Colonial Health Services

In the surveyor’s words

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

• Immediate jeopardy, isolatedF580Aug 19, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF684Aug 19, 2025

  Based 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… […]

• No harm, potential for more than minimal, widespreadF812Jul 8, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF628Jul 8, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF607Jan 20, 2022

  Based on interview, policy review, and record review the facility did not implement abuse prohibition policies for 4 out of 8 random staff. The facility did not screen new employees for abuse allegations or criminal charges prior to or within 60 days of employment. CNA (Certified Nursing Assistant) J, L, and M did not have a BID (Background Information Disclosure) form or an IBIS (Integrated Background Information System) form completed. CNA K did not have an IBIS form completed. This is evidenced by: On 01/18/2022, Surveyor requested and reviewed the facility policy titled Abuse Prohibition. The policy noted that all employees upon hire would complete the BID form and all abuse screening procedures would be completed. […]