The January inspection at River Bend Nursing and Rehabilitation documented multiple infection control failures that put residents at risk. Inspectors found blood spots on a glucose meter and watched staff repeatedly break sterile protocols during critical respiratory care.
On January 23, inspectors observed Registered Nurse 11 performing tracheostomy suctioning on Resident N, who was designated for Enhanced Barrier Protocol due to the invasive breathing tube. The nurse failed to wash her hands before putting on gloves and never donned the required protective gown.
Two certified nursing assistants entered the room to help reposition the resident. Neither wore gowns despite the enhanced precautions.
The violations escalated as the nurse began the sterile procedure. She opened the tracheostomy care kit and sterile water container while wearing the same contaminated gloves. After removing those gloves and washing her hands for 60 seconds, she put on a sterile glove on her right hand.
Then the contamination began.
The nurse touched the trach collar with her sterile gloved hand, then touched the suction catheter with her dirty left hand without changing gloves or washing her hands. She inserted the contaminated catheter into the resident's tracheostomy while suction was running.
After clearing the catheter with sterile water, she repeated the contaminated process two more times, passing the same compromised equipment into the resident's airway. She coiled the used catheter in its container, reattached the trach collar, and only then removed her gloves and discarded the contaminated equipment.
The day before, inspectors discovered a glucose meter on the insulin cart with two visible blood spots. The contaminated device remained in use despite facility policies requiring cleaning after each patient.
When questioned, the staff acknowledged their mistakes. Registered Nurse 11 admitted she should have worn a gown. The two nursing assistants agreed they also should have used protective gowns.
Registered Nurse 8 confirmed that glucometers should never have blood on them and must be cleaned between each use.
The facility's Infection Preventionist explained that residents with high-contact circumstances like tracheostomies should have Enhanced Barrier Protocol signs posted and require proper protective equipment. She emphasized that gloves must be changed when moving from contaminated to clean tasks.
River Bend's own policies contradicted the observed practices. The October 2023 hand hygiene policy specified that hand washing is required when performing aseptic tasks and immediately after removing gloves. The policy stated that hand hygiene must occur before applying non-sterile gloves.
The facility's Personal Protective Equipment policy from October 2018 outlined that required PPE depends on transmission-based precautions and includes gowns and gloves for protection.
The glucometer policy was explicit: "The meter should be cleaned and disinfected after use on each patient."
The inspection classified the violations as having minimal harm or potential for actual harm, affecting few residents. However, the failures occurred during some of the most infection-sensitive procedures in nursing home care.
Tracheostomy patients face heightened infection risks due to their compromised airways and dependence on mechanical breathing assistance. Contaminated glucose testing equipment can transmit bloodborne pathogens between residents during routine diabetes monitoring.
The observed violations occurred despite multiple staff members being present, suggesting the infection control lapses were routine rather than isolated incidents. The presence of dried blood on medical equipment indicated the contamination had persisted over time before discovery.
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.