Little Chute Health Services

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision and interventions were in place to prevent falls for 2 residents (R) (R1 and R3) of 3 sampled residents from a total sample of 11 residents. R1 sustained multiple falls with injury (including a broken nose and patella fracture) and without injury while on 1:1 supervision and 30-minute checks. Check sheets contained gaps in completion and were missing entries for days which coincided with some of R1's falls. In addition, R1's medical record did not consistently indicate when they were on 1:1 supervision, 15-minute checks, or 30-minute checks. (This example is being cited at a level G.) R3 was left in bed connected to a Hoyer lift without staff in the room to provide supervision.

Inspectors wroteBased on observation, interview, and record review, the facility did not have an effective process for labeling items and did not ensure missing laundry was returned or replaced for 3 residents (R) (R4, R10, and R11) of 3 sampled residents. Power of Attorney for Healthcare (POAHC)-N reported R4 was missing pants and shirts. POAHC-N replaced the items when the facility could not find the items and did not provide follow-up communication. R10 informed Laundry Staff (LS)-M they were missing a nightgown. The nightgown had not been found or replaced. R11 was missing underwear and t-shirts which had not been found or replaced.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the care plan was followed for 1 resident (R) (R3) of 3 sampled residents. R3 had an order and a care plan intervention for pressure relieving boots to bilateral feet at all times. R3 was observed in bed without pressure relieving boots.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R3) of 1 resident. R3 had an order for oxygen to prevent low oxygen saturation levels. R3 was observed in bed without oxygen. In addition, R3's care plan did not indicate they received oxygen.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased on staff interview and record review, the facility did not provide care and services to maintain the highest practicable physical well-being when they did not recognize and appropriately respond to a change in condition for 1 resident (R) (R1) of 6 sampled residents. On 12/23/25, R1 was admitted to the facility following a C3-C4 laminectomy (major spinal surgery in which part of the vertebra is removed). R1 was alert and oriented upon admission. From 12/24/25 to 12/29/25, R1 experienced a change in condition including decreased cognition, an oxygen saturation level of 79% which required continuous supplemental oxygen, an episode of hypoglycemia (low blood sugar) that required 2 doses of glucose gel, and abnormal vital signs. During a care conference on 12/29/25, R1's family reported concerns to staff regarding R1's overall condition. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure adequate supervision, positioning, and assistive devices were provided during a meal for 1 resident (R) (R2) of 3 sampled residents. R2 had a history of aspiration. R2's care plan indicated R2 required 1:1 supervision for meals. The care plan contained interventions to encourage R2 to take small bites and clear mouth before the next bite, to seal R2's lips around the cup opening until R2 swallowed, and to be seated upright during meals and have a neck pillow in place for proper positioning. R2 was hospitalized from [DATE] to 12/22/25 for sepsis caused by urinary tract infection (UTI) and aspiration. On 1/15/26, Surveyor heard R2 coughing and observed R2 eating alone in R2's room with the curtain drawn and the head of the bed at 45 degrees. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide the necessary care and services to prevent the development of avoidable pressure injuries and/or promote healing for 2 residents (R) (R1 and R2) of 5 sampled residents. R1 was admitted to the facility on [DATE] without any pressure injuries. A Braden Scale assessment completed upon admission indicated R1 was at high risk for the development of pressure injuries. R1 was admitted to the hospital on [DATE] with a bilateral sacral pressure injury with serosanguineous (a fluid mixture of serous fluid (clear plasma) and blood, appearing as thin, watery, pinkish or light red indicating mild capillary bleeding) drainage, a right posterior thigh pressure injury, and a right heel pressure injury. The facility was unaware of the pressure injuries. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on staff interview and record review, the facility did not ensure adequate supervision was provided for 1 resident (R) (R89) of 1 resident reviewed for elopement. Upon admission on [DATE], R89 was assessed to be at risk for elopement and a wanderguard (a security device that triggers an alarm if the wearer exits the facility) was placed on R89's right ankle. On 2/10/24 at 9:00 AM, a community member altered staff that R89 was a few blocks away from the facility. Staff were unaware R89 left the facility but were able to locate R89 and bring him back to the facility. An assessment indicated R89 had no injuries. The failure to provide adequate supervision created a finding of Immediate Jeopardy (IJ) which began on 2/10/24. Surveyor notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on 3/25/24 at 3:30 PM. The immediate jeopardy was removed and corrected on 2/10/24.

Inspectors wroteBased 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.

Inspectors wroteBased 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.