Colonial Health Services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Respiratory examination such as auscultate lung sounds for crackles or wheezing and assess respiratory effort, daily weights, edema assessments, dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Example 1 Surveyor reviewed facility policy titled, Disposal of Medications, dated as revised in January 2024, stated in part, .1. Discontinued medications and/or medications left in the nursing care center after a resident's discharge, which do not qualify for return to the pharmacy, are identified and removed from current medication supply in a timely manner according to state and federal regulations for disposition . On 05/19/25 at 10:07 AM, Surveyor toured medication storage room on 400 hall with Registered Nurse (RN) E. Surveyor observed a locked narcotic box located on the wall. Surveyor asked RN E if RN E could unlock box and Surveyor assess what is in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Corticosteroids-administer last if more than one inhaler to be administered at the same med pass time . Example 1 On 05/20/25 at 7:53 AM, Surveyor observed LPN D administer R32's Fluticasone Propionate inhaler as the second…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Hand hygiene is indicated and will be performed under conditions listed in, but not limited to. the attached hand hygiene table. Additional Considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves; perform…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician. 8. The nursing staff will contact the physician based on the urgency of the situation. For…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: The Wisconsin Caregiver Program Manual for Entities Regulated by the Division of Quality Assurance (P-00038 updated 2/2016) stated, After the initial background check at the time of employment or contracting, entities must conduct new caregiver background checks at least every four years or at any time within that period that an entity has reason to believe new checks should be obtained. Facility provided policy titled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Remove gloves, wash hands, apply new gloves . 18. Apply prescribed topical agent to wound. 19. Apply wound dressing . 23. Discard gloves . 24. Wash hands . The CDC had outlined the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Apply wound dressing . According to the National Pressure Injury Advisory Panel (NPIAP), 2019, . Wound cleansing is the process of using fluids…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews and record review, the facility did not ensure 1 of 2 residents (R302) were assessed for excess fluid and weight gain, potentially placing resident at risk for cardiac and pulmonary concerns. R302 was recently hospitalized for diagnoses of hypertension urgency, hyponatremia and pulmonary edema. The facility did not monitor and assess R302's clinical status and did not notify the physician of clinical changes of weight gain and edema. This is evidenced by: R302's most recent MDS (Minimum Data Set) dated 01/10/2023 has medical diagnoses that include, but are not limited to Traumatic Spinal Cord Dysfunction, Quadriplegia, Anemia, Coronary Artery Disease and Hyperlipidemia. The facility completed weight monitoring on R302, which were: 01/01/2023 = 231 lbs 02/01/2023 = 256 lbs (25 lbs weight gain from prior weight) Of concern is, R302's medical record included documentation on 2/4/2023 that Patient noted to have 4 plus pitting edema to bilateral lower extremeties and swelling noted all the way up to abdominal area. SOB (Shortness of Breath) noted with cares and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility did not ensure a medication administration error rate of less than 5%. During the Medication Administration Task, Surveyor identified three errors from 25 opportunities, yielding a medication error rate of 12.0%. This is evidenced by: - Drugs.com states the following in relation to Insulin Aspart: . Insulin Aspart is a rapid-acting insulin that starts to work about 15 minutes after injection . After using Novolog (Aspart), you should eat a meal within 5 to 10 minutes . - Drugs.com states .Humalog is taken within 15 minutes before eating or right after eating a meal. On 2/15/23, Surveyor observed Registered Nurse (RN) D administer medications. The following errors were noted: 1. RN D administered 5 units of Insulin Aspart to R5 at 10:55 AM. R5 received her noon meal at 11:32 AM and began to drink her chocolate milk at that time. This was 37 minutes after she was administered a rapid-acting insulin. 2. On this same date at 11:05 AM, RN D administered 6 units Insulin Aspart to R3 in the right abdomen, stating to Surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility did not ensure a rapid-insulin administration was not given timely within meal or beverage service. During the Medication Administration task, Surveyor observed 3 nurses administer rapid-acting insulin to 3 residents (R3, R5 and R17). 1. R3 was administered rapid-acting insulin and was not served her meal until 35 minutes afterwards. 2. R5 was administered rapid-acting insulin and was not served her meal until 37 minutes afterwards. 3. R17 was administered rapid-acting insulin and was not served his meal until 21 minutes afterwards. Beverages or meals were not served within the allotted time frame of onset of effects of the insulin, creating a potential for each of these residents to develop a hypoglycemia reaction. This is evidenced by: - Drugs. com states the following in relation to Insulin Aspart (Novolog): . Insulin Aspart is a rapid-acting insulin that starts to work about 15 minutes after injection . After using Novolog (Aspart), you should eat a meal within 5 to 10 minutes . - Drugs.com states . Humalog is taken…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review, the facility did not ensure staff maintained an effective infection control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of potential communicable diseases and infections. The facility utilizes shared glucometer devices. LPN E (Licensed Practical Nurse) was observed to measure R44's (Resident) blood sugar with a glucometer, and did not sanitize the machine prior to measuring R17's blood sugar. This is evidenced by: The CDC (Centers for Disease Control and Prevention) states, . If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. On 2/16/23 at 6:55 AM, Surveyor observed LPN E measure the blood glucose level of R44 with a shared glucometer device. LPN E then placed the device onto the medication cart and began to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.