Colonial Health Services
COLONIAL HEALTH SERVICES in COLBY, WI — inspection on August 19, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Colonial Health Services
702 W Dolf St Colby, WI 54421
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
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 R1 had refused to get up for lunch.
Staff stated they tried multiple times to see if R1 wanted to have some lunch and the resident refused.
Nurse checked on R1and R1 got angry and stated that he did not want to eat lunch either.
Will reapproach R1 later and see if he would like a snack later. On 07/13/25 at 4:43 PM, the nurse notified provider of R1's blood sugar of 270 and 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 R1's penis reddened, discharge noted from tip of penis. |Surveyor could not find treatment for the assessment of R1's tip of penis being reddened and having discharge.
Surveyor could not find a pain assessment completed for 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 R1's penis reddened, and discharge noted from tip of penis. On 07/13/25 at 11:00 PM, the nurse notified provider of R1's redness around the base of the glans penis. 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, R1 is noted to have redness around the base of the glans penis. 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 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 R1 was transferred to the hospital on 7/14/25. On 07/14/25 at 9:35 AM, 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. 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, R1 was admitted to the hospital on [DATE] for UTI, transient hypotension, and decreased oxygen level. 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 R1's care before R1 was transferred to the hospital on [DATE].
Surveyor asked DON B what DON B's expectation is when the nurse found redness and drainage on 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 R1 could receive treatment instead of waiting hours later.
Facility ID: