Accura Healthcare: Care Quality Deficiencies - IA
The resident at Accura Healthcare of Marshalltown needed the PICC line in his arm replaced on November 19. Staff transported him to the hospital in the facility van but left his oxygen equipment behind.
"The hospital nurse had to send oxygen with him back to the facility," the resident told inspectors the next day. His oxygen saturation measured just 88 percent on room air when he arrived at the hospital. Normal levels range from 95 to 100 percent.
The hospital's infusion registered nurse confirmed the account. "Resident came to the hospital with no oxygen," she told state inspectors on November 20. "She said Resident said the facility forgot the oxygen as they were in a hurry to get to the hospital."
The nurse placed him on supplemental oxygen immediately and sent him back to the facility with a portable tank.
But the missing oxygen tank represented just one symptom of a larger problem. Federal inspectors discovered that staff had ignored the resident's physician-ordered oxygen therapy for months.
The resident's doctor ordered continuous oxygen at 2 liters per minute through nasal cannula on August 22. His medical conditions included chronic obstructive pulmonary disease, chronic respiratory failure, hypertension, chronic kidney disease, and diabetes. His care plan specifically directed staff to "make sure Resident had the oxygen on and that he was using it correctly."
Yet from August through November, nursing staff documented his oxygen saturations while he breathed room air instead of supplemental oxygen. The oxygen readings were recorded on room air 26 different days between August 22 and November 18.
Staff never entered the physician's oxygen order into the facility's medication administration records or treatment administration records during those three months.
"The MDS Coordinator verified the oxygen order was not on the MAR or TAR," inspectors wrote.
The resident, whose mental status assessment showed intact cognition, understood his medical needs clearly. He told the hospital nurse "that he wore oxygen continuously" and explained that facility staff had forgotten his equipment in their rush to reach the hospital.
When questioned, facility staff offered contradictory explanations. Staff A, a licensed practical nurse, said she wasn't sure whether the resident had oxygen during transport but acknowledged "he was on continuous oxygen so it should have been sent with him."
The assistant director of nursing suggested staff made documentation errors. She "reported she thought the staff hit the wrong button on the electronic charting and made a mistake when documenting the oxygen saturations on room air."
The administrator admitted the facility lacked formal oxygen policies. "The Administrator reported the facility did not have a formal oxygen policy as the facility follows the regulations," inspectors noted.
This wasn't the first time the resident required emergency medical care. His skilled progress notes showed he had previously gone to the emergency room on September 8 to have his PICC line replaced.
The resident remained alert and conversational throughout the November incident. "He reported he was breathing ok when he was without the oxygen," inspectors documented, though his oxygen saturation told a different story.
The hospital nurse said she didn't observe obvious breathing problems before applying oxygen, but the low saturation reading indicated his body wasn't receiving adequate oxygen.
Federal regulators cited the facility for failing to provide safe and appropriate respiratory care, noting minimal harm or potential for actual harm to the resident.
The MDS coordinator and quality assurance nurse told inspectors they "would expect staff to follow the physician orders for the oxygen administration and would expect staff to send portable oxygen to physician appointments."
The resident returned to the facility with the hospital's portable oxygen tank, finally receiving the respiratory support his doctor had ordered three months earlier.
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: August 5, 2026 · Our methodology
Accura Healthcare of Marshalltown in Marshalltown, IA was cited for violations during a health inspection on November 24, 2025.
The resident at Accura Healthcare of Marshalltown needed the PICC line in his arm replaced on November 19.
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.