje J, et al. Hygienic Monitoring in LTCFs using ATP, crAssphage, and Human Norovirus to Detect Environmental Surface Cleaning. AJIC. 2022; 50: 289-294.
9.     McKinnell J, Miller L, Singh R,  Walters D, Peterson E, Huang S. High Prevalence of MDRO Colonization in 28 NHs: An Iceberg Effect. JAMDA. 2020;21(12):1937-1943
10.  Cassone M, Wang J, Lansing B, Mantey J, Gibson K, Gontjes K, et al. Proceeding from SHEA 2022. Poster: Diversity and persistence of MRSA and VRE in NHs: Environmental screening and whole-genome sequencing. ASHE. 2022;2:s80.
11. McKinnell J, Singh R, Miller L, Kleinman K, Gussin G, He J, et al. The SHIELD Orange County Project: MDRO Prevalence in 21 NHs and LTACHs in So Cal. Clin Infect Dis. 2019;69(9):1566-1573.
12. CMS. State Operations Manual-Appendix PP – Guidance to Surveyors for Long-Term Care Facilities, 2017. [Internet]. [Cited 2022 July 16]. Available from
13. Landers T, Davis J, Christ K, Malik C. APIC MegaSurvey: Methodology and Overview. AJIC. 2017; 1;45(6):584-588.
14. Ogundimu, A. Proceedings from APIC 2019: Association for Professionals in Infection Control and Epidemiology on Infection Prevention and Control (IPC) Practices in Nursing Homes: Findings from a CMS Infection Control Pilot Project. Philadelphia, PA.
15. Carling PC, Bartley JM. Evaluating hygienic cleaning in health care settings: what you do not know can harm your patients. AM J Infect Control. 2010;38:S41-50
16. Chemaly R, Simmons S, Dale C, Ghantoji S, Rodriguez M, Gubb J, et al. The role of the healthcare environment in the spread of MDROs: update on current best practices. Ther Adv Infect Dis. 2014;2(3-4), 79-90.
17. Haenen A, Greeff S, Voss A, Liefers J, Hulscher M, Huis A. Hand hygiene compliance and its drivers in LTCFs; observations and a survey. Antimicrob Resist Infect Control. 2022; 11(50)
18. Suleyman G, Alangaden G, Bardossy A. The Role of Environmental Contamination in the Transmission of Nosocomial Pathogens and HAIs. Curr Infect Dis Rep. 2018; 20:12