# F880: infection prevention and control

> F880 is the CMS tag for infection prevention and control. A nursing home must run a program that prevents, finds, reports, investigates and controls infections. It needs written policies, surveillance, an incident record, safe laundry handling and an annual review. It is the most cited tag.

Source: https://incidentkit.ai/compliance/f-tags/f880 · Updated Oct 5, 2026

## Key facts

- **Tag title:** Infection Prevention & Control
- **Regulation:** 42 CFR 483.80(a)(1), (a)(2), (a)(4), (e) and (f). Antibiotic stewardship is F881; the infection preventionist is F882
- **Guidance relied on:** Appendix PP Rev. 232 (issued 07-23-25, in use since 04-28-25); F880 section Rev. 229 (04-25-25, implementation 04-28-25)
- **How often cited:** 4,146 citations nationally in the first half of 2026, the most cited tag (Wisconsin DHS summary)
- **Review clock:** At least annually. CMS's level 1 example is a review at 14 months
- **Reporting clock:** Set by state and local public health rules, not CMS. Policy must say when and to whom
- **Recent change:** Enhanced Barrier Precautions guidance used on surveys from April 28, 2025

- **Citation:** F880 · 42 CFR 483.80(a)(1)-(2), (a)(4), (e) and (f)
- **Authority:** CMS
- **Applies to:** Medicare-certified skilled nursing facilities, Medicaid-certified nursing facilities

## What F880 covers

F880 enforces the infection prevention and control program (IPCP) in 42 CFR 483.80. It must cover residents, staff, volunteers, visitors and contractors. It must follow accepted national standards and rest on the facility assessment.

Written policies must cover surveillance, when and to whom to report, precautions, isolation and hand hygiene. They must keep staff with a communicable disease or infected skin lesions from direct contact. The home must also record IPCP incidents and corrective actions ((a)(4)), handle linens safely ((e)) and review the program at least annually ((f)).

[F867](https://incidentkit.ai/compliance/f-tags/f867) can apply when the QAA committee should have caught a systemic problem. [F868](https://incidentkit.ai/compliance/f-tags/f868) covers the infection preventionist's seat on that committee.

## What surveyors check

Surveyors use the Infection Prevention, Control and Immunizations Facility Task. One surveyor leads, but the whole team watches practice: hand hygiene, PPE, enhanced barrier precautions, residents on transmission-based precautions and laundry. They interview staff and review documents.

| Surveyors ask for | Have ready |
| --- | --- |
| The written IPCP and policies | Current policies tied to national standards, annual review dated |
| Surveillance data | A data tool using national criteria, such as CDC NHSN long-term care or updated McGeer criteria: site, pathogen, symptoms, location |
| Analysis and follow-up | Trends shared with the DON, medical director and QAA committee; follow-up on key findings |
| Record of incidents and corrective actions | Each incident, the investigation, the fix, monitoring and staff feedback |
| Outbreak response | When the signal was seen, precautions started, who was told, public health report |
| Staff practice checks | Hand hygiene and PPE audits, and what happened when practice fell short |

## Outbreaks and when to act

An outbreak is more cases of a disease than expected in one place and time. CMS says not to wait for the formal definition: one laboratory-confirmed influenza case should start an outbreak investigation. The home must manage cases, apply precautions, prevent spread, track follow-up and meet public health rules. Surveyors use Appendix Q to decide if a cited outbreak is immediate jeopardy.

## What raises F880 severity

Severity rises with harm and with the number of residents exposed. Immediate jeopardy (level 4) means noncompliance has caused, or is likely to cause, serious injury, harm, impairment or death. F880 is outside the substandard quality of care list in 42 CFR 488.301, which names only paragraph (d) of section 483.80. Immediate jeopardy and harm citations still apply.

*CMS examples of F880 severity*

| Level | Example from CMS guidance |
| --- | --- |
| 4: immediate jeopardy | Fingerstick devices reused between residents. A gastrointestinal outbreak not investigated or tracked left residents on the next unit seriously ill and dehydrated. A nurse left a contact-precaution room for a multidrug-resistant germ (MDRO) without hand hygiene and went to another resident. An uninvestigated COVID-19 unit outbreak sent residents next door to hospital |
| 3: actual harm | A scabies case not diagnosed, treated or put on precautions; several residents got a rash with severe itching. A resident with COVID-19 symptoms was not tested before sharing a room, and the roommate caught it |
| 2: potential for more than minimal harm | The same gloves worn between two residents' medication passes. Contaminated linens carried against a uniform. Wound supplies put on a bed and returned to the cart |
| 1: minimal potential for harm | The IPCP was last reviewed at 14 months instead of 12, with no other findings |

## Reporting clocks

F880 sets no hour or day count. Policy must say when and to whom to report a communicable disease or infection. State and local public health rules set the deadlines and vary by place, so check yours.

## Gaps that lead to citations

- A line list of infections is never analyzed or shared with the QAA committee.
- Infections in nursing notes never reach the infection preventionist, so clusters go unseen.
- No record shows when an outbreak signal was seen or what was done.
- Practice audits find lapses, but no corrective action is recorded.
- Surveillance criteria are not named, so cases are defined inconsistently.
- No system records IPCP incidents and corrective actions, as (a)(4) requires.
- The annual review is undated or late.

## How to show a good investigation

CMS says the incident system should collect reports from residents, families and staff. It should investigate, set prevention measures, correct, check that changes work and give feedback.

1. **Record the incident** Note what happened, where, when and who was exposed.
2. **Investigate** Compare practice with policy. Find the cause.
3. **Correct** Give each fix an owner and a due date.
4. **Monitor** Audit the practice. Check cases or exposures afterward.
5. **Report up** Take results to the DON, medical director and QAA committee.

## How IncidentKit supports F880

IncidentKit is not an infection surveillance, line list or public health reporting system. It runs alongside your EHR and covers the incident record: practice lapses, exposures and outbreak signals. [Lauren](https://incidentkit.ai/product/lauren) drafts each report for a person to review and sign. [Routing and escalation](https://incidentkit.ai/product/routing-and-escalation) sends it to the infection preventionist. [Investigations](https://incidentkit.ai/product/investigations) and [corrective actions](https://incidentkit.ai/product/corrective-actions) track the fix to a verified close, and [compliance packets](https://incidentkit.ai/product/compliance-packets) add a QAPI summary.

## What the rule asks for, and how IncidentKit supports it

| Requirement | IncidentKit |
| --- | --- |
| A system for recording incidents and corrective actions (483.80(a)(4)) | Incident reporting and corrective actions, each with an owner, due date, evidence and effectiveness check. Nothing closes until verified. |
| Report possible incidents to the right people | Routing and escalation alerts the infection preventionist, DON and administrator. Public health reports go through their own channels. |
| Investigate failures in practice | Investigations record contributing factors and five whys. The audit trail logs who did what, when. |
| Report incidents to the QAA committee | Analytics cluster incidents by location, shift and cause. Compliance packets add a QAPI summary. |
| Surveillance, line lists and NHSN reporting | Not provided by IncidentKit. It runs alongside your EHR and surveillance tools. |

## Frequently asked questions

### What does F880 require a nursing home to have?

An infection prevention and control program with written policies, surveillance, an incident record, safe laundry handling and an annual review.

### What surveillance criteria does CMS expect?

Nationally recognized criteria and a data collection tool, such as the CDC's National Healthcare Safety Network long-term care criteria or the updated McGeer criteria. The home must analyze the data, share it and document follow-up on important findings.

### When is an infection cluster an outbreak?

When there are more cases than expected for a place and time. For a rare or serious condition, one case can count. CMS says one laboratory-confirmed influenza case should start an investigation.

### Does F880 set a deadline for reporting infections?

No. The home's policy must say when and to whom it reports. State and local public health authorities set the deadlines, so confirm yours with them.

### What is the incident record F880 asks for?

A system for recording incidents found under the infection program and the corrective actions taken (paragraph (a)(4)). CMS says to report failures in infection control practice to the director of nursing, medical director and QAA committee.

## Sources

- [eCFR, 42 CFR 483.80 (infection control), current through 2026-10-01](https://www.ecfr.gov/current/title-42/section-483.80)
- [CMS State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities (Rev. 232, issued 07-23-25; revised guidance used on surveys since 04-28-25): F880 section (Rev. 229, issued 04-25-25, effective 04-25-25, implementation 04-28-25)](https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107ap_pp_guidelines_ltcf.pdf)
- [CMS memo QSO-25-14-NH (revised 2025-03-10): Revised Long-Term Care Surveyor Guidance, effective April 28, 2025](https://www.cms.gov/files/document/qso-25-14-nh-revised-2025-03-10.pdf)
- [CMS State Operations Manual, Chapter 7, Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities (Rev. 244, issued 06-26-26): scope and severity matrix, immediate jeopardy, substandard quality of care](https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107c07pdf.pdf)
- [eCFR, 42 CFR 488.301 (definitions: immediate jeopardy, substandard quality of care), current through 2026-10-01](https://www.ecfr.gov/current/title-42/section-488.301)
- [Wisconsin Department of Health Services, Top Ten Federal Health Citations, First Half 2026 (national, state and CMS Region 5 citation counts)](https://www.dhs.wisconsin.gov/regulations/nh/2026-h1-dqa-bnhrc-top-citations-region.pdf)

## Related

- [F867 QAPI improvement activities: adverse event tracking](https://incidentkit.ai/compliance/f-tags/f867)
- [F868 QAA committee: members, meetings and evidence](https://incidentkit.ai/compliance/f-tags/f868)
- [Nursing home QAPI requirements: 42 CFR 483.75 explained](https://incidentkit.ai/compliance/cms-qapi/skilled-nursing-facilities)
- [Nursing home recertification survey: process and prep](https://incidentkit.ai/compliance/survey-readiness/snf-recertification-survey)
- [Corrective Actions: How to Close Them With Proof](https://incidentkit.ai/use-cases/close-corrective-actions)
- [Incident reporting software for skilled nursing facilities](https://incidentkit.ai/solutions/skilled-nursing-facilities)
- [Immediate jeopardy: definition and meaning](https://incidentkit.ai/glossary/immediate-jeopardy)