Little Chute Health Services

In the surveyor’s words

From the most serious findings on record at Little Chute Health Services, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jan 20, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF689Jan 20, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF689Mar 27, 2024

  Based 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 2/5/24, 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. […]

• Immediate jeopardy, isolatedF580May 27, 2022

  Based on staff interviews, outside provider interviews, and record review the facility did not ensure a physician was immediately notified and consulted with when a significant change in condition was identified for 1 of 4 sampled residents (R), R1. R1, who was receiving [MEDICATION(S)] (a high-risk anticoagulant medication/blood-thinner), experienced new bruising and nosebleed on 4/30/22. RN-C did not immediately notify and consult with a physician to determine if [MEDICATION(S)] should be held or new laboratory test should be ordered. […]

• Actual harm, isolatedF689Jul 29, 2026

  Based 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. […]