River Bend Nursing: Infection Control Failures - IN
The resident, identified in inspection records only as Resident N, was on Enhanced Barrier Protocol, a heightened infection control designation that the facility's own infection preventionist later told inspectors requires staff to wear gowns and change gloves when moving from dirty to clean contact. Three staff members entered the room that morning. None wore gowns.
Inspectors documented the procedure in precise sequence. The nurse, identified as RN 11, did not wash her hands before putting on gloves. She opened a tracheostomy care kit and a sterile water container with those same gloves. She then removed them, washed her hands for 60 seconds, and placed a sterile glove on her right hand.
Then the sequence broke down.
With that sterile glove, she touched the trach collar. She did not remove the glove or wash her hands. She then picked up the suction catheter with the same hand, now contaminated from contact with the collar. She passed the catheter into the resident's airway, cleared it with sterile water, and made two more passes. The contaminated suction catheter went into the resident's airway three times.
When inspectors spoke with RN 11 afterward, at 9:50 A.M. that same morning, she said she should have worn a gown. CNA 12 and CNA 13, the two nursing assistants who had entered the room without gowns, acknowledged the same thing five minutes later.
The tracheostomy observation was not the only infection control failure inspectors recorded that week.
The day before, on January 22, an inspector examining the insulin cart found a glucometer with two visible spots of blood on the machine. A registered nurse, identified as RN 8, told the inspector there should be no blood on glucometers and that the machines are cleaned between each use. The facility's own glucometer policy, which the administrator produced for inspectors on January 29, states the meter should be cleaned and disinfected after use on each patient.
It had not been.
The infection preventionist, interviewed on January 29, confirmed what the inspection had already shown: gloves should be changed when going from dirty to clean, the Enhanced Barrier Protocol sign on the door signals that gowns are required for high-contact procedures like tracheostomy care, and glucometers should be cleaned after every use. She described the standard. The inspection documented how far the morning's care had fallen from it.
The facility provided inspectors with three policies: a hand hygiene policy from October 2023, a personal protective equipment policy from October 2018, and an undated glucometer cleaning policy. The hand hygiene policy states that hand hygiene is required immediately after glove removal and before applying non-sterile gloves. The PPE policy lists gowns among the protective equipment staff are provided for transmission-based precautions.
The policies existed. The care on January 23 did not follow them.
Inspectors classified the deficiency as causing minimal harm, a designation that reflects the regulatory threshold met rather than a judgment about what the lapse could have meant for Resident N, whose airway was suctioned three times with a glove that had touched a contaminated surface. A tracheostomy is a direct opening into the airway. Infection in that space can move fast and move deep.
River Bend Nursing and Rehabilitation is located at 3400 Stocker Drive in Evansville. The inspection was completed January 30, 2026.
Resident N's name does not appear in the report. The inspection record does not say whether anyone told them what had happened that morning.
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.
Three staff members entered the room that morning.
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.