LVN A, who told inspectors she was "the facility Infection Preventionist in training," was in charge of tracking and surveillance for the facility's infection prevention program. During a November 26 interview at 2:29 p.m., she admitted she had not started any specialized training in infection prevention.
"She stated she was just in the phase where she identified the training program and had not yet registered and had not completed any portion of the training," inspectors wrote.
The confusion extended to facility leadership. When inspectors interviewed the administrator at 2:49 p.m. that same day, they were told the director of nursing was the infection control preventionist responsible for program oversight. But the director of nursing told a different story.
During her interview at 3:06 p.m., the director of nursing said LVN A was the designated infection preventionist. She said LVN A had just informed her that the training certification was not complete.
"The DON stated she was under the assumption that the training was already completed," the inspection report noted.
The director of nursing's own credentials had lapsed. She told inspectors she once held certification in 2023, but it had expired. She could not provide proof of any training when inspectors asked for documentation before they left the facility.
Federal regulations require nursing homes to designate qualified infection preventionists who complete specialized training. The facility's own policy, reviewed by inspectors, spelled out the requirements in detail.
The infection preventionist must have professional training in nursing, medical technology, microbiology, epidemiology or another related field. They must be qualified by education, training, experience or certification, and have the knowledge to perform the role through recommended specialized training.
The policy also required the infection preventionist to stay current with infection prevention and control issues and remain aware of guidelines from national organizations and public health authorities, particularly regarding emerging pathogens.
Most critically, the infection preventionist must physically work onsite at the facility. The person cannot be an off-site consultant or perform the work from a corporate office or affiliated hospital.
The director of nursing acknowledged the importance of proper training during her interview with inspectors. She said it was crucial to have someone with infection control training because the knowledge and courses required were lengthy and complex. Someone needed to understand the processes, she explained.
But neither she nor LVN A had the required credentials to fulfill that role.
Federal inspectors determined this failure could place residents at risk for cross contamination and infection. It also threatened the effectiveness of infection surveillance, a critical component of preventing outbreaks in nursing homes where vulnerable residents live in close quarters.
The inspection was conducted in response to a complaint, though the specific nature of the complaint was not detailed in the publicly available portion of the inspection report.
River Hills Health and Rehabilitation Center serves a population particularly vulnerable to infections. Elderly residents often have compromised immune systems and underlying health conditions that make them more susceptible to infectious diseases. Proper infection prevention and control programs are essential safeguards in these settings.
The facility's policy recognized this vulnerability, noting that infection preventionists should remain aware of guidelines regarding emerging pathogens. The COVID-19 pandemic highlighted how quickly infections can spread through nursing homes when proper prevention measures are not in place.
Yet despite having a written policy that outlined the requirements, River Hills Health failed to ensure anyone on staff actually met those standards. LVN A was performing infection prevention duties without training, while the director of nursing was operating with expired credentials.
The inspection revealed a breakdown in communication and oversight. The administrator believed the director of nursing was responsible, while the director of nursing had designated LVN A for the role without verifying her qualifications.
When pressed by inspectors, the director of nursing admitted she had assumed LVN A's training was already complete. This assumption left residents without proper infection prevention oversight from someone with the specialized knowledge required by federal regulations.
The facility must now correct these deficiencies to maintain participation in Medicare and Medicaid programs. River Hills Health has 14 days from receiving the inspection report to submit a plan of correction outlining how it will ensure a qualified infection preventionist is properly designated and trained.
Until then, residents remain at risk from a program overseen by staff who lack the specialized training federal regulations require to keep them safe.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for River Hills Health and Rehabilitation Center from 2025-11-26 including all violations, facility responses, and corrective action plans.
Additional Resources
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