Colonial Health Services

Inspectors wroteBased on observation and interview, the facility did not store and follow proper sanitation and food handling practices to prevent foodborne illnesses for 50 residents who consume food out of 51 residents who reside at facility. -The facility's resident refrigerator had food items brought in by family/visitors that were not labeled with resident names, content, or dated which could affect 50 of 51 residents at facility who consume food and this could lead to foodborne illnesses.-The facility's resident refrigerator had food items brought in by residents' families that were not dated for 3 residents (R16, R31, R38) of a possible 50 residents who may use refrigerator to store food. A plastic container of what appeared to be a pasta with meat soup or hotdish with R31's name, was not labeled with content or brought in date. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents (R) were notified of the specific reason for transfer/discharge, in writing to the resident or their representative. This occurred for 4 of 5 residents (R2, R3, R28, and R52) reviewed for hospitalization, out of a sample of 13 residents. -R2 was transferred to the hospital on 3/22/26. A written notice of transfer was not completed.-R3 was transferred to the hospital on [DATE], 11/8/25, and 7/5/26. A written notice of transfer with specific reason for transfer was not completed for all 3 days. -R28 was transferred to the hospital on 1/17/26, 2/3/26, and 3/19/26. A written notice of transfer with specific reason for transfer was not completed for all 3 dates. -R52 was transferred to the hospital on 3/11/26. A written notice of transfer with specific reason for transfer was not completed. This is evidenced by: [...]

Inspectors wroteBased on record review and interview, the facility did not conduct a Preadmission Screening Resident Review (PASRR) - Level II screening to ensure resident with mental illness received the care and services needed. This occurred for 1 of 1 resident (R) reviewed for PASSR, out of the sample size of 13. (R7) R7 has been admitted to the facility for greater than 30 days, has a serious mental disorder, is taking psychotropic medication, and does not have a PASSR Level II completed. This is evidenced by: The facility policy titled, Resident Assessment-Coordination with [PASSAR] (preadmission screening and resident review) Program, dated 11/20/25, states in part:5. If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days:a. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that professional standards of practice were met to maintain quality of care for 1 of 1 resident (R) reviewed for diabetic management and 1 of 1 resident reviewed for toileting out of 13 sampled residents.-Facility did not implement immediate hypoglycemic interventions and follow established protocols when R4's blood sugar was 60mg/dl.-Certified Nursing Assistant (CNA) P left R11 sitting unattended on a commode for 37 minutes and failed to monitor, identify, or report an open area between R11's buttocks to licensed nursing staff placing resident at risk for further skin breakdown, and pain. Example 1 Facility policy titled, 'Hypoglycemia Management,' with a revised date of 08/05/22, states: Compliance Guidelines: 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care consistent with professional standards of practice to prevent further deterioration and promote healing of an existing PI for 2 of 3 residents (R) reviewed for pressure injuries (PI) (R35 and R8) out of 13 sample residents. R35 is being cited at a scope and severity level of actual harm/isolated. R8 is being cited at a scope and severity of potential for harm/isolated. R35 was at risk for development of PIs and had 3 Deep Tissue Injuries upon admission to the facility. DTIS were on R35's sacrum, right buttocks, and the right heel. The facility failed to complete a comprehensive skin assessment upon admission, failed to complete weekly wound assessments, and implement offloading interventions. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 of 13 residents at risk for falls received adequate supervision and assistance devices to prevent accidents. Facility staff left R11 on commode alone without the ability to use call light for assistance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who receives nutrition and hydration maintains acceptable parameters of nutritional status unless the resident's clinical condition demonstrates otherwise for 1 of 13 residents (R6) reviewed for nutrition and hydration. R6 had a daily fluid restriction of 1500cc. On 03/12/26, 03/13/26, 03/17/26, 03/22/26, 03/29/26, 04/19/26, 04/20/26, 05/10/26, 05/23/26, 05/29/26, 06/22/26, and 06/30/26, R6 went over the fluid restriction. The facility did not complete additional lung assessments or notify the provider. This is evidenced by:R6 was admitted to the facility on [DATE] with stage 5 chronic kidney disease with heart failure and dependence on renal dialysis. R6's physician orders include:01/03/26 24-hour fluid intake one time a day for monitoring.03/21/26 1500 cc Fluid intake - record q shift. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure resident was free from complications of a feeding tube for 1 of 1 resident reviewed for tube feedings in a sample of 13 residents (R5). The facility did not verify proper Percutaneous Endoscopic Gastrostomy (PEG) tube placement on R5 prior to administering medication through it which could result in physical harm to resident.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide the necessary respiratory care and services for 1 of 1 resident (R5) reviewed of a sample of 13 residents. R5's bilevel positive airway pressure (BiPAP) machine was not applied per provider's orders. This is evidenced by:R5 was admitted to the facility on [DATE] with obstructive sleep apnea and asthma. R5's most recent significant change Minimum Data Set (MDS) assessment, dated 06/17/26, noted a Brief Interview for Mental Status (BIMS) score of 0/15, indicating severe cognitive impairment. R5 was noted to be dependent for all activities of daily living (ADL). R5's care plan, dated 11/05/25, with a target date of 09/18/26, states: Obstructive sleep apnea used bipap with a goal to adhere to CPAP/BiPAP regimen. Interventions include: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that its medication error rate was not 5 percent or greater for 2 residents (R5, R47) of 3 residents observed for medication administration in a sample of 13 residents. The facility:-Did not ensure R5's crushed Phenytoin was completely dissolved in water, and all medication particles were administered via R5's gastric tube resulting in R5 not receiving accurate dose of medication.-Did not correctly administer R5's subcutaneous injection of Lovenox possibly resulting in incorrect absorption/dosing of R5's Lovenox. -Gave R47 2 tablets of aspirin when physician order indicated 1 tablet to be given resulting in overdosing of R47's aspirin. -Had a medication error rate of 11.11%.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents are free of any significant medication errors for 1 of 3 residents (R) observed during medication administration in a sample of 13 residents (R5). The facility staff did not ensure R5's crushed Phenytoin was completely dissolved in water, and all medication particles were administered via R5's gastric tube resulting in R5 not receiving accurate dose of medication.

Inspectors wroteBased on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has potential to affect 51 of 51 residents reviewed. -R35 is on Enhanced Barrier Precautions (EBP) and Certified Nursing Assistant (CNA) P did not perform proper hand hygiene practices during personal care or utilize Personal Protective Equipment (PPE).-Medication Aide (MA) F directly touched R47's medications with their fingers for 1 of 3 residents (R) observed during medication administration (R47).

Inspectors wroteBased on interview and record review, the facility did not immediately report to the physician a significant decline in condition for 1 of 3 residents (R) reviewed for change of condition (R2). The facility did not immediately consult with the resident's physician regarding R2's significant change of condition on 07/13/25 at 3:00 PM until 07/14/25 at 1:52 PM, when R2 had a decline in cognition, developed an inability to communicate, had noted thick phlegm coming out of mouth, developed an inability to pivot transfer with assist of 2, and required use of a Hoyer lift for transfers, which ultimately required R2 to be transferred the emergency room (ER) and then to critical care for unresponsiveness, diaphoresis (excessive sweating), and bilateral crackle sounds noted in lungs. R2 was diagnosed with a Cerebrovascular Accident (CVA) (stroke) and pneumonia. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure 2 out of 3 residents (R) reviewed, (R2, R1), who had changes in condition were provided immediate care and treatment consistent with professional standards of practice (N6, Wisconsin Nurse Practice Act) for neurological/comprehensive assessments. The facility did not perform neurological assessments from 07/12/25 at 10:46 AM until 07/14/25 at 1:52 PM, when R2 had a decline in cognition, developed an inability to communicate, had noted thick phlegm coming out of mouth, developed an inability to pivot transfer with assist of 2 and required use of Hoyer lift for transfers, which ultimately required R2 to be transferred to the emergency room (ER) and then to critical care for unresponsiveness, diaphoresis, and bilateral crackle sounds noted in lungs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice for 2 of 15 residents (R) reviewed for quality of care (R34, R29). R34 did not receive adequate assessment and monitoring of edema associated with congestive heart failure (CHF) per current professional standards of practice. R29 did not receive adequate assessment and monitoring of cellulitis per current professional standards of practice. This is evidenced by: Example 1 According to the National Institutes of Health (NIH) Congestive Heart Failure (CHF): Nursing Diagnosis, 2023, indicates nurse assessment of CHF is to assess current symptoms such as dyspnea, fatigue, orthopnea, peripheral edema, vital signs, cardiovascular examination such as abnormal heart sounds, jugular venous distention. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide pharmaceutical services including procedures that ensure the accurate acquiring/accounting for, receiving, dispensing, administering and reconciliation of all drugs and biologicals to meet the needs of each resident for residents (R) R49, R113 and R262.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure a medication error rate of 5% or less for 2 of 5 residents (R32 and R50) observed for medication administration. The facility had 37 opportunities and 2 medication errors resulting in a 5.41% error rate. Licensed Practical Nurse (LPN) D administered two different inhalers in the wrong sequence for R32. LPN D administered Carafate after breakfast for R50. This is evidenced by: Facility policy titled, Oral inhalations dated January 2023, stated in part, .Inhaler Sequencing: 1. Bronchodilators/Beta Agonists-administer first if more than one inhaler to be administered at the same med pass time. a. These agents work by promoting bronchodilation which relaxes bronchial smooth muscle. 2. Anticholinergic Agents a. Antagonizes the action of acetylcholine with resulting bronchodilation 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff did not implement infection control practices when warranted. Facility staff did not perform hand hygiene when warranted during care affecting 1 of 7 residents (R) observed for care (R19). Insulin pens were not disinfected for 2 of 2 observations for R6. This is evidenced by: Example 1 Surveyor requested and received the facility policy titled Hand Hygiene dated 11/02/2022. The policy in part read: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards practice. 2. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the Comprehensive Person-Centered Care Plan, and the residents' choices for 1 of 3 sampled residents (R2). R2 had 4 tarry red stools between 11:00 AM and 1:00 PM on 8/31/24. R2's vitals were not monitored. There is no documentation of red tarry stools or physician notification until R2 was sent to the emergency room on 9/01/24 at 1:58 AM. This is evidenced by: Facility policy titled, Acute Condition Changes - Clinical Protocol, last revised, 3/2018, states in part . 2. In addition, the nurse shall assess and document/report the following baseline information: a. vital signs. g. onset, duration, severity. 7. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure screening of all employees was completed to prevent abuse, by failing to conduct timely background checks for 1 of 8 facility staff (LPN (Licensed Practical Nurse) G). This had the potential to affect all residents. LPN G was hired by the facility on [DATE]. Facility was not able to provide proof that LPN's BID (Background Information Disclosure) form, DOJ (Department of Justice) letter or IBIS (Integrated Background Information System) letter were completed within the past four years as required to screen.

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure 1 of 2 residents (R) (R167) reviewed for wound care, received the necessary treatment and services to promote healing of existing skin integrity impairment according to current standards of practice. Licensed Practical Nurse (LPN) C completed dressing changes on trauma-induced wounds for R167 and did not practice appropriate hand hygiene. This is evidenced by: The Wound Care Education Institute, 2013, directs the caregiver for Non-Sterile dressing changes in the following manner: The purpose of non-sterile dressings is to protect open wounds from contamination and absorb drainage . 5. wash hands and apply gloves .9. Remove soiled dressing .10. Remove gloves, wash hands, apply new gloves .12. Clean wound with normal saline or prescribed cleanser. 13. Pat tissue surrounding the wound with dry 4 x 4 gauze .16. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure 1 of 2 residents (R)reviewed (R41) for wound care, received the necessary treatment and services to promote healing of an existing pressure injury (PI) according to current standards of practice. R41 has an existing stage 3 PI that was observed to not be cleansed during wound care prior to the application of a new dressing. This is evidenced by: The Wound Care Education Institute, 2013, directs the caregiver for Non-Sterile dressing changes in the following manner: The purpose of non-sterile dressings is to protect open wounds from contamination and absorb drainage . 5. wash hands and apply gloves .9. Remove soiled dressing . 12. Clean wound with normal saline or prescribed cleanser. 13. Pat tissue surrounding the wound with dry 4 x 4 gauze . 18. Apply prescribed topical agent to wound. 19. [...]