F880 — Infection Prevention and Control Program
Most-cited F-tag during and after COVID. Failure to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
Reg cite · 42 CFR 483.80
518 surveys in corpus
39 states
What surveyors look for
- Designated Infection Preventionist with documented qualifications and training
- Annual infection control risk assessment, current and reviewed by QAPI
- Hand hygiene compliance audited routinely with documented results and improvement actions
- Isolation precautions implemented correctly — appropriate PPE, room signage, dedicated equipment
- Surveillance data tracking infections by type, unit, and resident with trend analysis
- Annual influenza and pneumococcal vaccine offerings with declination forms
Common gotchas
- Hand hygiene observed at <90% compliance during multiple rounds
- Staff entering isolation rooms with PPE but no eye protection (or wrong type)
- Shared equipment (vital signs machines, glucometers) not cleaned between residents
- C. diff or MDRO residents in shared rooms without justification
- Surveillance log lists infections but no aggregation, no trend, no QAPI action
- Linen carts in resident hallways with mix of clean and soiled
Real survey examples
From CMS-published 2567s in our corpus. Resident identifiers redacted.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide and implement an infection prevention and control program.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, medical record review, and review of a facility policy titled Hand Hygiene, the
facility failed to ensure:
1) a Licensed Practical Nurse (LPN) washed hands or used hand sanitizer after administering Resident
Identifier (RI) #213's nebulizer treatment and placing a garbage bag in the medication cart garbage can,
prior to reentering RI #213's …
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Preventionist/Registered Nurse (RN). EI #6 was asked how are the licensed staff trained at the facility on
hand hygiene. EI #6 was asked what a licensed nurse should do after after she started RI #213's inhalation
nebulizer treatment, placed a plastic garbage bag in the medication cart garbage can, and prior to
reentering RI #213's room. EI #6 stated she should have washed her hands or use hand sanitizer. EI #6
was asked what should a licensed nurse have done after she cleaned RI #213's facemask, removed her
glo…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Provide and implement an infection prevention and control program.
Based on observations, interviews and review of facility policies titled, Handling Clean Linen, Hand
Hygiene, and Hand Hygiene Table, the facility failed to ensure:
(1) Employee Identifier (EI) #5 Registered Nurse (RN) performed hand hygiene in a manner to prevent the
spread of infection. EI #5 was observed exiting Resident Identifier (RI) #16's room wearing gloves and
holding a plastic medication tray containing a medicine cup, a used insulin s…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
On [date] at 10:33 AM, EI #3, Infection Preventionist was asked about what EI #5 had been observed
doing. EI #3 said the nurse should have changed the gloves and performed hand hygiene before cleaning
the tray. EI #3 said a nurse should never reach in her pocket with dirty gloves to retrieve the keys for the
medication cart due to the the risk of cross contamination. EI #3 said using dirty gloves to open a
medication cart or pick up anything in the medication cart was a risk for infection and cross contaminatio…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide and implement an infection prevention and control program.
Based on observations, interviews, record review, and review of the facility policy titled, Standard
Precautions, the facility failed to ensure Certified Nursing Assistant (CNA) #12, did not create the potential
for cross-contamination when she wiped feces from the floor with a dry towel and failed to use an
appropriate disinfectant. Multiple staff were observed walking through the area after the feces was removed
and before the floor was disinfe…
Accepted POC examples
Real accepted-POC examples for this F-tag are not yet in the open corpus. The POC drafter above generates a structurally correct draft from CMS S&C Letter 13-21's four-question schema — edit it to fit your facility's specifics before submission.
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