North Crest Living: Infection Control Failures - IA
The violation occurred August 25 when inspectors observed Staff H and Staff I caring for Resident #3, who had an indwelling urinary catheter and was placed on Enhanced Barrier Precautions to prevent the spread of multi-drug resistant organisms. The resident, who showed no cognitive impairment on mental status testing, was sitting on a commode when the care began.
Staff H initially entered the room alone, then left to request help with personal care. When he returned with Staff I, both assistants put on gloves but skipped the required gowns entirely. Neither completed hand hygiene before starting care.
The assistants then proceeded with intimate care. Staff H used a gait belt to help the resident stand while Staff I cleaned the catheter and penis from behind, then cleansed the resident's buttocks with wipes. They pulled up his brief and pants before Staff H helped transfer him to a wheelchair.
Only after completing care did Staff H remove his gloves and wash his hands. Staff I gathered trash, removed her gloves, and walked down the hall to the soiled utility room before finally completing hand hygiene outside in the hallway.
When questioned thirty minutes later, both assistants demonstrated confusion about infection control requirements. Staff H told inspectors he wasn't required to wear a gown when the resident was on the commode, explaining he only needed protective equipment when "working directly with the bodily fluids."
"When he was not working directly with the bodily fluids the gown would not be expected," Staff H said, acknowledging that his colleague also wasn't wearing a gown during catheter and personal care.
Staff H insisted that because the resident was having a bowel movement, "there is no expectation for gown application." He stated that Enhanced Barrier Precautions required gowns for catheter and personal care, "but not required when Resident #3 was having a bowel movement."
Staff I showed even less understanding of the protocols. She told inspectors "the only time she would apply a gown was when she emptied Resident #3's catheter."
Their supervisors painted a different picture of facility expectations. The Director of Nursing stated that gowns should be worn by both the staff member transferring the resident and anyone providing care. An LPN explained that "when there was any care provided to a resident with catheters the staff are required to wear a gown, gloves and complete hand hygiene before and after application of gloves or resident contact."
The Director of Nursing confirmed that hand hygiene should happen "prior to resident care, after resident care, before applying gloves and after removal of gloves." She acknowledged that "the staff should have worn gowns with the resident cares on Resident #3."
Enhanced Barrier Precautions exist specifically to prevent the spread of multi-drug resistant organisms to other residents. According to facility policy, these precautions apply when a resident "is not known to be infected or is known to be infected with a CDC-targeted MDRO and has a wound or indwelling medical device." Urinary catheters qualify as indwelling medical devices under this definition.
The facility's own hand hygiene policy requires washing "before anticipated contact with resident, after contact with a resident, after contact with blood, body fluids, visibly contaminated surfaces, after contact with objects in the residents room, after removing Personal Protective Equipment."
Resident #3 had physician's orders for monthly catheter changes that began August 4, indicating ongoing medical device management that would require consistent infection control measures.
The inspection occurred during a complaint investigation at the 57-bed facility. Federal regulators classified the violation as causing minimal harm or potential for actual harm, but the breakdown in basic infection control protocols exposed other residents to unnecessary risk of acquiring dangerous antibiotic-resistant infections.
The gap between written policies and actual practice extended beyond the two assistants to a fundamental misunderstanding of when protective equipment was required, suggesting broader training failures in infection prevention protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Crest Living Center from 2025-08-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 25, 2026 · Our methodology
North Crest Living Center in Council Bluffs, IA was cited for violations during a health inspection on August 26, 2025.
The resident, who showed no cognitive impairment on mental status testing, was sitting on a commode when the care began.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.