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F0882
F

Infection Preventionist Lacked Required Specialized Training

Kerrville, Texas Survey Completed on 11-26-2025

Penalty

No penalty information released
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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 ensure that the individual designated as the Infection Preventionist (IP) had completed specialized training in infection prevention and control. Record review showed that the Director of Nursing (DON) was listed as the facility's IP, but during interviews, it was revealed that an LVN was acting as the IP in training and had not started or completed any specialized training. The LVN was only in the process of identifying a training program and had not registered for or completed any portion of the required training. The DON, who was responsible for oversight of the infection prevention program, stated she believed the LVN had already completed the necessary training, but learned during the interview that this was not the case. The DON also stated that her own infection prevention certification had expired and she was unable to provide proof of current training. Facility policy requires that the IP be qualified by education, training, experience, or certification, and remain current with infection prevention and control issues. The policy also specifies that the IP must physically work onsite and cannot be an off-site consultant. Despite these requirements, neither the DON nor the LVN designated as the IP had completed the necessary specialized training at the time of the survey, resulting in a deficiency related to the facility's infection prevention and control program.

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