Good Samaritan - Ottumwa: Infection Control Failures - IA
The violation occurred during an August 28 inspection at Good Samaritan - Ottumwa, where Staff U was observed preparing to provide personal care to Resident #6 while wearing only gloves instead of the full protective equipment mandated by facility policy.
Resident #6, a cognitively intact patient with Parkinson's disease and multiple medical conditions, requires enhanced barrier precautions due to his indwelling urinary catheter. His care plan, revised July 22, explicitly states staff must wear both gown and gloves when performing "high contact care activities including dressing, bathing, transferring, providing hygiene such as shaving or brushing teeth, changing linens, repositioning, checking and changing, device care and/or use, and wound care."
The inspection revealed a cascade of preparation failures. When the surveyor entered the room at 9 a.m., Staff U was positioned at the resident's bedside with his brief open, apparently preparing for personal care. A new brief sat at the foot of the bed. She wore only gloves.
Staff U immediately stopped and left to get a supervisor.
Upon returning, she donned the required gown and gloves, then stated she needed to empty the catheter bag. But she lacked basic supplies. She asked her supervisor to retrieve a graduate container for measuring urine output. When the supervisor returned with the container, Staff U discovered she had no alcohol wipes and sent the supervisor away again.
Only after obtaining proper supplies did Staff U empty the catheter bag using correct aseptic technique.
The aide then removed her protective equipment, put on fresh gloves, and opened the resident's brief. She announced he was clean and claimed she had completed catheter care before the surveyor arrived. She left the old brief on the resident, reattached it, finished dressing him, and transferred him to his wheelchair for breakfast.
The facility's own enhanced barrier precaution policy defines the requirements Staff U violated. The policy states that enhanced barrier precautions "expand the use of personal protective equipment beyond situations in which exposure to blood and body fluids is anticipated" and require gown and gloves during high-contact care activities.
These precautions specifically apply to residents with indwelling medical devices like urinary catheters, "even if the resident is not known to be infected or colonized with an MDRO," according to the policy. MDROs are multidrug-resistant organisms that can spread between patients and healthcare workers.
Resident #6 represents a textbook case requiring enhanced precautions. His medical record shows he needs moderate assistance with transfers and mobility, and depends entirely on staff for dressing, toilet use, and personal hygiene. Beyond his indwelling catheter, he experiences occasional bowel incontinence and has been diagnosed with malnutrition, coronary artery disease, and other conditions that compromise his health status.
The 92-bed facility's infection control failure occurred despite clear documentation of the resident's needs. His care plan had been recently updated in July, and his cognitive status remained intact with a score of 14 out of 15 on mental status testing, meaning he was fully aware of the care being provided.
Staff U's behavior suggests either inadequate training or deliberate shortcuts in infection control procedures. Her immediate departure when observed, followed by the scramble to locate basic supplies, indicates systemic preparation problems beyond the missing protective equipment.
The violation carries particular significance given the resident's vulnerability. Parkinson's disease, combined with his recent right femur neck fracture and multiple chronic conditions, creates heightened infection risks. His dependence on staff for intimate care activities means any breakdown in infection control protocols directly threatens his health.
Enhanced barrier precautions exist precisely because healthcare-associated infections remain a leading cause of preventable harm in nursing homes. The Centers for Disease Control and Prevention estimates that nursing home residents experience more than 380,000 infections annually, with urinary tract infections among the most common.
Federal inspectors classified the violation as having caused minimal harm or potential for actual harm. But the incident reveals gaps in basic infection control practices that could affect any of the facility's 92 residents requiring similar care.
The inspection occurred following a complaint, suggesting someone reported concerns about infection control practices at Good Samaritan - Ottumwa. The facility now must demonstrate corrected procedures to prevent similar violations during future care activities.
Resident #6 remains dependent on staff who may or may not follow the protocols designed to protect him.
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 20, 2026 · Our methodology
Good Samaritan - Ottumwa in Ottumwa, IA was cited for violations during a health inspection on September 3, 2025.
When the surveyor entered the room at 9 a.m., Staff U was positioned at the resident's bedside with his brief open, apparently preparing for personal care.
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.