River Bend Nursing And Rehabilitation
RIVER BEND NURSING AND REHABILITATION in EVANSVILLE, IN — inspection on January 30, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
On 1/29/26 at 2:24 P.M., the Administrator provided a policy titled Enteral Nutrition, dated 11/18, that indicated Risk of aspiration is assessed by the nurse and provider and addressed in the individual care plan.
Risk of aspiration may be affected by improper positioning of the resident during feeding.
This citation relates to Intake 2707708.
3.1-35(a)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/30/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
River Bend Nursing and Rehabilitation
3400 Stocker Dr Evansville, IN 47720
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation record review, and interview, the facility failed to ensure there was an order and care plan for oxygen, tubing was properly dated, and there was an administration posted on door for 1 of 2 residents reviewed for oxygen administration.(Resident W) Finding includes:During a random observation on 1/22/26 at 10:27 A.M., Resident W was observed lying in bed with Oxygen (O2) tubing connected to concentrator with no date on the tubing or water bottle along with the nebulizer, and there was no oxygen administration sign on the door.
During a random observation on 1/27/26 at 9:05 A.M., Resident W was observed lying in bed without oxygen on.
The nebulizer face mask was observed on the floor and lacked a date on the tubing.
Current physician orders lacked documentation of an oxygen order The current clinical record lack documentation of a care plan for oxygen.
During an interview on 1/27/26 at 9:30 A.M., Hospice Provider 2 indicated residents on oxygen will have an order for the resident with them but should also have an order with the facility for O2.
During an interview on 1/27/26 at 10:30 A.M., Registered Nurse (RN) 4 indicated there should be an order for oxygen for anyone utilizing it.On 1/29/26 at 1:42 P.M., the Administrator provided a current policy Oxygen Administration revised October 2010.
The policy indicated .Verify that there is a physician's order.review the resident's care plan to assess for any special needs of the resident.
Place an Oxygen in Use sign on the outside of the room entrance door.
This citation relates to Intake 2707708. 3.1-47(a)(6)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/30/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
River Bend Nursing and Rehabilitation
3400 Stocker Dr Evansville, IN 47720
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 1/29/26 at 11:46 A.M., The Director of Nursing indicated the night shift nurse obtained A.M. blood sugars for residents, gave blood sugar results to day shift nurse, and day shift nurse gave insulin at breakfast, sometimes it gets missed in documentation.
During an interview on 1/23/26 at 8:27 A.M., Resident Y's responsible party indicated the facility had not invited them to a care conference in the last six to eight months.
On 1/23/26 at 2:23 P.M., Resident Y's clinical record was reviewed.
Resident Y was admitted on [DATE].
Diagnoses included, but were not limited to, congestive heart failure.
The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/5/25, indicated Resident Y was severely cognitively impaired and was dependent on staff (staff do all of the work) for eating, toileting, bathing, and transfers.
Resident Y's clinical record lacked quarterly care plan conferences since admission.
Care plan conferences were requested on 1/29/26 at 8:51 A.M.
On 1/29/26 at 10:18 A.M., the social services director provided quarterly care plan conferences on dated 10/28/25 (created on 1/29/26), 6/26/25 (created on 1/29/26), and 5/13/25 (created on 1/29/26). 3.1-50(a)(1) 3.1-50(a)(2)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/30/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
River Bend Nursing and Rehabilitation
3400 Stocker Dr Evansville, IN 47720
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation, record review, and interview, the facility failed to ensure infection control practices and standards were performed on 2 of 2 random observations.
Staff observed not utilizing the proper use of PPE of donning and doffing a gown when entering and exiting a room on Enhanced Barrier Protocol (EBP), did not utilize proper hand hygiene and changing gloves when performing tracheostomy suctioning, and locating a glucometer that was not cleaned after use. (Resident N, glucometer) Findings include:Findings include:1. On 1/22/26 at 9:30 A.M., during a random observation of the Insulin Cart, was observed to have a glucometer noted to have 2 spots of blood on the machine.2. On 1/23/2026 at 8:25 A.M., during a random observation of tracheal suction of Resident N, the following was observed:Resident N was noted to be on Enhanced Barrier Protocol due to a tracheostomy.Registered Nurse (RN)11 did not wash hands prior to donning gloves and did not place a gown of Personal Protective Equipment.2 Certified Nurses Assistants (CNA) 12 and 13 entered the room to help pull the resident up and neither donned gowns on for EBP, but they did have gloves. RN 11 paused tube feeding and obtained a tracheostomy care kit.Opened the kit with the same gloves, and also open sterile water container.Removed gloves, washed hands for 60 seconds with soap and water.Placed a sterile glove on the right hand.Touched the trach collar with a sterile gloved hand.
Did not remove the glove or wash hands.Touched the suction catheter with a dirty gloved hand.
Did not remove the dirty/soiled glove and change to a sterile one and wash hands.Passed a suction catheter into the tracheostomy with the suction on.Cleared the suction catheter with sterile water and proceeded to do 2 more passes with the suction catheter.Put the suction catheter into the container uncurled.Reattached trach collar.Removed gloves and then threw away the contaminated suction catheter.
During an interview on 1/22/2036 at 9:30 A.M., Registered Nurse 8 (RN) indicated there should be no blood on glucometers, and the machines are cleaned in between each use.
During an interview on 1/23/26 at 9:50 A.M., RN 11 indicated that she should have worn a gown.
During an interview on 1/23/26 at 9:55 A.M., CNA 13 and CNA 12 should have worn gowns also.
During an interview on 1/29/26 at 10:27 A.M., with the Infection Preventionist, she indicated if residents are in high contact circumstances, such as tracheostomy, there should be a sign for EBP sign on the door and wear proper PPE.
She also indicated that if gloves were worn, the gloves should be changed when going from dirty to clean.
When asked about cleaning glucometers, she indicated that glucometer should be cleaned after each use.On 1/29/26 at 1:23 P.M., the Administrator provided a policy Handwashing/Hand Hygiene dated October/ 2023.
The policy indicated .hand hygiene is indicated with the following: performing an aseptic task.g. immediately after glove removal.Applying and removing gloves should be performed.Perform hand hygiene before applying non-sterile gloves.On 1/29/26 at 2:04 P.M., the Administrator provided a policy Personal Protective Equipment dated October/2018.
The policy indicated .The type of PPE required for a task is based on. the type of transmission-based precaution.Personal protective equipment provided to our personnel includes but is not necessarily limited to a. gowns. (disposable, cloth, and/or plastic)); gloves (sterile, non-sterile) .On 1/29/26 at 2:44 P.M., the Administrator provided a current, non-dated policy, Assure Glucometer Platinum Policy.
The policy indicated .The meter should be cleaned and disinfected after use on each patient.
This citation relates to Intake 2707708. 3.1-18(b)3.1-18(l)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/30/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
River Bend Nursing and Rehabilitation
3400 Stocker Dr Evansville, IN 47720
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment during four random observations.
Odors were present in the facility. (Main lobby, Stocker Unit 1, Stocker Unit 2, Conference Room) Findings include:
- On 1/22/26 at 9:40 A.M., The hallways on Stocker Unit 1 and Stocker Unit 2 had a strong smell of urine.
- On 1/23/26 at 8:56 A.M., the main lobby, Stocker Unit 1, and Stocker Unit 2 had a strong, pungent smell
- On 1/28/26 at 9:05 A.M., the hallway outside of the conference room had a smell consistent with bowel
consistent with sewer gas.
movement.
During an interview on 1/29/26 at 11:20 A.M., the Administrator indicated odors in the facility should be controlled by general routine cleaning and staff should increase cleaning in areas that are prone to odors.
On 1/29/26 at 1:16 P.M., the Administrator provided a policy titled Environmental, dated 5/17, that indicated The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.
These characteristics include: pleasant, neutral scents; The facility staff and management shall minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting.
These characteristics include: institutional odors This citation relates to intake 2707708. 3.1-19(f)
Facility ID: