Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colonial Health Services during CMS and state inspections, most recent first.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
Two residents did not receive care and treatment in accordance with professional standards. One resident with CHF was not adequately assessed or monitored for edema, with missing daily weights, incomplete lung and edema assessments, and improper use of Tubi grips. Another resident with cellulitis did not have consistent documentation or monitoring of the infection, including lack of erythema marking and incomplete skin assessments. Staff and the DON confirmed there was no standard practice in place for these assessments, leading to deficiencies in care.
Surveyors found that controlled medications belonging to two discharged residents were not destroyed in a timely manner, remaining in a locked narcotic box after discharge. Additionally, a resident with dementia was given a half dose of PRN alprazolam at family request, despite the prescriber's order specifying a full tablet, and without a new provider order. The DON confirmed the medication was administered in a dosage different from the order.
Two residents experienced medication administration errors when an LPN gave inhalers in the wrong sequence and administered Carafate after, rather than before, a meal, resulting in a medication error rate above 5%. Facility policy and physician orders were not followed in both cases.
Staff did not follow infection control protocols during resident care and insulin administration. A CNA failed to perform hand hygiene before handling clean clothing and after removing gloves post-peri care, then dressed a resident with clean items. Additionally, a nurse administered insulin to a resident using two pens without sanitizing the rubber caps as required by facility policy. Both staff members acknowledged the lapses, and facility leadership confirmed the expected procedures.
A resident experienced four episodes of tarry red stools, but the facility failed to monitor vital signs or notify a physician until the resident was sent to the emergency department. Despite the resident's history of gastrointestinal issues, the facility did not adhere to protocols for monitoring and reporting changes in condition. Staff interviews revealed inconsistencies in understanding the notification process.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Follow Professional Standards for Assessment and Monitoring of CHF and Cellulitis
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice for two residents. One resident with a history of congestive heart failure (CHF) did not receive adequate assessment and monitoring of edema. Despite orders and care plans specifying the need for daily weights, lung sound assessments, and monitoring for signs of fluid overload, there were significant lapses. Weights were not documented for a 10-day period during which the resident experienced a notable weight gain, and provider notification only occurred after this increase. Routine assessments did not include lung sounds, pedal pulses, or proper edema measurements such as circumference and length, as recommended by professional guidelines. Staff interviews revealed a lack of awareness and implementation of manufacturer instructions for Tubi grip sizing and use, and no standard practice was in place for edema assessment. Another resident with a diagnosis of cellulitis did not receive adequate assessment and monitoring of the condition. The care plan required regular skin inspections, but the facility could not provide documentation of nail care and inspection as ordered. After the resident developed pain and drainage from the toenail, there was no consistent documentation of erythema, tenderness, drainage, or other signs of infection before or after the diagnosis of cellulitis. The area of erythema was not marked to monitor for spread, contrary to current standards of practice. Staff interviews confirmed that there was no standard protocol for marking or monitoring the area, and assessments were only performed if specifically ordered by the provider. In both cases, the Director of Nursing and nursing staff acknowledged the absence of facility standards for assessment and monitoring of these conditions, relying instead on provider orders. This resulted in incomplete and inconsistent monitoring and documentation, which did not align with current professional standards of practice for managing CHF-related edema and cellulitis.
Failure to Dispose of Discontinued Narcotics and Administer Medications per Prescriber Orders
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring the timely and appropriate disposal of controlled medications after residents were discharged. During a medication storage room inspection, surveyors found that narcotic medications belonging to two discharged residents remained in a locked narcotic box more than a week after the residents had left the facility. Facility policy required discontinued or leftover medications to be removed from current medication supply in a timely manner, but staff were unable to explain why these medications had not been destroyed as required. Additionally, the facility did not ensure that medications were administered according to prescriber orders. In one instance, a resident with Alzheimer's disease and dementia was given a half dose of PRN alprazolam at the request of family, despite the physician's order specifying a full tablet. The DON confirmed that the medication was administered in a dosage different from the order and was unable to provide documentation of a provider order authorizing the change. This administration was not in accordance with the Wisconsin Nurse Practice Act, which prohibits nurses from altering medication dosages without a prescriber's order.
Medication Error Rate Exceeds 5% Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with 2 errors identified out of 37 observed medication administration opportunities, resulting in a 5.41% error rate. In one instance, an LPN administered three inhalers to a resident in the incorrect sequence, contrary to the facility's policy. The beta agonist inhaler was given first as required, but the corticosteroid inhaler was administered second instead of last, and the anticholinergic inhaler was given last instead of second. The LPN admitted uncertainty about the correct sequence and did not verify the order before administration. The Nursing Home Administrator confirmed that the facility policy was not followed in this case. In another instance, the same LPN administered Carafate to a different resident after breakfast, despite physician orders specifying that the medication should be given before meals. The LPN acknowledged the error, stating that the medication should have been administered prior to the meal but was not due to timing. The Nursing Home Administrator confirmed that the expectation was to follow the physician's order for Carafate administration before meals.
Failure to Follow Infection Control Practices During Resident Care and Insulin Administration
Penalty
Summary
Facility staff failed to implement infection control practices as required by facility policy and standard infection prevention protocols. During morning care for one resident, a CNA did not perform hand hygiene before handling clean clothing and supplies, nor after removing gloves following peri care, and proceeded to dress the resident with clean items. The CNA acknowledged during interview that hand hygiene should have been performed after glove removal and before touching clean items. The Director of Nursing confirmed that the expectation is for staff to perform hand hygiene when entering resident rooms for care and after removing gloves following peri care. Additionally, a registered nurse was observed preparing and administering insulin to a resident using two different insulin pens without sanitizing the rubber caps with an antimicrobial agent prior to attaching the needle, as required by facility policy. The nurse admitted to forgetting this step and acknowledged the requirement to sanitize the rubber tips before administration. The Nursing Home Administrator confirmed that the facility policy mandates sanitizing the rubber caps before insulin administration.
Failure to Monitor and Report Resident's Change in Condition
Penalty
Summary
The facility failed to ensure that a resident, identified as R2, received treatment and care in accordance with professional standards of practice, the Comprehensive Person-Centered Care Plan, and the resident's choices. R2 experienced four episodes of tarry red stools between 11:00 AM and 1:00 PM on August 31, 2024, but the facility did not monitor R2's vital signs or notify a physician until R2 was sent to the emergency department at 1:58 AM the following day. This lack of timely monitoring and communication with a physician was contrary to the facility's policies and professional guidelines. R2 was admitted to the facility with multiple diagnoses, including ankylosing spondylitis, dementia, gastrointestinal hemorrhage, and a history of gastrointestinal bleeding. The care plan for R2 included monitoring for signs and symptoms of anemia but did not specifically address monitoring for bleeding. Despite R2's history and the occurrence of red tarry stools, the facility did not take appropriate action to assess and report the change in condition, as required by their policies and professional standards. Interviews with facility staff revealed inconsistencies in understanding and implementing the protocol for notifying physicians of changes in a resident's condition. Some staff members indicated they would notify a physician after a second episode of symptoms, while others stated they would notify after the first occurrence. Additionally, a blood pressure reading for R2 on the same day was outside of normal parameters and was not reported to a physician, further highlighting the facility's failure to adhere to established protocols for monitoring and reporting significant changes in a resident's condition.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Colby
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Abbotsford Health Care Center | 1.9 mi | ★★★★★ | 7 | 0 |
| Clark County Rehabilitation & Living Center | 10.8 mi | ★★★★★ | 18 | 0 |
| Aspirus Care & Rehab-medford | 15.1 mi | ★★★★★ | 2 | 0 |
| Three Oaks Health Services | 17.4 mi | ★★★★★ | 9 | 0 |
| Norwood Health Ctr-central | 18 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.