The January 23 observation revealed multiple infection control failures during care for a resident with a tracheostomy who was supposed to be on Enhanced Barrier Protocol. The resident required special precautions, but staff repeatedly violated basic safety procedures designed to prevent the spread of infection.
Registered Nurse 11 began the tracheostomy suctioning without washing her hands or putting on a protective gown. When two certified nursing assistants entered to help reposition the resident, neither wore the required gowns, though they did have gloves.
The nurse opened a sterile tracheostomy care kit with the same gloves she had been wearing, then opened a sterile water container. She removed her gloves and washed her hands for 60 seconds before putting on a sterile glove on her right hand.
But then the procedure went wrong.
The nurse touched the resident's trach collar with her sterile gloved hand, contaminating it. Without removing the contaminated glove or washing her hands, she then touched the suction catheter with what inspectors described as her "dirty gloved hand."
She passed the contaminated suction catheter into the resident's tracheostomy with suction on, cleared it with sterile water, and performed two more passes with the same catheter. The nurse put the used catheter into a container and reattached the trach collar before removing her gloves and disposing of the contaminated equipment.
A day earlier, inspectors discovered a glucometer on the insulin cart with two spots of blood on the machine. The device had not been cleaned after its previous use, violating the facility's own policy requiring disinfection after each patient.
When confronted about the violations, staff acknowledged their mistakes. Registered Nurse 11 admitted she should have worn a gown during the tracheostomy procedure. The two nursing assistants, CNA 12 and CNA 13, also acknowledged they should have worn gowns when entering the Enhanced Barrier Protocol room.
Registered Nurse 8 told inspectors there should never be blood on glucometers and confirmed the machines are supposed to 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 on their doors, and staff must wear proper protective equipment. She confirmed that gloves should be changed when moving from dirty to clean procedures and that glucometers must be cleaned after each use.
River Bend's own policies supported the inspectors' findings. The facility's Hand Hygiene policy from October 2023 requires hand washing before performing aseptic tasks and immediately after glove removal. It also mandates hand hygiene before applying non-sterile gloves.
The Personal Protective Equipment policy from October 2018 states that required PPE depends on the type of transmission-based precaution in place and includes gowns and gloves among available equipment.
The facility's Glucometer Policy specifically requires that "the meter should be cleaned and disinfected after use on each patient."
The inspection was conducted in response to a complaint and focused on infection prevention and control practices. Inspectors rated the violations as causing minimal harm or potential for actual harm, but noted that few residents were affected by the deficient practices.
The failures occurred despite clear policies and staff knowledge of proper procedures. The tracheostomy incident involved multiple staff members who each had opportunities to follow correct infection control protocols but chose not to, potentially exposing a vulnerable resident to preventable infection risks.
Federal regulators classified the violations under the requirement that nursing homes provide and implement an infection prevention and control program, a basic safety standard designed to protect residents from healthcare-associated infections.
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.