The January inspection also uncovered a blood-stained glucometer on the facility's insulin cart.
On January 22, inspectors conducting a random check of the insulin cart discovered a glucometer with two spots of blood on the machine. Registered Nurse 8 told investigators that glucometers should have no blood on them and must be cleaned between each use.
The facility's own policy for the Assure Glucometer Platinum states "the meter should be cleaned and disinfected after use on each patient."
The following day brought more serious violations during tracheostomy care. At 8:25 a.m., inspectors observed Registered Nurse 11 performing tracheal suctioning on a patient designated as Resident N, who required Enhanced Barrier Protocol due to the tracheostomy.
RN 11 failed to wash hands before putting on gloves and did not wear the required protective gown. When two certified nursing assistants entered the room to help reposition the patient, neither wore gowns despite the Enhanced Barrier Protocol requirements, though they did have gloves.
The contamination sequence grew worse as the procedure continued.
RN 11 opened the tracheostomy care kit and sterile water container while wearing the same gloves used for other tasks. After removing those gloves and washing hands for 60 seconds, the nurse put on a sterile glove on the right hand only.
Then the critical violations began. The nurse touched the patient's trach collar with the sterile gloved hand, contaminating it. Without removing the contaminated glove or washing hands, RN 11 then touched the suction catheter with what inspectors described as a "dirty gloved hand."
The nurse inserted the contaminated suction catheter into the patient's tracheostomy with suction activated, cleared it with sterile water, and performed two additional passes with the same contaminated equipment.
When questioned the same day, RN 11 acknowledged she should have worn a gown. The two nursing assistants also admitted they should have worn gowns during the procedure.
The facility's infection preventionist explained during a January 29 interview that residents requiring Enhanced Barrier Protocol due to high-contact circumstances like tracheostomies should have warning signs posted on their doors, and staff must wear proper protective equipment. She confirmed that gloves must be changed when moving from dirty to clean tasks.
River Bend's own policies supported the inspector findings. The facility's Hand Hygiene policy from October 2023 requires hand washing before applying gloves and immediately after glove removal, particularly when "performing an aseptic task."
The Personal Protective Equipment policy from October 2018 specifies that required PPE depends on "the type of transmission-based precaution" and includes gowns and gloves among available equipment.
Enhanced Barrier Protocol exists specifically to prevent infections in vulnerable patients with medical devices like tracheostomies. The breathing tubes create direct pathways into patients' respiratory systems, making proper sterile technique critical to prevent potentially fatal infections.
Federal investigators classified the violations as having "minimal harm or potential for actual harm" and noted they affected "few" residents. The facility now must submit a correction plan detailing how it will prevent future infection control failures.
The inspection stemmed from a complaint, suggesting someone witnessed concerning practices at the 47720 Stocker Drive facility and reported them to state authorities.
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.