Little Chute Health Services

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Develop and implement policies and procedures to prevent abuse, neglect, and theft. Based on staff interview and record review, the facility did not ensure its abuse policy was implemented for 1 CNA, CNA-G, of 8 employees reviewed for caregiver background checks. The facility did not complete an out-of-state background check for CNA-G even though the CNA's Background Information Disclosure form indicated a prior residence outside Wisconsin within the previous three years. The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, states that potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property and that background checks will be completed consistent with applicable state laws and regulation, with documentation maintained to show the screening occurred. Surveyor review on 5/21/26 found CNA-G was hired on 4/14/26, and the requested out-of-state background check was not available. The Guest Services Coordinator, who assisted with human resources and onboarding, stated the out-of-state background check had not been completed prior to hire and should have been completed before employment. The Nursing Home Administrator also stated all background checks and pre-employment screening, including out-of-state background checks when applicable, should be completed prior to employment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure weight monitoring was completed as ordered for a resident with diagnoses including dysphagia, constipation, anxiety, major depression, and intracranial injury. The resident had a BIMS score of 13 out of 15 and was protectively placed with a legal guardian. The care plan identified the resident as at risk for nutritional status changes and obesity related to continued weight gain, and it directed staff to review weights and notify the RD, MD, and responsible party of significant weight changes. The resident’s record showed a weight of 256.5 lbs, followed by a weight of 272.0 lbs on a wheelchair scale, a gain of 16 lbs. The record did not contain a progress note for that weight gain. A note later documented that the provider was notified and staff would obtain a re-weight, and the resident was re-weighed at 268.0 lbs on a wheelchair scale. Later weights were obtained on a mechanical lift scale, including 263.0 lbs and then 270.0 lbs, showing a 7 lb gain; the record again did not contain a progress note for that weight gain. The record also showed provider notes indicating the need for a dietary consult for diabetic diet education to address weight gain and snacking, but an order was not obtained. Staff interviews confirmed that nurses were expected to re-weigh a resident if there was a 5 lb difference and notify the provider, and that the resident’s weight should be obtained using a consistent scale. The UM confirmed the dietary consult order was not transcribed from the provider’s notes, and the DON confirmed the resident did not have an active or discontinued order for dietary education as suggested in the provider documentation. The report also states the provider, POA, and RD were not notified regarding the resident’s weight loss/gain greater than 5 lbs, and the resident’s weight was not obtained with a consistent device.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not provide necessary respiratory care and services for one resident with diagnoses including COPD, congestive diastolic heart failure, atrial fibrillation, acute respiratory failure with hypoxia, and pleural effusions. The resident’s care plan indicated oxygen should be administered per physician orders, but it did not identify COPD. The resident’s MAR ordered oxygen at 1-2 liters per minute via nasal cannula at rest and with activity to maintain oxygen saturation of 88-92%, and the resident had been hospitalized for acute hypoxic respiratory failure secondary to bilateral pleural effusions, COPD/asthma exacerbation, and new atrial fibrillation. Surveyors observed the resident’s oxygen concentrator in the room on multiple occasions with the nasal cannula in use, and the flow rate was set at 3.5 liters per minute each time instead of the ordered 1-2 liters per minute. The resident stated staff set the oxygen flow rate and that the resident liked the current setting. An LPN confirmed the concentrator should have been set at 1-2 liters per minute, that the resident was not in distress or low oxygen saturation, and that increasing oxygen flow for a resident with COPD can increase carbon dioxide levels. The LPN also observed the concentrator left on when not in use and turned it off. The DON confirmed oxygen orders should be followed as written, that the concentrator and portable oxygen machine should be correctly set, and that COPD should be reflected on the care plan. The NHA also confirmed a resident on oxygen therapy with COPD should have a care plan reflecting that diagnosis.

Penalty

Inspection fine: $29,165

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to recognize and appropriately respond to a resident’s change in condition over several days following admission after major spinal surgery. The resident was admitted after a C3–C4 laminectomy with diagnoses including cervical spondylosis, diabetes, hypertension, hypothyroidism, atrial fibrillation, and congestive heart failure. On admission, the resident was documented as alert and oriented x4, able to make needs known, with clear lungs on room air and a patent Foley catheter draining clear amber urine. The facility’s policy on change in condition required staff to assess the need for immediate care, provide emergency care as needed, and evaluate the resident, including vital signs, oxygen saturation, blood glucose, and alterations in level of consciousness, and to notify the physician immediately for acute or sudden onset symptoms. Beginning the day after admission, the resident showed multiple documented changes in condition. Progress notes indicated the resident became drowsy and hard of hearing, with the diet downgraded to pureed per the resident’s choice and medications crushed due to swallowing difficulty. On one night, the resident’s oxygen saturation dropped to 79%, improving only to 84% after deep breathing, leading to an order for supplemental oxygen at 2–5 liters, and the resident was placed on 2 liters. Subsequent notes described the resident sleeping throughout a shift, being only alert and oriented x2, spending a lot of time sleeping, and having blood glucose of 45 with involuntary jolting arm movements consistent with hypoglycemia, requiring two doses of 40% glucose gel. A change in condition evaluation documented abnormal vital signs, decreased food and fluid intake, and other changes such as talking less, being tired, weak, confused, and drowsy. Additional notes recorded a slight cough, low blood pressure of 94/52 with an order to hold hydralazine, continued need for 2 liters of oxygen with oxygen saturation at 93%, poor eating, sips of orange juice through the night, and a productive cough with mucus. Despite these ongoing changes, the facility did not initiate and follow through with an appropriate change in condition response. During a care conference, the resident’s family reported concerns about the resident’s eating, confusion, and overall medical condition to the DON. The following morning, when an RN obtained the resident’s vital signs, the blood pressure was 102/53, and the RN attempted to administer medications in pudding but was unable to arouse the resident, who did not drink or open their eyes. The RN left the room and did not return, did not perform a further assessment, did not check the resident’s blood sugar, and did not promptly notify medical staff, despite the family member’s expressed concern that the resident was not eating or drinking and appeared unresponsive. The family member later informed the RN they were going to call 911. When EMS arrived and asked about the resident’s blood sugar, facility staff reported they did not know. EMS found the resident’s blood sugar to be 42, and the resident was subsequently admitted to the hospital with diagnoses including severe hypoglycemia with coma requiring emergent IV glucose administration, sepsis secondary to acute cystitis, depressed Glasgow Coma Scale with decreased responsiveness, and acute kidney injury. The surveyors determined that the facility failed to recognize and appropriately respond to the resident’s change in condition over several days, leading to a finding of immediate jeopardy.

Removal Plan

• Reviewed current residents with like diagnoses to ensure appropriate monitoring and interventions were in place.
• Reviewed residents' progress notes and vital signs to identify residents with a potential change in condition that required provider notification, care plan changes, or additional monitoring.
• Educated licensed nurses on the need to promptly recognize, assess and report a change in condition, including the importance of implementing appropriate follow-up monitoring.
• Educated CNAs on recognizing and reporting changes in condition to a licensed nurse.
• Initiated audits to ensure monitoring protocols are in place for new admissions with diabetes.
• Initiated audits of nursing documentation to ensure changes in condition are promptly identified, pertinent and accurate medical information is communicated to the physician, and appropriate monitoring interventions are implemented.

Penalty

Inspection fine: $29,165

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure adequate supervision, positioning, and use of assistive devices during meals for a resident with a known history of aspiration. The resident had diagnoses including quadriplegia, dysphagia, expressive aphasia, and anxiety, and required mechanically altered textures and thickened liquids. The resident’s comprehensive care plan, revised in late November, specified 1:1 supervision for all meals, encouragement of small bites and clearing the mouth before the next bite, sealing lips around the cup opening until swallowing was completed, use of a neck pillow for proper neck positioning for all meals, and upright positioning in a wheelchair for meals. The facility’s Dining Experience policy also required individuals to be positioned upright as close to 90 degrees as possible when eating in bed and to receive appropriate cueing and assistance to promote safe swallowing. Prior to the surveyor’s observation, there were documented indications of swallowing and respiratory concerns that were not fully acted upon. On one date in November, a progress note recorded that the resident coughed and had food coming out of the mouth during lunch; staff elevated the head of the bed, assisted with finishing the meal, and provided cues for small bites and clearing the mouth, but the LPN who documented the event did not notify the physician and was unsure if anything further was done. The APNP later stated they had not been notified and would have wanted respiratory assessments at least each shift. In mid-December, the resident reported that their lungs felt funny, had crackles on lung assessment, vomited during the night, and later that day had abnormal vital signs and lung sounds with rhonchi, leading to transfer to the hospital. Hospital records showed the resident was treated for aspiration-related right lower lobe infiltrate and septic shock, and an OT evaluation there reiterated the need for upright positioning, one sip or bite at a time, alternating liquids and solids, and 1:1 supervision during meals. Speech therapy documentation before and after the hospitalization reinforced the need for strict swallowing precautions. A speech therapy progress note in early December indicated the resident required prompting to improve oral containment and bolus management, with safety precautions such as upright posture emphasized to staff. A speech therapy evaluation at the end of December recommended pureed texture, honey-thick liquids, eating in a wheelchair with total supervision, and upright positioning during meals and for at least 30 minutes afterward. A treatment note in mid-January confirmed the resident remained on a pureed diet with honey-thick liquids and required total supervision while upright for meals. A videofluoroscopic swallow study reviewed by the speech therapist showed airway invasion by nectar-thick liquids and poor posture with inability to sense penetration/aspiration. Despite these documented needs and care plan directives, on the morning of January 15 the surveyor observed the resident eating breakfast alone in bed with the head of the bed at approximately 45 degrees and without the prescribed neck pillow. The surveyor heard several deep, congested coughs before the resident’s airway cleared and then observed a large amount of food on the resident’s dignity cover and juice spilling from the right side of the mouth. No staff were present in the room or in the hallway, and the resident indicated that staff had not been in the room to assist or check since breakfast began and that staff did not usually sit in the room to provide supervision during meals. CNAs assigned to the wing reported that they assisted with meal setup and checked on the resident every 15–20 minutes, and the RN confirmed the resident should be directly supervised when eating, as indicated on the Kardex, but also stated the resident typically ate in the room. The DON verified that staff should be with the resident when eating in the room and should watch for signs and symptoms of aspiration. These observations and interviews demonstrated that the facility did not follow its own policy, the resident’s care plan, or therapy recommendations for 1:1 supervision, upright positioning, and use of a neck pillow during meals, leading to a finding of immediate jeopardy beginning on January 15.

Removal Plan

• Reviewed R2's care plan, dietary orders, and ST recommendations and made appropriate updates and revisions.
• Reviewed residents to identify those who require supervision, assistance, cueing, or monitoring during meals due to aspiration risk.
• Educated staff on R2's care plan and supervised meals and snacks for residents at risk for choking or aspiration.
• Instructed nursing staff to verify diet orders and supervision levels prior to serving meals, document the supervision provided, and report swallowing concerns and condition changes.
• Observed meal service to ensure compliance with supervision recommendations.
• Conducted record review and observation audits to ensure ST recommendations are documented in residents' care plans and followed by staff.

Penalty

Inspection fine: $29,165

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide necessary care and services to prevent the development of avoidable pressure injuries and to promote healing of existing pressure injuries for two residents. One resident was admitted without any documented pressure injuries, with an admission Braden Scale score of 15 indicating high risk for pressure injury development. Admission documentation and hospital transfer orders listed only a cervical surgical incision and bruising on the hands, antecubital area, and wrists, with no sacral, thigh, or heel wounds noted. Despite the high-risk Braden score, the initial care plan created on the day of admission did not include a focus area or interventions for skin integrity, and a skin integrity care plan was not initiated until nearly two weeks later, after the resident had already been transferred to the hospital. Nursing documentation from admission through the date of hospital transfer did not include ongoing skin integrity assessments beyond the initial Braden assessment. During this same period, staff interviews revealed gaps and inconsistencies in skin assessment and monitoring. A registered nurse reported performing a head-to-toe assessment on admission and stated that the coccyx would have been assessed only if wounds were documented on the Braden assessment, and did not recall whether a specialty mattress was used. A CNA reported that the resident had a bowel movement several days after admission and that there was a dressing on the coccyx at that time, but did not know who applied it and stated it was not removed during care. Another nurse recalled assisting with repositioning and stated that zinc was applied to the coccyx but did not recall any specific skin injuries. The DON stated that staff had documented no wounds other than the surgical incision on admission and was not aware that a dressing had been applied to the coccyx or that a skin integrity care plan focus area was only added after the resident’s hospitalization. When the resident was admitted to the hospital, wound care documentation identified multiple pressure injuries that had not been recognized or documented by the facility. Hospital assessments described a bilateral sacral deep tissue pressure injury with serosanguineous drainage, a right posterior thigh deep tissue pressure injury, and a right heel deep tissue pressure injury, all measured and characterized in detail. An advanced practice nurse who had completed the facility admission assessment later reviewed the hospital wound photos and documentation and stated that the coccyx wound appeared older than 24 hours, while the age of the thigh and heel wounds was uncertain. The facility was unaware of these pressure injuries prior to the hospital admission, and no ongoing skin integrity monitoring or targeted interventions had been documented during the resident’s stay. The second resident was admitted with a documented stage 4 sacral pressure injury and had a care plan and physician order for an air mattress set to 250 pounds on an alternating setting, along with a pressure redistribution cushion for the chair. The treatment administration record included an order for staff to check the function and setting of the air mattress every shift, with documentation that the mattress was set appropriately at 250 pounds. However, surveyor observations on two consecutive days showed that the air mattress was actually set at 350 pounds, first on an alternating mode and then on a static (non-alternating) mode, contrary to the care plan and orders. The most recent recorded weight for this resident was 156 pounds, and manufacturer guidance indicated that the mattress setting should be as close as possible to the resident’s current weight to ensure proper pressure relief. Despite these requirements, staff documentation in the TAR indicated that the air mattress was correctly set at 250 pounds on the shifts when surveyors observed it at 350 pounds and, on one day, in static mode. An LPN stated that staff were responsible for checking the air mattress setting each shift and documenting it, and that incorrect settings should be corrected and reported to the DON or wound nurse. The DON later confirmed that the mattress had been set too high and that it was not on the alternating mode as ordered. The discrepancy between the observed settings and the documented TAR entries, combined with the failure to match the mattress setting to the resident’s actual weight and prescribed alternating mode, demonstrates that the resident with a stage 4 sacral pressure injury did not receive care and services consistent with the care plan, physician orders, and manufacturer guidelines for pressure redistribution therapy.

Penalty

Inspection fine: $29,165

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that a resident and physician met face-to-face at all required visits during the first 90 days after admission, as required by facility policy. The facility’s “Physician Visits and Physician Delegation” policy, revised 7/27/25, states that the physician should see a resident within 30 days of initial admission and that the resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission. Record review for one resident (R6), who was admitted on an unspecified date and had diagnoses including vascular dementia, hemiplegia, cerebral infarction, and diabetes, showed that R6 was not seen by a physician within 30 days of admission (including a 10‑day grace period) and was not seen every 30 days thereafter during the first 90 days. R6’s MDS dated 12/30/25 documented a BIMS score of 6/15, indicating severe cognitive impairment. The initial post‑admission visit was completed by an Advance Practice Nurse Prescriber (APNP) on 2/20/25 rather than by a physician, and subsequent physician visits occurred on 4/8/25 and 6/10/25, leaving a missed physician visit in May 2025. In an interview on 1/20/26, the Nursing Home Administrator confirmed that R6 was not seen by a physician for the initial visit and that a required physician visit was missing in May 2025. These findings show that, for this resident, the facility did not follow its own policy requiring timely, face‑to‑face physician visits within the first 90 days after admission, resulting in missed and delayed physician evaluations documented through staff interview and medical record review.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to revise the comprehensive care plan to reflect the specific personal care needs of a resident with significant medical and cognitive impairments. The resident, who had a history of cerebral vascular accident with right-sided hemiplegia, dysphagia, aphasia, depression, cognitive communication deficit, and epilepsy, was assessed as having severe cognitive impairment. Multiple staff interviews revealed that the resident required specialized care techniques during activities of daily living, such as providing step-by-step explanations, working slowly and gently, offering breaks, and monitoring for signs of frustration or pain, particularly with right arm movement. Staff consistently described the need for these individualized approaches due to the resident's right-sided weakness, pain, and tendency to become anxious or frustrated during care. Despite these identified needs, the resident's care plan did not include detailed, person-centered interventions specific to the resident's care requirements. The care plan noted a right-sided deficit and a general intervention to explain activities prior to starting them, but it lacked instructions for providing care slowly and gently, offering breaks, and monitoring for increased frustration. Staff were unable to identify documentation of these specific actions in the care plan, and the plan did not fully address the specialized techniques necessary for the resident's safe and comfortable care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with quadriplegia and an activity of daily living (ADL) self-care deficit was dependent on staff for personal hygiene, including nail care, as documented in the care plan and nursing orders. The resident's care plan specified the need for assistance with personal hygiene and highlighted the importance of careful nail trimming due to abnormal nails and build-up. Nursing orders required weekly nail care, and staff were expected to provide nail care on shower days. Despite these documented needs and requests, the resident reported asking multiple staff members to trim their fingernails over several days, including a specific request prior to leaving the facility for a family gathering. These requests were not fulfilled, and the resident's fingernails remained longer than preferred. Staff interviews confirmed that nail care was not provided as requested, and that there was no specific facility policy or routine documentation for nail care or grooming. The Director of Nursing confirmed that nail care should be completed on shower days, which were scheduled twice weekly for the resident. Observation by the surveyor confirmed that the resident's fingernails extended approximately two millimeters past the fingertip, and the resident expressed dissatisfaction with the lack of nail care, referring to their nails as "claws."

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that two residents were adequately monitored for adverse reactions to high-risk medications, as required by their own medication management and antibiotic stewardship policies. One resident with heart failure, hypertension, and diabetes was prescribed furosemide for edema, but there was no evidence in the medical record or care plan that staff monitored for adverse reactions to this diuretic. The Director of Nursing confirmed that monitoring should have been included in the care plan and acknowledged the facility was transitioning its monitoring process from medication administration records to care plans. Additionally, the facility did not have a specific policy for diuretic or heart failure management. Another resident with a history of intraspinal abscess, end stage renal disease, and dependence on dialysis was prescribed cefazolin, an antibiotic, to be administered during dialysis sessions. The medical record did not show any monitoring for adverse reactions to the antibiotic prior to a specific date, and the DON verified this omission. The facility's policies require ongoing monitoring for adverse consequences of medications, but this was not documented or performed for these two residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with quadriplegia, who was dependent on staff for oral intake and at risk for nutritional status change, consistently received meals at unappetizing temperatures. The resident reported that meals were rarely served hot and were typically lukewarm, with meal trays left on the bedside table for up to an hour before staff were available to assist with feeding. Observations confirmed that meal trays were delivered to the resident's room and left unattended for extended periods before staff provided feeding assistance. Temperature checks revealed that milk on the breakfast tray was above the recommended holding temperature, and the resident confirmed that the food was not warm. Multiple staff interviews corroborated that all meal trays were distributed to residents before any assistance with eating was provided, resulting in delays for residents who required help. Staff acknowledged that several residents, including the affected resident, had reported their food becoming cold while waiting for assistance. The Director of Nursing stated there was no specific policy for feeding assistance and was unaware of the resident's concerns about meal trays being left out for extended periods.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Staff failed to maintain an effective infection prevention and control program for one resident who was on enhanced barrier precautions (EBP) due to the presence of a Foley catheter and a percutaneous endoscopic gastrostomy (PEG) tube. The facility's policy required staff to don appropriate personal protective equipment (PPE), including gowns and gloves, during high-contact care activities such as transferring and device care. However, during observed care activities, staff only donned gloves and did not wear gowns while disconnecting the resident's tube feeding and transferring the resident. Additionally, there was no EBP sign posted on or near the resident's door to alert staff to the required precautions. Interviews with staff revealed a lack of awareness regarding the resident's EBP status, with some initially indicating the resident was not on precautions. The LPN and CNAs involved in the care confirmed that appropriate PPE was not used, and the absence of the EBP sign was acknowledged by both staff and the Director of Nursing. The resident involved had significant medical needs, including hemiplegia, dysphagia, and severe cognitive impairment, and was under orders for EBP due to the presence of indwelling medical devices.

Penalty

Inspection fine: $8,827

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure all medications were labeled appropriately for two residents during medication administration. Resident 138 was administered furosemide 40 mg, but the medication card was labeled incorrectly as one tablet daily, while the physician's order stated it should be administered twice daily. This discrepancy was confirmed by the Licensed Practical Nurse (LPN) and the Director of Nursing (DON), who acknowledged the error in the medication card label. Similarly, Resident 8 was administered metoprolol succinate ER 50 mg, but the medication card was labeled incorrectly as 25 mg twice daily, whereas the physician's order indicated a 50 mg dose once daily. This error was also verified by the LPN and the DON. Both instances highlight the facility's failure to adhere to its Medication Ordering and Receiving From Pharmacy Provider policy, which mandates accurate labeling of prescription medications.