Little Chute Health Services

Based on staff interview and record review, the facility did not ensure their abuse policy was implemented for 1 (Certified Nursing Assistant (CNA)-G) of 8 employees reviewed for caregiver background checks. The facility did not complete an out-of-state background check for CNA-G. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: .I. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees .Background checks, including re-checks, will be completed consistent with applicable state laws and regulation .2. Screenings may be conducted by the facility itself, a third-party agency or academic institution. 3. The facility will maintain documentation of proof that the screening occurred . On 5/21/26 Surveyor requested background check information, including Background Information Disclosure (BID) forms, Department of Justice (DOJ) and Governmental findings letters,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure weight monitoring was provided for 1 resident (R) (R12) of 2 sampled residents.R12 was not re-weighed for weight loss/gain greater than 5 pounds (lbs). R12's provider, Power of Attorney (POA), and the facility's Registered Dietician (RD) were not notified regarding R12's weight loss/gain greater than 5 lbs. In addition, R12's weight was not obtained with a consistent device.Findings include:The facility's Weight Monitoring policy, revised 12/21/22, indicates: Weight Assessment:.5. Team members will follow a consistent approach to weighing and using an appropriately calibrated and functioning scale. Since weight varies throughout the day, a consistent process and technique (e.g., weighing the resident wearing a similar type of clothing, at approximately the same time of day, using the same scale, either consistently wearing or not wearing orthotics or prostheses, and verifying scale accuracy) can help make weight comparison more reliable. 6.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R1) of 1 sampled resident. R1's oxygen concentrator was not consistently set in accordance with a physician's order. In addition, R1's care plan did not indicate R1 had a diagnosis of chronic obstructive pulmonary disease (a progressive inflammatory lung disease that obstructs airflow from the lungs making it difficult to breathe). Findings include: The facility's Oxygen Concentrator policy, dated 6/3/22, indicates: .1. Staff responsible for the use and care of oxygen concentrators receive training on oxygen safety and the functionality of the device. 2. Oxygen is administered under orders of the attending physician, except in the case of an emergency .4. Use of the Concentrator: a. Orders for the rate of flow and route of administration of oxygen (mask, nasal cannula etc.) .k. Keep turned off when set up for use in the resident's room, but not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure physician visits were completed timely for 1 resident (R) (R6) of 3 sampled residents. R6 was admitted to the facility on [DATE]. R6 was not seen by a physician at least once every 30 days for the first 90 days after admission.Findings include:The facility's Physician Visits and Physician Delegation policy, revised 7/27/25, indicates: .2. The physician should: a. See resident within 30 days of initial admission to the facility. b. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission .On 1/20/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, hemiplegia, cerebral infarction, and diabetes. R6's Minimum Data Set (MDS) assessment, dated 12/30/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R6 had severe cognitive impairment.Surveyor reviewed R6's physician visits after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure the appropriate care and treatment regarding dressing changes and lab work was provided for 2 residents (R) (R3 and R9) of 3 sampled residents.Staff did not complete R3's peripherally inserted central catheter (PICC) line dressing change as ordered. In addition, R3's weekly labs were not completed as ordered.Staff did not complete R9's PICC line dressing change as ordered. Findings include:The facility's Dressing Change for Vascular Access Devices policy, revised 10/2024, indicates: Purpose: To prevent local and systemic infection related to the intravenous (IV) catheter .A sterile dressing is maintained on all peripheral and central vascular access devices to protect the site, provide a microbial barrier, and to provide vascular access device securement .3. Central venous access device and peripheral midline dressings are changed every 7 days and immediately if the integrity of the dressing is compromised, if moisture,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure adequate supervision was implemented for 1 resident (R) (R2) of 8 sampled residents.On 7/1/25, R8 reported to Registered Nurse (RN)-E that R2 rubbed R8's arm and made sexual statements to R8 including What size are your breasts? and Can I feel your breasts? The facility did not place R2 on supervision to prevent reoccurrence. On 7/13/25, RN-E witnessed R2 rubbing R1's arm. RN-E intervened and R1 indicated that R1 squeezed R2's breasts. R2 was placed on 1:1 supervision following the incident.Findings include:The facility's Abuse, Neglect and Exploitation policy, dated 7/15/22, indicates the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves .B. Identifying, correcting, and intervening in situations in which abuse .is more likely to occur with the deployment of trained and qualified, registered, licensed, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not revise the comprehensive plan of care to reflect personal care needs for 1 resident (R) (R2) of 1 sampled resident. R2's care plan did not reflect specialized techniques of care that R2 required with activities of daily living. Findings include: The facility's Comprehensive Care Plan policy, revised 9/23/22, indicates: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .5. The comprehensive care plan will be reviewed and revised as appropriate by the interdisciplinary team after each Comprehensive and Quarterly Minimum Data Set (MDS) assessment and as needed with change in condition . On 6/13/25 at 9:20 AM, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including cerebral vascular accident with right-sided hemiplegia, dysphagia, aphasia, depression, cognitive communication deficit, and epilepsy. R2's MDS assessment, dated 3/24/25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure nail care was provided for 1 resident (R) (R21) of two sampled residents. R21's fingernails were not trimmed per R21's request. Findings include: From 3/30/25 to 4/1/25, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] and had a diagnosis of quadriplegia. R21's most recent Minimum Data Set (MDS) assessment, dated 3/14/25, indicated R21 had intact cognition. R21's plan of care, dated 3/20/25, indicated R21 had an activity of daily living (ADL) self-care deficit and was dependent on staff to complete ADLs due to physical limitations secondary to transverse myelitis quadriplegia. R21's plan of care also indicated R21 was at risk for alteration in skin integrity related to impaired mobility and contained interventions for personal hygiene assist of one, bathing/showering assist of one, and to be extra careful when trimming R21's nails due to abnormal nails and build-up under the nails.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 2 residents (R) (R7 and R16) of 6 sampled residents were monitored for adverse reactions to high-risk medications. R7 was prescribed furosemide (a diuretic medication) for edema (swelling). R7 was not monitored for adverse reactions to the high-risk medication. R16 was prescribed cefazolin (an antibiotic medication) for infection. R16 was not monitored for adverse reactions to the high-risk medication. Findings include: The facility's Medication Management policy, dated 1/2025, indicates: Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug: .for excessive duration, without adequate monitoring .in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combination of these reasons. Medication management is based on the care process and includes recognition or identification of the problem/need .management/treatment, monitoring, and revising…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure an as needed (PRN) psychotropic medication order for 1 resident (R) (R7) of 5 sampled residents was discontinued after 14 days. R7 was prescribed lorazepam (an anti-anxiety medication) for anxiety. R7's PRN lorazepam order was not discontinued after 14 days and did not contain a stop date. Findings include: The facility's Medication Management policy, dated 1/2025, indicates: Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug: .for excessive duration, without adequate monitoring .in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combination of these reasons. Medication management is based on the care process and includes recognition or identification of the problem/need .management/treatment, monitoring, and revising interventions .In order to optimize the therapeutic benefit of medication therapy and minimize or prevent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure food was served in a manner that conserved palatability and temperature for 1 resident (R) (R21) of 14 sampled residents. The facility served R21's meals at an unappetizing temperature. Findings include: The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 3-501.16: Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone of 5 degrees Celsius (C) to 57 degrees C (41 degrees Fahrenheit (F) to 135 degrees F) too long. From 3/30/25 to 4/1/25, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] and had a diagnosis of quadriplegia. R21's most recent Minimum Data Set (MDS) assessment, dated 3/14/25, indicated R21 had intact cognition. A care plan, dated 3/20/25, indicated R21 was at risk for nutritional status change related to congestive heart failure and quadriplegia and was dependent on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R138) of 14 sampled residents. R138 was on enhanced barrier precautions (EBP) which require staff to wear personal protective equipment (PPE) during high-contact resident cares. On 3/31/25, staff provided care, transferred, and disconnected R138's tube feeding without donning the appropriate PPE. In addition, there was not an EBP sign posted on or near R138's door. Findings include: The facility's Enhanced Barrier Precautions policy, revised 8/8/24, indicates: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs) .Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms that employs targeted gown and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and record review, the facility did not ensure all medications were labeled appropriately for 2 Residents (R) (R138 and R8) of 5 residents observed during medication administration. R138 was administered furosemide 40 mg (milligrams). The medication card was not labeled correctly. R8 was administered metoprolol succinate ER (extended release) 50 mg. The medication card was not labeled correctly. Findings include: The facility's Medication Ordering and Receiving From Pharmacy Provider policy and procedure, dated 1/23, indicates: .Each prescription medication will be labeled to include specific directions for use .3. Improperly or inaccurately labeled medications are refused and returned to the dispensing pharmacy. 1. On 3/26/24 at 9:00 AM, Surveyor observed Licensed Practical Nurse (LPN)-F administer medication to R138. LPN-F retrieved a medication card for R138 from the medication cart and handed the card to Surveyor. The medication card label read furosemide 40 mg one tablet daily. On 3/26/24, Surveyor reviewed R138's current physician order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and record review, the facility did not implement their written policies and procedures to prohibit and prevent abuse for 1 (Certified Nursing Assistant (CNA)-C) of 8 facility and contracted staff reviewed for caregiver background checks. The facility did not ensure a thorough and timely caregiver background check was completed for CNA-C. Findings include: The facility's Abuse, Neglect and Exploitation policy, with a review date of 7/15/22, indicated: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Background checks,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.