The contaminated device represented one of multiple infection control failures inspectors documented at the Stocker Drive facility. Staff violated basic safety protocols while performing tracheostomy care on a resident requiring enhanced barrier precautions, touching sterile equipment with contaminated gloves and skipping required protective gear.
On January 22, inspectors conducting a random check of the insulin cart found the blood-stained glucometer at 9:30 a.m. When questioned the same day, Registered Nurse 8 told investigators there should be no blood on the machines and confirmed they must be cleaned between each use.
The facility's own policy, provided by the administrator, states the glucometer "should be cleaned and disinfected after use on each patient." But the device sat ready for the next resident with visible blood contamination.
A day later, inspectors watched a registered nurse perform tracheostomy suctioning on Resident N, who required enhanced barrier protocol due to the breathing tube. The observation revealed a cascade of infection control violations that put the vulnerable resident at risk.
Registered Nurse 11 failed to wash her hands before putting on gloves and never donned the required gown for enhanced barrier protocol. Two certified nursing assistants who entered to help reposition the resident also skipped the mandatory gowns, though they did wear gloves.
The violations escalated as the procedure continued. RN 11 opened a sterile tracheostomy care kit with the same gloves she had worn while handling other equipment. She opened sterile water with those same contaminated gloves.
She then removed the gloves, washed her hands for 60 seconds, and put on a sterile glove on her right hand. But she immediately contaminated that sterile glove by touching the trach collar.
Without changing gloves or washing hands, she touched the suction catheter with her now-contaminated hand. She passed the catheter into the resident's tracheostomy while maintaining suction, cleared it with sterile water, and performed two more passes.
The nurse completed the procedure by placing the contaminated suction catheter into a container and reattaching the trach collar. Only then did she remove her gloves and dispose of the catheter.
When confronted about the violations on January 23, RN 11 acknowledged she should have worn a gown. The two nursing assistants similarly admitted they should have worn the required protective equipment.
The facility's infection preventionist confirmed the violations during a January 29 interview. She told inspectors that residents in high-contact situations like tracheostomy care should have enhanced barrier protocol signs on their doors, and staff must wear proper protective equipment. She emphasized that gloves must be changed when moving from dirty to clean procedures.
The preventionist also confirmed glucometers require cleaning after each use.
River Bend's own policies, dating from 2018 and 2023, clearly outline the requirements staff violated. The hand hygiene policy mandates handwashing before performing aseptic tasks and immediately after removing gloves. The personal protective equipment policy specifies that gown requirements depend on transmission-based precautions.
The inspection stemmed from a complaint and focused on infection prevention and control practices. Inspectors rated the violations as causing minimal harm or potential for actual harm, but the failures affected basic safety protocols designed to protect vulnerable residents from preventable infections.
Resident N, requiring enhanced precautions due to the tracheostomy, received care that violated multiple sterile technique requirements. The contaminated glucometer could have exposed any resident requiring blood sugar monitoring to bloodborne pathogens.
The violations occurred despite clear facility policies and staff acknowledgment of proper procedures when questioned by inspectors.
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.