Good Samaritan - Ottumwa: Empty Oxygen Tanks - IA
Federal inspectors found two residents at Good Samaritan - Ottumwa going hours without the supplemental oxygen their doctors had ordered to keep them breathing properly. Both residents had intact mental abilities and could understand their life-sustaining equipment wasn't working.
Resident #6 needed oxygen at 2-3 liters per minute to keep his blood oxygen levels above 90 percent. His medical conditions included Parkinson's disease, coronary artery disease, malnutrition and a fractured right hip. He required moderate help transferring and moving around, and depended on staff for dressing, using the toilet and personal hygiene.
On August 21, inspectors watched him sit in his wheelchair in the dining room at 11:40 a.m., waiting for lunch. He wore his nasal cannula, connected to an oxygen tank with the gauge needle deep in the red range, indicating the tank was empty or nearly empty.
Nearly four hours later, at 3:20 p.m., the same resident attended an activity in his wheelchair. His oxygen tank gauge still showed red. Empty.
Staff L, a licensed practical nurse, told inspectors that nurses were responsible for changing oxygen tanks but typically waited for aides to alert them when tanks ran low. The Director of Nursing said tank monitoring was "everyone's" responsibility - nurses or aides could exchange empty tanks if they noticed the problem.
Nobody noticed for at least four hours.
Resident #7 faced the same equipment failure. She had rheumatoid arthritis and severe acid reflux, requiring maximum assistance with transfers and complete dependence on staff for dressing, toileting and hygiene. She was always incontinent of both bladder and bowel.
Her care plan, dating to October 2024, specified oxygen therapy for low blood oxygen levels. Staff were supposed to monitor for respiratory distress, check her positioning to prevent breathing problems, and provide oxygen at 1-4 liters per minute to maintain blood oxygen above 90 percent.
During the same lunch period on August 21, inspectors found her sitting in the dining room without her nasal cannula. Her oxygen tank gauge showed red - completely empty.
By 1:15 p.m., someone had finally exchanged her tank for one that was half full and put her nasal cannula back on. But for hours that morning, she had received no supplemental oxygen despite doctor's orders requiring it.
The facility's 92 residents depended on staff to monitor life-sustaining equipment. Federal regulations require nursing homes to provide treatment according to physician orders and each resident's individual care plan. When oxygen tanks run empty, residents with breathing problems can experience dangerous drops in blood oxygen levels.
Both residents had scored 14 out of 15 on cognitive assessments, meaning they understood what was happening around them. They knew their oxygen wasn't working.
The inspection revealed a systemic breakdown in basic medical equipment monitoring. Staff had established no reliable system to ensure oxygen tanks stayed filled, instead relying on informal communication between nurses and aides that clearly wasn't working.
Resident #6's case was particularly concerning given his multiple serious medical conditions. His Parkinson's disease already affected his mobility and daily functioning. His coronary artery disease meant his heart was already working harder to pump blood. Without adequate oxygen, both conditions could worsen rapidly.
The facility's policy of having "everyone" responsible for oxygen tank monitoring meant no one was actually accountable. When inspectors asked who should change empty tanks, they received vague answers about shared responsibility rather than clear protocols.
For residents requiring continuous oxygen therapy, empty tanks represent more than equipment failure. They represent a failure to provide the most basic medical care ordered by physicians to keep people alive and breathing properly.
The inspection found this wasn't an isolated incident affecting one resident on one day. Two separate residents experienced the same equipment failure during the same time period, suggesting the monitoring breakdown was facility-wide.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm. But for residents sitting in wheelchairs, fully aware their oxygen tanks were empty while they waited for meals and attended activities, the experience likely felt far from minimal.
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.
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 21, 2026 · Our methodology
Good Samaritan - Ottumwa in Ottumwa, IA was cited for violations during a health inspection on September 3, 2025.
Both residents had intact mental abilities and could understand their life-sustaining equipment wasn't working.
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.