Colonial Health Services

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

condition have complete assessment. Any changes from baseline will be reported to Primary care physician. This assessment will be completed by 8/6/25. 2. The DON initiated re-education with Licensed Nurses on change of condition policy including interact change of condition Sbar documentation to ensure thorough assessment of resident & primary care physician notification as appropriate. Licensed nurses will utilize interact 5.1 tool as guidance to determine change of condition and document in resident's medical record.3. On 8/6/2025, the DON VP of success and Executive Director reviewed facility established policies and guideline including Change in condition Primary Care Provider notification E-interact 4.5 guidelines (MD notification)*Policies and guidelines remain appropriate4. DON/designee to complete audits of nursing documentation and provider notification daily x 2 weeks. This audit will include ensuring accurate and thorough assessment of resident. After the initial audit period, audits will continue 5x week for 6 weeks. Ad Hoc QAPI held on 08/06/25, with Director of Nursing, Executive Director, VP of Success to review recovery plan. 5. Results of audits to be brought to monthly QAPI meeting for further review and recommendations.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Colonial Health Services

702 W Dolf St Colby, WI 54421

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

General frail appearing, no acute distress, comfortable at rest. Respiratory-clear, no wheeze, no accessory muscle use. Musculoskeletal- no erythema, no increased warmth, no significant joint deformity. Skin- warm and dry, no apparent rash or suspicious lesions on exposed skin. Neurological-cranial nerves grossly intact, able to move all four extremities, sensation intact, generalized weakness. Psychiatric alert, oriented to person, poor memory, impaired insight and judgement, underlying dementia. R1combative with cares, sometimes swinging at nursing staff. On 07/12/25 at 3:31 AM, the nurse documented skin turgor: normal, neuromuscular: none of the above. musculoskeletal: none of the above. On 07/13/25 at 12:10 PM, the nurse documented Resident R1 had refused to get up for lunch. Staff stated they tried multiple times to see if Resident R1 wanted to have some lunch and the resident refused. Nurse checked on R1and Resident R1 got angry and stated that he did not want to eat lunch either. Will reapproach Resident R1 later and see if he would like a snack later. On 07/13/25 at 4:43 PM, the nurse notified provider of Resident R1's blood sugar of 270 and Resident R1 having behaviors and refusing to eat lunch, stating he was not hungry. No assessment completed.On 07/13/25 at 5:54 PM, the nurse documented Resident R1's penis reddened, discharge noted from tip of penis. |Surveyor could not find treatment for the assessment of Resident R1's tip of penis being reddened and having discharge. Surveyor could not find a pain assessment completed for Resident R1. Nurse did not complete a comprehensive assessment to include vital signs, to assess for signs of infection.On 07/13/25 at 10:14 PM, the nurse documented Resident R1's penis reddened, and discharge noted from tip of penis. On 07/13/25 at 11:00 PM, the nurse notified provider of Resident R1's redness around the base of the glans penis. Resident R1's foreskin is retractable and resident yells it hurts when area is cleansed. Purulent drainage noted from ureteral meatus and urine is dark. No assessment completed. On 07/13/25 at 11:01 PM, Resident R1 is noted to have redness around the base of the glans penis. Resident R1's foreskin is non-retractable, and the resident yells out and states it hurts when the area is cleansed. Purulent drainage is noted from the urethral meatus. Area gently cleansed. Foley patent and draining. Urine is dark

in color. No assessment completed. On 07/14/25 at 7:24 AM, provider reported to nurse that NP will see Resident R1 today. There is concern for compartmental syndrome. On 07/14/25 at 8:00 AM, a change in condition form was completed for altered mental status, behavioral symptoms, decrease in food intake, and functional decline. Unresponsiveness. And hypoxia. Surveyor found that no comprehensive assessment was completed by nurses before Resident R1 was transferred to the hospital on 7/14/25. On 07/14/25 at 9:35 AM, Resident R1 left

the facility via ambulance to ED for further evaluation. On 07/16/25 at 12:00 PM, NP progress note: History of Present IllnessR1 is an [AGE] year-old male, is being seen today for initial SNF evaluation following a recent hospitalization and emergency department visit on 07/14/2025. Resident R1 was sent to the ED two days ago due to altered level of consciousness, genital swelling with nonretractable foreskin, and poor oral intake. At that time, he was unresponsive to questions and sternal rub, which represented a marked decrease in his level of consciousness from previous visits. Examination had revealed paraphimosis with erythema, crusting, edema, and purulent drainage from the urethra.Following the ED visit, Resident R1 was admitted to the hospital on [DATE REDACTED] for UTI, transient hypotension, and decreased oxygen level. Resident R1 returned to facility and

on 8/6/25 was back to baseline.On 08/06/25 at 11:25 AM, Surveyor interviewed Director of Nursing (DON) B. Surveyor reported a timeline through record review of Resident R1's care before Resident R1 was transferred to the hospital

on [DATE REDACTED]. Surveyor asked DON B what DON B's expectation is when the nurse found redness and drainage on Resident R1's penis on 07/13/25 at 5:54 PM. DON B reported that staff should have followed the facility's change in condition policy and felt the nurse should have reported the finding immediately to the provider on call so that Resident R1 could receive treatment instead of waiting hours later.

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