River Bend Nursing: Respiratory Care Failures - IN
The patient, identified in the report as Resident N, was on Enhanced Barrier Protocol specifically because of the tracheostomy. That designation is supposed to trigger a specific set of precautions for anyone entering the room. It didn't.
Before the procedure began on January 23, RN 11 skipped hand washing before putting on her first pair of gloves. She opened the tracheostomy care kit and the sterile water container with those same gloves. Then she removed them and washed her hands for 60 seconds. So far, the protocol held.
It broke down at the next step. She placed a sterile glove only on her right hand. With that gloved hand, she touched the trach collar. She did not then change the glove. She reached for the suction catheter with the same hand she had used on the collar, touching a sterile instrument with what was now a contaminated glove. Then she passed the catheter into the patient's airway. She cleared it with sterile water and ran it through two more times.
When an inspector interviewed RN 11 afterward, she said she should have worn a gown. She did not address the glove sequencing.
Two certified nursing assistants, CNA 12 and CNA 13, had come into the room during the procedure to help reposition the patient. Neither wore a gown. Both later told inspectors they should have. The facility's infection preventionist confirmed to inspectors on January 29 that anyone in high-contact situations like a tracheostomy procedure was required to wear proper PPE and change gloves when moving from a dirty surface to a clean one.
The tracheostomy observation was not the only infection control problem inspectors found that week.
On January 22, a random check of the insulin cart turned up a glucometer with two visible spots of blood on the machine. RN 8, interviewed at the cart that morning, told inspectors there should never be blood on a glucometer and that the machines are cleaned between each use. This one had not been. The facility's own glucometer policy, provided by the administrator during the inspection, states the meter must be cleaned and disinfected after use on each patient.
The administrator also handed over a hand hygiene policy from October 2023 and a personal protective equipment policy from October 2018 during the inspection's final days. Both said what the staff already knew and did not do: wash hands before applying gloves, change gloves between dirty and clean tasks, wear gowns when required.
The infection preventionist's summary to inspectors was precise. Gloves going from dirty to clean require a change. Trach procedures require gowns. Glucometers require cleaning after every patient. The staff interviewed agreed with all of it. The gap was not knowledge. It was practice.
Resident N had a device surgically placed in their throat to breathe. The suction procedure that nurses perform on tracheostomy patients is not a routine task in the way that taking a blood pressure reading is routine. It requires passing a catheter through an opening directly into the airway. Contaminating that catheter before insertion, then repeating the contaminated passes twice more, is the kind of lapse the Enhanced Barrier Protocol exists to prevent.
The inspection was conducted on January 30, 2026, following a complaint. Inspectors cited the facility at a level of minimal harm, meaning no documented injury resulted from what they observed. That determination is based on what the record shows.
What the record shows is a blood-spotted glucometer sitting on the insulin cart, and a nurse threading a dirty catheter into a patient's throat three times while two aides stood nearby in a room that required gowns, and nobody in the room stopped it.
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 patient, identified in the report as Resident N, was on Enhanced Barrier Protocol specifically because of 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.