Columbus Health and Rehab: Hospice Care Gaps Found - WI
The surveyor was reviewing care for Resident 7, who was receiving hospice services. When she asked a registered nurse, identified in inspection records as RN D, where the hospice coordination documents were kept, the nurse couldn't find them. The Director of Nursing had to be called over to locate a binder tucked in a cupboard at the nurse's station.
Inside the binder: a plan of care covering the benefit period from November 9 through January 7, and a skilled nursing visit summary from December 17. Nothing from 2025.
The surveyor asked RN D whether there should be a current plan of care and visit notes available for staff to reference. RN D said yes. The surveyor asked how the facility ensures its own care plan matches the hospice provider's plan. RN D's answer was direct: "If we don't have a current plan of care, we can't."
That exchange captured the core of what inspectors found. Columbus Health and Rehab had no system for making sure the people caring for a dying resident knew what the hospice team had most recently decided about that resident's care.
The coordination problem went beyond missing paperwork. RN D told the surveyor that hospice communication happens one to two times a week, more if needed, but that these conversations are mostly verbal and not documented. There is no designated person at the facility responsible for hospice coordination. All the nurses contact hospice on their own, as needed, with no central point of contact and no record of what was discussed or decided.
The Director of Nursing, identified as DON B, confirmed the same picture when the surveyor interviewed her separately that morning. DON B said the nurses handle hospice communication independently. There is no in-house coordinator. Asked whether a current hospice plan of care and visit notes should be in the binder for staff to reference, DON B said yes.
What that means in practice: a nurse coming on shift to care for Resident 7 would have been working from a care plan that was, at minimum, ten weeks old, with no way of knowing what the hospice team had assessed, changed, or recommended in the intervening weeks.
Hospice care involves closely managed decisions about pain, comfort, and the goals of a dying person's final period of life. Those decisions shift. A plan from early December does not necessarily reflect what a resident needs in late February. When the facility's care plan and the hospice plan diverge, and staff have no current documentation to close that gap, the resident absorbs the difference.
The inspection finding was categorized as causing minimal harm or the potential for actual harm, affecting a small number of residents. The facility received the finding under the federal standard requiring nursing homes to ensure that the care and services provided by a hospice under contract are consistent with the facility's own plan of care for the resident.
No one at the facility disputed what the surveyor found. RN D acknowledged the binder had nothing from 2025. DON B acknowledged current documentation should be there. The gap between what both of them said should exist and what actually existed in that cupboard at the nurse's station was not a matter of interpretation.
Resident 7 was on hospice. The people responsible for their daily care were working without a current picture of their hospice team's guidance, and the facility had built no structure to make sure that picture stayed current.
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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Last verified: November 7, 2026 · Our methodology
Columbus Health and Rehab in Columbus, WI was cited for violations during a health inspection on March 12, 2025.
The surveyor was reviewing care for Resident 7, who was receiving hospice services.
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.