River Bend Nursing: Environmental Safety Violations - IN
The resident, identified only as Resident N, was on Enhanced Barrier Protocol, a heightened infection precaution status tied directly to the tracheostomy. The protocol requires gowns, gloves, and strict hand hygiene from anyone entering the room.
None of that happened the way it was supposed to.
On January 23, at 8:25 in the morning, inspectors watched Registered Nurse 11 enter the room without washing her hands before putting on gloves. She did not put on a gown. Two certified nursing assistants, CNA 12 and CNA 13, came in to help reposition the resident. Neither wore a gown either, though both had gloves.
RN 11 paused the resident's tube feeding and opened a tracheostomy care kit with the same gloves she had been wearing. She then removed those gloves, washed her hands for 60 seconds with soap and water, and placed a sterile glove on her right hand only.
What happened next is the core of the problem.
She touched the trach collar with that sterile glove. Without removing it or washing her hands, she then touched the suction catheter with the same hand. The glove was no longer sterile. She passed the catheter into the tracheostomy anyway, with suction on, cleared it with sterile water, and made two more passes into the airway.
When inspectors spoke with RN 11 afterward, at 9:50 that morning, she acknowledged she should have worn a gown.
CNA 12 and CNA 13, interviewed five minutes later, said the same thing about themselves.
The facility's infection preventionist, interviewed on January 29, described what should have occurred: an Enhanced Barrier Protocol sign on the door, proper PPE for anyone entering, and glove changes whenever moving from a dirty surface to a clean one. She said it plainly — gloves should be changed when going from dirty to clean.
That did not happen during the tracheostomy procedure inspectors witnessed.
The second violation was discovered the day before, on January 22, during a routine look at the insulin cart. Inspectors found a glucometer sitting on the cart with two visible spots of blood on the machine.
RN 8, interviewed that morning, said there should never be blood on a glucometer and that the machines are cleaned between each use. The facility's own policy, provided by the administrator on January 29, states the meter should be cleaned and disinfected after use on each patient.
The glucometer inspectors found had not been.
The inspection report rated the harm level as minimal, affecting few residents. That classification reflects the regulatory framework inspectors use, not a judgment that a contaminated suction pass into a tracheostomy carries no risk. A tracheostomy is an open airway. A resident on Enhanced Barrier Protocol is already considered high-contact, high-risk. The protocol exists precisely because the consequences of introducing contamination into that airway can be severe.
River Bend's own policies, some dating to 2018, required gowns as part of personal protective equipment for transmission-based precautions. The hand hygiene policy required hand washing before applying gloves and immediately after removing them. The glucometer policy required cleaning after every patient.
The nurse who performed the tracheostomy suctioning knew the gown requirement. She said so herself, twenty-five minutes after the procedure ended.
Resident N remained in that room, on that protocol, with a tracheostomy that someone had just suctioned with a glove that had touched a contaminated surface.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for River Bend Nursing and Rehabilitation from 2026-01-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
RIVER BEND NURSING AND REHABILITATION in EVANSVILLE, IN was cited for violations during a health inspection on January 30, 2026.
The resident, identified only as Resident N, was on Enhanced Barrier Protocol, a heightened infection precaution status tied directly to the tracheostomy.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.