Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accura Healthcare Of New Hampton during CMS and state inspections, most recent first.
During a prolonged heating system malfunction, several residents experienced cold room temperatures, with some rooms documented as low as 50 to 60°F. Staff provided extra blankets and placed space heaters in hallways, but did not consistently offer warm drinks or promptly relocate residents to warmer areas. Maintenance delays and incomplete implementation of facility policy contributed to ongoing resident discomfort.
The facility failed to designate a qualified IP who worked at least part-time in the role. The IP/MDS Coordinator said she spent about an hour a week on infection control duties, had not completed staff competencies or audits, and was often pulled to the floor or to MDS work. The Facility Assessment called for one employee to work 3-8 hours part-time, and the Administrator and DON both indicated the IP was not consistently meeting that expectation.
Soiled gloves and utensils contacted food during meal service when a dietary staff member repeatedly handled bread and other food items with gloved hands after touching equipment, clothing, doors, tickets, and personal items without washing hands between tasks. The staff member also used a scoop in a contaminated manner while plating meals for multiple residents. Interviews and facility policy confirmed gloves were to be used for one task only and hands were to be washed before donning new gloves.
A resident’s current PASRR did not reflect all current mental health diagnoses and psychotropic medications. The MDS showed a BIMS of 15 and stated the resident was not a PASRR level II, but the PASRR only listed depression and anxiety with antidepressant use. A later MD order summary documented additional diagnoses including insomnia, delusional disorders, hallucinations, and a history of adult neglect, along with antipsychotic, antidepressant, and antianxiety medications; the care plan also noted occasional refusal of care and impaired thought processes.
Failure to serve ordered diets and nutritional additions: A resident ordered pureed diet with double protein was only given one portion of pureed meat, and two residents with care plans for extra butter and gravy were served meals without those additions. Dietary staff stated they relied on meal tickets to identify special diet needs, but the tickets did not reflect the care plan instructions.
Failure to complete an SCSA MDS for a resident with a documented decline in toileting and continence. The resident’s MDS changed from independent toileting hygiene with frequent urinary incontinence and bowel continence to substantial/maximal assist for toileting hygiene with always incontinent of urine and bowel. A validation report flagged the significant change, but the resident was not set up for an SCSA, and the MDS Coordinator said the change slipped through the cracks.
Staff did not follow the care plan for a resident with significant medical needs, resulting in two falls where the resident was found on the floor with abrasions to the knees. The care plan required the bed to be in the lowest position and regular staff checks, but these interventions were not consistently implemented, as confirmed by staff interviews.
A resident who experienced a fall did not receive required neurological assessments or timely documentation of injuries, and staff failed to complete an Incident Report as per facility policy. Communication lapses among LPNs and lack of adherence to risk management protocols resulted in inadequate assessment and documentation of the resident's condition.
A resident with severe cognitive loss and significant weight loss did not receive the Dietician's recommended dietary interventions, including ice cream with meals, due to inadequate communication and execution of the care plan. Staff were unaware of the dietary requirements, and the facility's process for implementing recommendations was insufficient, leading to the resident not receiving necessary interventions.
A resident with chronic pain from osteoarthritis and osteoporosis was administered an incorrect dose of Lidocaine patch, leading to unrelieved pain. The LPN applied a 4% patch instead of the prescribed 5%, and the DON was unaware of the error due to a lack of policy for verifying physician orders.
A facility failed to have emergency equipment readily available for a resident with a tracheostomy. The resident's care plan required a hemostat at the bedside, but it was not found, and the LPN was unaware of its location. The DON confirmed the absence of accessible tracheostomy care kits in the room and acknowledged the lack of documented emergency training for nurses.
A facility failed to provide eye protection for a resident's tracheostomy care, despite the potential for droplet exposure. An LPN performed the care without goggles or a face shield, as these were not available in the isolation bin. The DON and IP acknowledged the need for face shields, which were stored in the basement.
The facility failed to ensure the Dietary Service Manager had the required qualifications in the absence of a full-time dietician. The Dietary Manager is not certified but is currently enrolled in the certification course, and the dietician visits once a week.
The facility failed to maintain sanitary practices in the kitchen, with improperly stored dishes, dirty shelves, and food particles on equipment. The Dietary Manager confirmed a lack of documented cleaning and absence of a sanitation policy.
The facility failed to follow protocols for insulin administration and G-tube flushing. An LPN did not check G-tube placement or elevate a resident's head before flushing, and insulin pens were not primed before administration to three residents. Additionally, a resident's insulin refusals were not reported to the physician as required.
Failure to Maintain Comfortable Room Temperatures During Heating System Malfunction
Penalty
Summary
The facility failed to maintain comfortable room temperatures and implement adequate interventions during a prolonged heating system malfunction affecting multiple residents. Over a period of approximately 1.5 weeks, residents reported feeling cold in their rooms, with temperatures documented as low as 50 to 60 degrees Fahrenheit. While staff provided extra blankets and placed space heaters in hallways, residents indicated these measures were insufficient, and some were not offered warm drinks except during meals. Several residents were only offered the option to move to warmer rooms after an extended period, despite ongoing complaints of discomfort. Staff interviews confirmed that most residents complained about the cold, and interventions such as offering hot drinks or proactively relocating residents were inconsistently applied. Maintenance staff reported delays in repairing the heating system due to the need for corporate approval, with the malfunction affecting specific hallways and resident rooms. Temperature readings taken during the survey confirmed that some occupied rooms remained below the recommended comfort level. Facility policy required the provision of extra blankets, grouping residents, and offering hot foods and drinks during heating system failures, but these directives were not fully implemented. Residents, including those unable to advocate for themselves, experienced discomfort due to the lack of timely and comprehensive interventions.
Infection Preventionist Not Working Required Part-Time Hours
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) to be responsible for the infection prevention and control program. Based on staff interviews, the employee job description, and the Facility Assessment, the facility did not have the IP working at least part-time in the role. The facility reported a census of 40 residents, and the Facility Assessment Tool last reviewed on 1/7/25 stated the facility need for infection prevention was one employee working part-time for 3-8 hours. During an interview on 7/30/25, the Infection Preventionist/Minimum Data Set Coordinator stated she worked in the IP role about an hour a week and had not completed staff competencies or infection control audits. She said she did not have time to complete the duties because she was pulled to the floor or had to work on MDSs, and that she mainly looked at the antibiotic resident line listing report to see what was going on. The job description for Quality Assurance & Infection Preventionist Nurse listed education on infection prevention and control principles, policies, and procedures as an essential function, and the Administrator later stated the IP nurse was expected to focus weekly on audits, education, tracking/trending, and antibiotic stewardship. The DON stated she did not think the IP was working 3-8 hours a week in that role and believed it was more like 1-2 hours or a couple of hours weekly.
Soiled gloves and utensils contacted food during meal service
Penalty
Summary
The facility failed to prevent soiled gloves and soiled utensils from contacting food during meal service for 34 of 40 residents served. During continuous observation, a dietary staff member applied gloves without washing hands after touching the stove, steam pan, thermometer, and steam pan lid, then rubbed the back of a gloved hand on her hip and pulled down her uniform top with both gloved hands before continuing to plate food. She used her gloved hand to move or hold bread in place while plating mashed potatoes, roast beef, and mixed vegetables for multiple residents, and continued this same method while plating additional meals throughout the observation period. The same staff member was observed handling tray carts, plate covers, the walk-in refrigerator door, a covered bowl, meal tickets, and a small bowl while wearing gloves, then later removed the gloves, drank from a personal water bottle, and reapplied gloves without washing her hands. She also touched utensils and used a blue #16 scoop in a manner that required bracing it against her apron to turn it around before serving pureed bread. Throughout the meal period, she repeatedly touched bread with her gloved hand while plating food for numerous residents, including residents served at 12:21 PM, 12:30 PM, 12:41 PM, and 12:44 PM. During interviews, the dietary staff member stated she had only been trained by the prior staff member who trained her and had not received other training or video training on food handling or gloving. Other dietary staff and the Certified Dietary Manager stated gloves are to be used for one task only, and if staff touch anything else they must remove gloves, wash hands, and put on new gloves before returning to food handling. Facility policies and the 2022 FDA Food Code were reviewed and stated that hands must be washed before donning gloves, after removing gloves, and when changing tasks, and that ready-to-eat food must not be contacted with bare hands and should be handled with suitable utensils or single-use gloves.
PASRR Did Not Reflect Current Mental Health Diagnoses and Medications
Penalty
Summary
The facility failed to ensure that 1 of 1 resident’s current PASRR assessment reflected all current mental health diagnoses and medications. Resident #7’s MDS documented a BIMS score of 15, indicating no cognitive impairment, and the MDS stated she was not considered by the state to be a PASRR level II. However, the resident’s current PASRR dated 6/26/2024 documented mental health diagnoses of depression and anxiety and noted that she was taking antidepressant medications. Record review of the resident’s Order Summary Report signed by her doctor on 6/16/2025 documented additional current mental health diagnoses of anxiety, insomnia, delusional disorders, personal history of adult neglect, depression, and hallucinations. It also documented that she was taking antipsychotic, antidepressant, and antianxiety medications. The resident’s care plan documented occasional refusal or rejection of necessary care related to anxiety disorder and major depressive disorder, and impaired thought processes related to behavioral symptoms, delusional disorders, aging process, and hallucinations.
Failure to Serve Ordered Diets and Nutritional Additions
Penalty
Summary
The facility failed to serve diets that matched residents’ individualized nutritional needs for 3 of 3 sampled residents. Resident #15 had a physician order for a regular diet with pureed texture and double protein, and the care plan directed staff to serve the diet as ordered with double protein to help with weight gain. During lunch meal service, dietary staff prepared pureed roast beef from four 3-ounce servings, but only one #10 scoop was plated for Resident #15. Staff then realized the resident had not been served a double protein portion, but no second portion of pureed roast beef was served before meal service ended, even though a small amount remained in the steam pan. Resident #23 had a regular diet and a care plan intervention directing staff to add extra butter and gravies to appropriate foods to increase caloric intake. During lunch service, staff placed bread on the resident’s plate and served mashed potatoes and gravy, but did not add extra butter or additional gravy. The resident’s meal ticket documented a regular diet with thin fluids, but it did not include the care plan instruction for extra butter or gravy. Resident #34 also had a regular diet and a care plan intervention directing staff to add extra butter and gravies to appropriate foods to increase caloric intake. During lunch service, staff plated roast beef, bread, mashed potatoes with one 2-ounce ladle of gravy, and vegetables, but did not serve extra butter or gravy. The resident’s meal ticket listed a regular diet with thin liquids and did not include any communication about providing extra butter or gravy. Staff interviews confirmed that meal tickets were used to guide service, that dietary staff relied on them to know which residents needed special items, and that the CDM was responsible for updating the meal tickets.
Failure to Complete Significant Change MDS for Decline in Toileting and Continence
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) for Resident #3 after the resident’s status changed in toileting and continence. The resident’s January annual MDS documented intact cognition with a BIMS score of 15/15, use of a walker, upper and lower extremity impairment on one side, independence in toileting hygiene, frequent bladder incontinence, and bowel continence. The urinary incontinence CAA described the resident as frequently incontinent of urine, wearing pull-up briefs, and needing occasional assistance with incontinence care. The resident’s diagnoses included non-traumatic brain dysfunction, BPH, diabetes mellitus, thyroid disorder, non-Alzheimer’s dementia, anxiety, bipolar disorder, urinary retention, and other kidney and ureter disorder. By April, the quarterly MDS documented a decline in toileting hygiene to substantial/maximal assistance and coded the resident as always incontinent of urine and always incontinent of bowel. The MDS Validation Warnings Report identified a significant change decline in toileting and bowel continence, and the MDS Coordinator acknowledged the warning. However, the resident was not set up for a Significant Change in Status MDS from January through July. During interview, the MDS Coordinator stated she relied on what she saw or what staff reported, had been working the floor a lot, and said the issue slipped through the cracks; she also stated the facility did not have an MDS policy and that she follows the CMS RAI User Manual. A CNA reported the resident had not used the toilet or urinal for a long time and had been dependent on staff for check and changes for a long time.
Failure to Follow Care Plan Results in Resident Falls and Injury
Penalty
Summary
Facility staff failed to follow the individualized care plan for a resident with multiple complex medical conditions, including a history of stroke, type II diabetes, PEG tube, low vision, obesity, hemiplegia, and respiratory failure. The care plan specified that the resident required assistance from two staff members for bed mobility, the bed should be kept in the lowest position, a body pillow should be used during repositioning, and that staff, family, and caregivers should be notified of any new skin breakdown. Despite these directives, the resident was found on two separate occasions on the floor beside the bed, having sustained abrasions to the knees. In both incidents, the bed was not in the lowest position as required by the care plan. Staff interviews confirmed that the care plan interventions were not consistently followed. On one occasion, an LPN was not informed of the resident's abrasion or the new intervention requiring two-hour staff checks. A CNA also confirmed that the bed was not in the lowest position at the time of the fall and acknowledged that staff should have adhered to the care plan. The administrator confirmed the expectation that staff follow each resident's care plan, but the documented events and staff statements indicate that this did not occur for the resident in question.
Failure to Assess and Document Care Following Resident Fall
Penalty
Summary
The facility failed to properly assess and intervene following a fall for one resident. After the resident experienced a fall, staff did not complete an Incident Report as required by facility policy, and there was a lack of documentation regarding the presence of an abrasion on the resident's right knee. Nursing staff did not perform neurological assessments according to protocol, which required checks every 15 minutes for the first three intervals, then every four hours, and then every eight hours. Additionally, there was no documentation of treatment provided to the resident's knees, despite the presence of a bandage with sanguineous drainage and an open area the size of a half-dollar noted on the right knee. Staff interviews revealed confusion and lack of communication regarding the fall, the resident's injuries, and the required interventions. The nurse on duty at the time of the fall was new and had not previously managed a fall incident, contributing to the failure to complete necessary documentation and assessments. The facility's risk management policy required neurological assessments for unwitnessed falls or possible head injuries and completion of Incident Reports by the end of the nurse's shift, both of which were not followed in this case.
Failure to Implement Dietician's Recommendations for Resident's Weight Loss
Penalty
Summary
The facility failed to implement the Dietician's recommended dietary interventions for a resident with severe cognitive loss and significant weight loss. The resident, who required supervision for eating and had a diagnosis of dementia, chronic kidney disease, and hypertension, was supposed to receive Premier Protein shakes twice a day and ice cream with lunch and dinner to prevent further weight loss. Despite these recommendations, observations revealed that the resident was not served ice cream with her meals, and staff interviews confirmed that ice cream was not consistently provided as part of the resident's dietary plan. The facility's process for implementing dietary recommendations was inadequate, as evidenced by the lack of communication and execution of the Dietician's recommendations. Staff members, including a CNA and an LPN, were unaware of the requirement to serve ice cream with meals, and the Dietary Manager noted delays in receiving and implementing the Dietician's recommendations. The DON acknowledged responsibility for overseeing dietary recommendations but confirmed that the dietary staff failed to serve the recommended items. This deficiency highlights a breakdown in communication and adherence to the care plan, resulting in the resident not receiving the necessary dietary interventions to address her weight loss.
Failure to Follow Physician Orders for Pain Management
Penalty
Summary
The facility failed to follow physician orders for a resident, identified as Resident #32, who was receiving treatment for chronic pain related to osteoarthritis and osteoporosis. The resident's Minimum Data Set (MDS) assessment indicated intact cognition and documented the use of scheduled pain medication for a pain level of 7 out of 10. The care plan for Resident #32 included monitoring for side effects of pain medication and reporting any significant changes in pain to the physician. However, the facility did not adhere to these directives. On multiple occasions, Resident #32 reported moderate to severe pain levels, yet was administered an incorrect dose of the prescribed medication. Specifically, a Licensed Practical Nurse (LPN) applied a 4% Lidocaine patch instead of the prescribed 5% patch. This discrepancy was observed and confirmed during interviews with the resident and staff. The Director of Nursing (DON) was unaware of the medication error until notified and revealed that the facility lacked a policy for verifying and transcribing physician orders, which contributed to the oversight.
Emergency Equipment Not Available for Tracheostomy Care
Penalty
Summary
The facility failed to have emergency equipment readily available at the bedside for a resident requiring tracheostomy care. The resident, who had a tracheostomy due to a malignant neoplasm of the supraglottis, was observed to have a bag with suction equipment zipped inside a closet, not set up for emergency use. Additionally, a hemostat, which was required by the care plan to be at the bedside, was not found in the resident's room. The Licensed Practical Nurse (LPN) was unaware of the location of the hemostat and had to consult with the Director of Nursing (DON), who confirmed that the hemostat was expected to be in the room. The DON acknowledged that the tracheostomy care kits, which contained forceps that could be used in an emergency, were not stored in the resident's room and were not accessible in case of an emergency. Furthermore, the facility's assessment lacked documentation of emergency training regarding tracheostomy care, and the nurses did not have documented emergency training. The facility's tracheostomy care procedure also lacked specific directions on the emergency equipment that should be maintained at the bedside.
Lack of Eye Protection for Tracheostomy Care
Penalty
Summary
The facility failed to have eye protection readily available for enhanced barrier precautions (EBP) during tracheostomy care for a resident with a tracheostomy and a diagnosis of cancer. The resident, who had a mild cognitive loss, was observed during tracheostomy care performed by a Licensed Practical Nurse (LPN). The LPN wore a gown and gloves but did not have access to goggles or a face shield, which were not present in the isolation bin. The resident mentioned that he sometimes coughs during care, causing secretions to be expelled, but the LPN was not instructed to wear eye protection. The Director of Nursing (DON) and the Infection Preventionist (IP) were consulted regarding the use of face shields. The DON indicated that face shields should be used if there is potential for droplet or airborne secretions, and mentioned that face shields were stored in the basement with COVID-19 PPE. The IP acknowledged that the facility follows CDC guidelines and recognized that staff should probably wear face shields during such procedures. However, at the time of the observation, the necessary eye protection was not readily available for the staff.
Dietary Service Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure the Dietary Service Manager had the required qualifications in the absence of a full-time dietician. The facility had a census of 42 residents. During an interview, the Administrator and the Dietary Manager both reported that the Dietary Manager is not certified but is currently enrolled in the certification course. The dietician visits the facility once a week.
Improper Kitchen Sanitation and Dish Storage
Penalty
Summary
The facility failed to maintain sanitary practices in the kitchen, as observed during an initial inspection. Clean dishes were improperly stored on open shelving next to the prep area without being inverted, and the shelves were covered in dust and soiled dark spots. The front of the oven and stove top were covered in dry food spills and particles. Additionally, a window in front of the prep area was open, allowing dirt and dried leaves to blow onto the food on the counter. The large mixer and open shelving next to the steam table were also dirty, with food particles present and dishes inconsistently inverted. During a follow-up observation, the same unsanitary conditions were noted, with no changes made to address the issues. The Dietary Manager confirmed that the kitchen staff had a cleaning schedule, but the last documented cleaning was on 4/9/24, and the facility lacked a policy on kitchen sanitation or proper dish storage. The cleaning list for the night cook tasks did not include directions for cleaning the shelves, storing dishes, or cleaning the large mixer.
Failure to Follow Insulin Administration and G-Tube Flushing Protocols
Penalty
Summary
The facility failed to adhere to professional standards of quality in several instances. For Resident #24, a Licensed Practical Nurse (LPN) did not check the placement of the gastrostomy tube (G-tube) and did not elevate the resident's head before flushing the tube with warm water. This was observed during a specific incident, and the Director of Nursing (DON) confirmed that the expected procedure was not followed. The facility's policy also required the head of the bed to be elevated and the tube placement to be verified before flushing, which was not done in this case. For Resident #33, the facility failed to follow physician's orders for insulin administration. The resident's Medication Administration Records (MAR) showed inconsistent blood sugar levels and multiple instances where insulin was either refused by the resident or held by the nurse without notifying the physician. Interviews with various staff members, including LPNs and RNs, revealed that the physician was not notified of these refusals or holds, and there was no documentation of staff educating the resident on the risks of not taking insulin as prescribed. The facility's policy required the physician to be notified of any medication refusal, which was not adhered to. Additionally, the facility failed to prime insulin pens before administering insulin to three residents. Observations showed that an LPN did not prime the insulin pens before injecting insulin and did not keep the pens in place for the recommended duration after administration. The DON confirmed that the manufacturer's recommendations for priming and holding the insulin pens were not followed. This issue was observed in the administration of insulin to Residents #24, #33, and #37, and the LPN acknowledged the mistake during an interview.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 54 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near New Hampton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New Hampton Nursing & Rehab Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Colonial Manor Of Elma | 14.9 mi | ★★★★★ | 16 | 0 |
| Tripoli Nursing & Rehab | 17.1 mi | ★★★★★ | 0 | 0 |
| Hillcrest Home | 17.5 mi | ★★★★★ | 0 | 0 |
| Chautauqua Guest Home #3 | 18.1 mi | ★★★★★ | 0 | 0 |
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