Accura Healthcare of New Hampton

Inspectors wroteBased on observation, clinical record review, resident interview, staff interview, and facility policy review the facility failed to maintain comfortable room temperatures and interventions to maintain resident comfort levels during a heating mechanism malfunction that lasted for an extended period of time for 5 of 5 residents reviewed (Resident #1, #2, #3, #5, and #6). The facility identified a census of 31 residents.

Inspectors wroteBased on staff interviews, employee job description, and Facility Assessment the facility failed to have the Infection Preventionist (IP) work at least part-time in the role. The facility reported a census of 40 residents. During an interview with the Infection Preventionist/Minimum Data Set Coordinator on 7/30/25 at 2:05 PM revealed she works in the IP role about an hour a week and has not completed staff competencies or audits related to infection control. She informed she does not have time to complete as she will get pulled to the floor or have to work on MDS's. She revealed she will look at the antibiotic resident line listing report to see what's going on but that is it. Review of the Facility Assessment Tool last reviewed on 1/7/25 instructed the Infection Preventionist need for the facility is one (1) employee who works part-time (3-8 hours). Review of Job Description: [...]

Inspectors wroteBased on observation, policy review, 2022 United States (US) Food and Drug Administration (FDA) Food Code, and staff interviews, the facility failed to prevent soiled gloves or soiled utensils from coming into contact with food during food service for 34 of 40 residents served (Resident #2, #3, #5, #6, #7, #8, #9, #10, #12, #13, #14, #15, #16, #18, #20, #22, #23, #24, #25, #26, #27, #28, #29, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, and #42. The facility identified a census of 40 residents.

Inspectors wroteBased on staff interviews and record review the facility failed to ensure 1 of 1 residents current Preadmission Screening and Resident Review (PASRR) assessment reflected all current diagnoses and medications related to mental health (Resident #7). The facility reported a census of 40 residents. Record review of Resident #7 Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15 which indicated no cognitive impairment. The MDS informed she is not considered by the state to be a PASRR level II. Record review of Resident #7 current PASRR dated 6/26/2024 documented mental health diagnoses of depression and anxiety. The PASRR also documented she currently takes antidepressant medications. [...]

Inspectors wroteBased on observation, clinical record review, policy review and staff interview the facility failed to serve diets to meet the residents individualized needs for of 3 of 3 residents sampled (Resident #15, #23, and #34). The facility identified a census of 40 residentsFindings include:1. Resident #15's clinical record showed a 3/11/25 Physician Order for a regular diet, pureed texture, double protein. Resident #15's Potential Nutritional Problem Care Plan, revised 3/27/25, documented Resident #15 received a double portion with all three meals to aide in weight gain and directed the staff to serve the diet as ordered with double protein, pureed texture. On 7/28/25 the facility provided a Tuesday, Week 5 Menu signed by the Dietician which listed the following regular and pureed diet:a. Roast Beef 3 ounces, 1 servingb. Mash Potatoes 4 ounces (oz)c. Beef gravy 2 oz ladled. [...]

Inspectors wroteBased on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User Manual, and staff interview the facility failed to complete a Minimum Data Set (MDS) Significant Change in Condition Assessment (SCSA) for 1 of 1 residents reviewed for bowel and bladder (Resident #3). The facility identified a census of 40 residents.

Inspectors wroteBased on clinical record review and staff interview the facility failed to follow the Care Plan for 1 of 3 residents reviewed (Resident #1). The facility identified a census of 42 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review, the facility failed to properly assess and intervene for 1 of 3 residents following a fall. (Resident #1) The facility identified a census of 42 residents.

Inspectors wroteBased on observation, clinical record review, and staff interview, the facility failed to provide the Dietician recommended dietary interventions to prevent weight loss for 1 of 1 residents sampled (Resident #14). The facility reported a census of 38 residents.

Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to follow physician orders for 1 of 3 residents sampled (Resident #32). Facility reported a census of 38 residents.

Inspectors wroteBased on observation, clinical record review, and staff interview the facility failed to have emergency equipment readily available at the bedside for 1 of 1 residents reviewed for tracheostomy care (Resident #22). The Facility identified a census of 38 residents.

Inspectors wroteBased on observation, clinical record review, and staff interview the facility failed to have eye protection readily available for enhanced barrier precautions (EBP) for 1 of 1 residents reviewed for tracheostomy care (Resident #22). The Facility identified a census of 38 residents.

Inspectors wroteBased on facility record review and staff interviews, the facility failed to ensure the facility's Dietary Service Manager had the required qualifications in the absence of a full-time dietician. The facility reported a census of 42 residents.

Inspectors wroteBased on observation, staff interviews and policy review the facility failed to maintain sanitary practices by improperly storing clean dishes and maintaining a clean kitchen. The facility reported a census of 42 residents.

Inspectors wroteBased on observation, staff interviews, record review and policy review the facility failed to check placement and elevate the resident's head of bed prior to flushing a g-tube for 1 of 1 resident reviewed (Resident #24); failed to follow physicians orders for insulin for 1of 1 resident reviewed (Resident #33); and failed to prime insulin pen prior to administering for 3 of 3 residents reviewed (Resident #24, #33 and #37). The facility reported a census of 42 residents.

Inspectors wroteBased on observation, photos, and provider contract review, and resident interview revealed the facility failed to maintain clean and safe oxygen concentrator filters for 2 residents reviewed on oxygen therapy (Resident #5 and #7). The facility identified a census of 42 residents.

Inspectors wroteBased on observation, photos, record review, staff interview and review of the facilities Resident Rights the facility failed to maintain an environment free of vermin. The facility identified a census of 42 residents.