Accura Healthcare Marshalltown: Care Plan Failures - IA
Resident #2, who has COPD and chronic respiratory failure, received a physician's order on August 22 requiring oxygen at 2 liters per minute through a nasal cannula. His care plan specifically directed staff to make sure he had the oxygen on and was using it correctly.
But medication and treatment records from August through November showed no documentation of the oxygen order. Staff repeatedly recorded his oxygen saturation levels "on room air" — meaning without supplemental oxygen — on 26 different dates during that three-month period.
The problem became apparent when the resident needed his PICC line replaced at the hospital in November. Staff transported him in the facility van without any portable oxygen tank.
"The staff did not send any oxygen with him when he went to the hospital," the resident told inspectors on November 19. "The hospital nurse had to send oxygen with him back to the facility."
The hospital's infusion nurse confirmed the facility's oversight had immediate consequences. When the resident arrived, his oxygen saturation measured just 88% on room air — below the normal range of 95-100%.
"I placed him on oxygen as it was a necessity," the hospital nurse told inspectors. She said the resident was alert and pleasant, and told her he wore oxygen continuously. "Resident #2 said the facility forgot the oxygen as they were in a hurry to get to the hospital."
The nurse sent him back to the nursing home with an oxygen tank to ensure he had breathing support during transport.
Back at Accura Healthcare, staff offered conflicting explanations for the oversight. Staff A, a licensed practical nurse, said she wasn't sure if the resident had his oxygen when he left for the hospital procedure.
"She reported Resident #2 was with it enough that he would have told the staff he needed the oxygen," according to the inspection report. "She said he was on continuous oxygen so it should have been sent with him."
The assistant director of nursing suggested the months of documentation showing oxygen readings "on room air" resulted from a charting error. "She thought the staff hit the wrong button on the electronic charting and made a mistake when documenting the oxygen saturations on room air."
But the MDS coordinator confirmed the fundamental problem: the physician's oxygen order never appeared on either the medication administration records or treatment administration records. Without the order properly entered into the facility's tracking systems, staff had no formal reminder to provide the prescribed therapy.
The resident, whose mental status assessment showed intact cognition, understood his medical needs. He told inspectors he was "breathing ok" during the period without oxygen, but acknowledged he didn't have a portable oxygen tank on his wheelchair at the time of the hospital visit.
His medical history painted a picture of someone who needed consistent respiratory support. In addition to COPD and chronic respiratory failure, his diagnoses included hypertension, chronic kidney disease, type 2 diabetes, and a recent blood stream infection that required the PICC line replacement.
The facility's administrator admitted they operated without formal oxygen policies, telling inspectors "the facility follows the regulations." But following regulations would have required staff to document and administer the physician-ordered oxygen therapy consistently.
The MDS coordinator and quality assurance nurse acknowledged the obvious expectation: staff should follow physician orders for oxygen administration and send portable oxygen to medical appointments.
For a resident with severe lung disease, the months without prescribed oxygen represented more than administrative oversight. Each trip outside his room, each medical appointment, each daily activity occurred without the breathing support his doctor determined medically necessary.
The hospital nurse's quick intervention prevented what could have been a more serious respiratory crisis. But the resident's experience illustrated how documentation failures can translate directly into gaps in essential medical care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accura Healthcare of Marshalltown from 2025-11-24 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
Accura Healthcare of Marshalltown in Marshalltown, IA was cited for violations during a health inspection on November 24, 2025.
His care plan specifically directed staff to make sure he had the oxygen on and was using it correctly.
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.