A list of the most recent deficiencies for Little Chute Health Services. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-10 | 2024-02-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-31 | 2023-06-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-29 | 2023-05-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-29 | 2023-05-03 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-03-28 | 2023-04-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-28 | 2023-04-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-28 | 2023-04-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-28 | 2023-04-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-28 | 2023-04-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-27 | 2022-06-25 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-27 | 2022-06-25 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-04-06 | 2022-05-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-06 | 2022-05-16 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-04-06 | 2022-05-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-06 | 2022-05-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-06 | 2022-05-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-06 | 2022-05-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-06 | 2022-05-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-06 | 2022-05-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-04-06 | 2022-05-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-06 | 2022-05-16 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-04-07 | 2022-05-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-04-07 | 2022-05-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-07 | 2022-05-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-07 | 2022-05-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-07 | 2022-05-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-07 | 2022-05-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-07 | 2022-05-16 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-10-27 | 2021-12-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-27 | 2021-12-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-13 | 2021-10-12 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-09-02 | 2021-10-01 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-09-02 | 2021-10-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-05 | 2021-06-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-03 | 2021-06-17 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-05-05 | 2021-06-03 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-05-05 | 2021-06-03 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-05-05 | 2021-06-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-05 | 2021-06-03 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-05-05 | 2021-06-03 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-05-05 | 2021-06-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-05 | 2021-06-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-05 | 2021-06-03 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-05-05 | 2021-06-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-05 | 2021-06-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-05 | 2021-06-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-05 | 2021-06-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-05-05 | 2021-06-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-05 | 2021-06-03 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-05-05 | 2021-06-03 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-05-05 | 2021-06-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-05 | 2021-06-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-05-05 | 2021-06-03 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-05-05 | 2021-06-03 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-05-05 | 2021-06-03 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-05 | 2021-06-03 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-05 | 2021-06-03 | Y |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-05-03 | 2021-05-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-03 | 2021-05-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-03 | 2021-05-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-03 | 2021-05-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-30 | 2021-04-20 | Y |
