Infection Control in Nursing Homes: What Leaders Need to Know About F880, Compliance, and Culture
IColleen Toebe, MSN, CWCN, RAC-MTA, RAC-MT, DNS MT, VP of Clinical Services, Pathway Health
Infection control isn’t just a box to check—it’s a daily commitment to resident safety, staff well-being, and regulatory compliance. And if you’re a Nursing Home Administrator (NHA) or Director of Nursing (DON), F880 from the State Operations Manual Appendix PP should be on your radar every single day.
What Is F880?
F880 is the federal regulation that governs the Infection Prevention and Control Program (IPCP) in nursing homes. It requires facilities to:
- Prevent, identify, report, investigate, and control infections
- Follow national standards and guidelines
- Use standard and transmission-based precautions
- Maintain proper hand hygiene and PPE use
- Assign a trained Infection Preventionist (IP)
- Review and update the IPCP annually
CMS Citation Trends: F880 Still Tops the List
According to CMS data, F880 remains the most frequently cited deficiency in nursing homes. Common reasons include:
- Inconsistent or improper hand hygiene
- PPE misuse or lack of availability
- Inadequate staff training
- Failure to isolate residents appropriately
- Missing or outdated surveillance logs
CMS has increased scrutiny on infection control, especially in the wake of COVID-19 and other outbreaks. Facilities with repeat citations may face civil monetary penalties or denial of payment.
Real-World Examples
Example 1: The Forgotten Hand Hygiene
A CNA assists a resident with toileting, removes gloves, but doesn’t wash hands before helping the next resident. A surveyor observes this—and it’s an immediate F880 citation.
Fix: Daily hand hygiene audits and real-time coaching.
Example 2: PPE Confusion
During flu season, a nurse enters an isolation room without a gown. When asked, she says, “I didn’t think I needed one for just a quick check.”
Fix: Post clear signage and provide refresher training on transmission-based precautions.
Example 3: Missing Surveillance Logs
The Infection Preventionist is out sick, and no one else knows where the infection tracking logs are—or how to update them.
Fix: Cross-train staff and keep logs accessible and up to date.
What a Comprehensive Infection Control Program Must Include
- A trained Infection Preventionist (IP)
- Written policies based on CDC and CMS guidance
- Surveillance systems for tracking infections
- Antibiotic stewardship program
- Staff education and competency checks
- Environmental cleaning protocols
- Emergency preparedness for outbreaks
- Audit tools for hand hygiene, PPE, and cleaning
Infection Preventionist Checklist: A Leadership Tool
A strong IPCP is only as good as its implementation. The Infection Preventionist Checklist (April 2024) outlines daily, monthly, quarterly, and annual tasks, including:
- Daily: Review 24-hour reports, update infection logs, monitor PPE use, check signage and supplies
- Monthly: Conduct audits (hand hygiene, cleaning, PPE), review staff call-in logs for illness trends
- Quarterly: Analyze outcome surveillance data, report to QAA, review construction projects
- Annually: Update policies, conduct facility-wide risk assessments, review state and federal guidance
This checklist ensures that infection control is not reactive—it’s proactive, structured, and embedded in daily operations.
Incorporating Infection Control into the Facility Assessment
Your Facility Assessment must reflect:
- The types of infections common in your population
- Staffing levels and training needs
- Availability of PPE and cleaning supplies
- Emergency response plans for outbreaks
- The role and qualifications of your Infection Preventionist
Tip: Update your assessment annually—or whenever there’s a significant change in services, population, or risk level.
What NHAs and DONs Need to Know and Monitor
For NHAs:
- Ensure the IP has the time and authority to lead the program
- Review infection control audits and trends monthly
- Monitor staffing levels to support infection control practices
- Include IPCP in QAPI and leadership meetings
- Stay current on CMS memos and enforcement updates
For DONs:
- Oversee staff training and competencies
- Ensure PPE is available and used correctly
- Review infection logs and antibiotic use
- Conduct mock surveys and real-time observations
- Support the IP in policy development and education
Final Thoughts
F880 isn’t just a regulation—it’s a reflection of your facility’s culture. When infection control is prioritized from the top down, it becomes second nature to your team. And when it’s not? Surveyors will notice.
Pathway Health Resources
- Infection Prevention and Control Resource Manual: The Pathway Health’s Infection Prevention and Control Manual provides a multitude of resources for the Infection Preventionist to be able to customize their Infection Prevention and Control Program for quality and strategies for compliance! This highly informative manual includes Enhanced Precautions, TB and comprehensive COVID-19 information. The manual is available in electronic and hard-copy versions.
- Infection Preventionist KSA Competency QuickPATH: This guide was written based on the most recent federal regulatory requirements/standards of practice. Click here to learn more.
- Infection Preventionist Certification Bootcamp for LTC Providers: This course is designed for nurses who are new to the role of Infection Preventionist. This comprehensive 20-hour program will cover essential aspects of the position, providing the foundational knowledge necessary to effectively begin their duties as an Infection Preventionist.
This interactive course provides opportunities for learners to ask questions and participate in case studies. Attendees will be provided with the Pathway Health Infection Prevention and Control Manual printed version as a reference guide. Classes available on the upcoming dates:
August 18-22, 2025 | 8:30 AM – 1:00 PM
November 3-7, 2025 | 8:30 AM – 1:00 PM
Register >
