Columbus Health and Rehab: Bladder Care Plan Failures - WI
Neither was done.
When a federal inspector reviewed the case during a March 2025 survey, the care plan for Resident 25 contained no mention of any habit training or scheduled toileting program. The plan listed briefs, washing after accidents, and monitoring for signs of urinary tract infection. It did not document a single attempt to help the resident reach a toilet on a schedule, despite the facility's own evaluation concluding that such an approach could make a difference.
The inspection report noted the discrepancy plainly: the bladder incontinence evaluation said the facility had a plan for habit training and scheduled toileting. The care plan had no record of either.
On February 26, at 4:53 in the afternoon, the surveyor sat down with RN L, a registered nurse who had recently taken over responsibility for completing resident care plans from the Director of Nursing. The surveyor asked who was responsible for setting up bladder and bowel programs. RN L said she set up the care plan. Beyond that, she said, she did not do anything with the bowel and bladder program or management diaries.
Thirteen minutes later, the surveyor interviewed DON B, the Director of Nursing.
DON B said care plan responsibility was shared between herself and RN L, with RN L handling most of the initial work and specialty departments handling their own sections. Then the surveyor asked who was responsible for completing bladder and bowel diaries, or managing the bowel and bladder program overall.
DON B said she was unsure whether the facility had been doing formal bladder and bowel diaries at all.
The surveyor told DON B directly what the records showed: that Resident 25's bladder incontinence evaluation indicated the facility had a plan to conduct habit training and scheduled toileting to improve or maintain the resident's urinary continence. The surveyor asked whether those interventions should have been carried out.
DON B said yes. If the facility said it was going to do those interventions, it should have done them and documented it.
What the exchange revealed was a gap that neither the nurse nor the director could fully account for. The facility's own evaluation identified an opportunity to help a resident maintain continence. The care plan that followed did not carry that evaluation forward into action. And the person overseeing nursing care could not confirm whether the systems meant to track that kind of program were even running.
Urinary incontinence in nursing home residents carries real consequences. Untreated or poorly managed incontinence raises the risk of skin breakdown, urinary tract infections, and falls during unassisted attempts to reach the bathroom. The care plan for Resident 25 acknowledged those risks, requiring staff to monitor for UTI symptoms and to ensure an unobstructed path to the bathroom. But the intervention most likely to reduce the number of incontinent episodes in the first place, the scheduled toileting the facility's own evaluation recommended, was never documented as occurring.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting few residents. Columbus Health and Rehab is located at 825 Western Ave. in Columbus, Wisconsin.
Resident 25's evaluation was dated May 9, 2024. The inspection that uncovered the lapse was completed March 12, 2025. That is ten months during which the facility's records show briefs were changed and accidents were cleaned up, but no one, by any account given to the surveyor, was walking Resident 25 to the bathroom on a schedule, the way the facility had said it would.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Columbus Health and Rehab from 2025-03-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 8, 2026 · Our methodology
Columbus Health and Rehab in Columbus, WI was cited for violations during a health inspection on March 12, 2025.
The plan listed briefs, washing after accidents, and monitoring for signs of urinary tract infection.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.