Accura Healthcare Marshalltown: Respiratory Care Failures - IA
Resident #2 at Accura Healthcare of Marshalltown required continuous oxygen at 2 liters per minute under physician orders dated August 22. But staff never added the order to medication records and documented his oxygen levels on room air for three straight months.
The 54-bed facility's oversight became apparent November 19 when the resident traveled to a medical center for a routine PICC line replacement. Staff forgot to send oxygen equipment with him in the facility van.
"The hospital nurse had to send oxygen with him back to the facility," the resident told inspectors the next day. He said he was breathing okay without the oxygen during the trip but confirmed he normally wore it continuously.
The hospital infusion nurse who treated him painted a different picture. She found his oxygen saturation at 88% on room air and immediately placed him on supplemental oxygen "as it was a necessity." Normal oxygen saturation ranges from 95% to 100%.
"Resident #2 said the facility forgot the oxygen as they were in a hurry to get to the hospital," the nurse told inspectors. She provided a portable tank for his return trip to the nursing home.
The resident's care plan specifically directed staff to "make sure Resident #2 had the oxygen on and that he was using it correctly." His medical record showed diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure, high blood pressure, diabetes, kidney disease and a recent blood infection.
Despite the clear physician order from August, inspection records show no documentation of oxygen administration on medication or treatment records through November. Staff instead recorded oxygen saturation readings "on room air" on 26 separate dates between August 22 and November 18.
Staff A, a licensed practical nurse, told inspectors she wasn't sure whether the resident had oxygen when he left for his appointment. "She reported Resident #2 was with it enough that he would have told the staff he needed the oxygen," according to the inspection report.
But the nurse acknowledged he was supposed to be on continuous oxygen and "it should have been sent with him."
The facility's MDS Coordinator confirmed the oxygen order never appeared on medication administration records. The Assistant Director of Nursing suggested staff may have hit "the wrong button on the electronic charting" when documenting oxygen levels without supplemental oxygen.
This wasn't the first time the resident traveled for medical care without his required oxygen. A skilled nursing note from September 8 documented another PICC line replacement at an emergency room, though the inspection doesn't specify whether oxygen accompanied him on that trip.
The resident maintained intact mental capacity with a cognitive assessment score of 15, indicating he was fully aware of his treatment needs and the facility's failures to meet them.
Federal inspectors found the facility lacked a formal oxygen policy. The Administrator told them the nursing home "follows the regulations" instead of having written protocols for oxygen administration and transport.
The MDS Coordinator and Quality Assurance Nurse acknowledged they would expect staff to follow physician orders for oxygen and send portable equipment to medical appointments.
The violation represents what inspectors classified as "minimal harm or potential for actual harm" to residents. But the hospital nurse's immediate intervention suggests the resident faced real respiratory distress during his oxygen-free transport.
For three months, staff at Accura Healthcare documented the resident's breathing without the supplemental oxygen his doctor had ordered. The pattern only came to light when he arrived at a medical appointment visibly needing the treatment his own facility had failed to provide.
The resident returned to Accura Healthcare that November day carrying a hospital oxygen tank, a reminder of care his nursing home should have been providing all along.
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.
Resident #2 at Accura Healthcare of Marshalltown required continuous oxygen at 2 liters per minute under physician orders dated August 22.
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.