Stay Ahead of Compliance with Monthly Citation Updates


In your State Survey window and need a snapshot of your risks?

Survey Preparedness Report

One Time Fee
$79
  • Last 12 months of citation data in one tailored report
  • Pinpoint the tags driving penalties in facilities like yours
  • Jump to regulations and pathways used by surveyors
  • Access to your report within 2 hours of purchase
  • Easily share it with your team - no registration needed
Get Your Report Now →

Monthly citation updates straight to your inbox for ongoing preparation?

Monthly Citation Reports

$18.90 per month
  • Latest citation updates delivered monthly to your email
  • Citations organized by compliance areas
  • Shared automatically with your team, by area
  • Customizable for your state(s) of interest
  • Direct links to CMS documentation relevant parts
Learn more →

Save Hours of Work with AI-Powered Plan of Correction Writer


One-Time Fee

$49 per Plan of Correction
Volume discounts available – save up to 20%
  • Quickly search for approved POC from other facilities
  • Instant access
  • Intuitive interface
  • No recurring fees
  • Save hours of work
F0880
E

Failure to Implement Infection Control and Enhanced Barrier Precautions

Pembroke, North Carolina Survey Completed on 11-21-2025

Penalty

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its infection prevention and control policies and procedures in multiple instances involving residents requiring special contact and droplet precautions, as well as Enhanced Barrier Precautions (EBP). In one case, a resident who tested positive for COVID-19 was on special contact and droplet precautions, as indicated by signage on the door and the availability of PPE supplies nearby. Despite this, a nurse aide entered the resident's room without donning gloves or a gown, moved a mechanical lift out of the room into the hallway without cleaning it, and later re-entered the room again without appropriate PPE to assist the resident. The mechanical lift was left unattended in the hallway until instructed by a unit manager to clean and store it properly. The nurse aide admitted to forgetting the required PPE and expressed confusion between different types of precautions, despite having received infection control training. In another instance, two nurse aides provided a bed bath and repositioned a resident with an indwelling urinary catheter, who was on EBP, while wearing gloves but not gowns. Both aides acknowledged during interviews that they were aware of the resident's precaution status and the need for gowns but failed to comply, attributing the lapse to forgetfulness. The Director of Nursing confirmed that all staff had received infection control training, especially following a recent COVID-19 outbreak, and that PPE supplies were adequate and available. Additional deficiencies were observed when a nurse aide provided care to a resident with a gastrostomy tube and another with a pressure ulcer, both on EBP, while only wearing gloves and not a gown. The aide also placed soiled linens on the floor instead of in a plastic bag, contrary to facility policy and her training. The aide admitted to not following protocol due to being rushed or not bringing the necessary supplies into the room. Interviews with supervisory staff confirmed that the expectation was for staff to follow posted EBP signage and infection control procedures, and that further education was needed.

An unhandled error has occurred. Reload 🗙