Good Samaritan Ottumwa: Infection Protocol Failures - IA
The resident, identified in inspection records only as Resident #6, is 92 years old in a facility of that many residents. He has Parkinson's disease, a right femur neck fracture, malnutrition, and an indwelling urinary catheter, which is precisely why his care plan required something more than gloves. Since July 22, staff had been directed in writing to wear both a gown and gloves for any high-contact care activity involving him, including dressing, bathing, repositioning, and anything involving his catheter. The precaution exists because indwelling catheters create a direct pathway for multidrug-resistant organisms to move from a caregiver's hands and clothing into a patient's body, whether or not that patient is already known to carry such an organism.
Staff U, the aide, was wearing no gown.
She stopped what she was doing when she saw the inspector and left the room to find a supervisor. When she came back, she put on both gloves and a gown. Then she said she needed to empty the catheter bag and asked her supervisor to go find a graduate, the container used to measure urine output, because she didn't have one. The supervisor left and returned with it. Staff U then said she had no alcohol wipes and sent the supervisor out again.
She eventually emptied the catheter bag using proper aseptic technique. Then she removed her gloves and gown, put on fresh gloves alone, and pulled open the resident's brief. She said he was clean and that she had finished catheter care before the inspector entered the room. She left the old brief in place, refastened it, finished dressing him, transferred him into his wheelchair, and brought him to the dining room for breakfast.
The inspection, conducted September 3, 2025, stemmed from a complaint. Inspectors cited the facility for failing to follow its own enhanced barrier precaution protocols, a finding tagged at a level of minimal harm or potential for actual harm.
What the inspection captured was not a single lapse but a sequence. The missing gown before the inspector arrived. The missing supplies discovered only once care was underway, requiring two separate interruptions while a resident lay with his brief open. The decision, at the end of all of it, to leave the original brief on rather than replace it.
Resident #6 has intact cognition. His Brief Interview for Mental Status score was 14 out of 15, meaning he understood what was happening in that room. He requires moderate assistance with transfers and mobility, and full assistance with dressing, toileting, and personal hygiene. He depends entirely on staff to perform these tasks correctly.
The facility's own policy states that enhanced barrier precautions apply to residents with indwelling urinary catheters even when no infection is known or suspected. The point is prevention. Multidrug-resistant organisms can be present on surfaces, on clothing, on hands, without any visible sign. A gown is not a response to a known problem. It is the barrier that keeps a known risk from becoming one.
Good Samaritan Ottumwa reported a census of 92 residents at the time of the inspection.
The aide did not have a gown when the inspector arrived. She did not have the equipment she needed to complete the procedure. The resident, cognitively intact and entirely dependent, waited.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan - Ottumwa from 2025-09-03 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Good Samaritan - Ottumwa in Ottumwa, IA was cited for violations during a health inspection on September 3, 2025.
The resident, identified in inspection records only as Resident #6, is 92 years old in a facility of that many residents.
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.