Columbus Health Rehab: Infection Control Failures - WI
The scene played out at Columbus Health and Rehab on February 25, when federal inspectors watched certified nursing assistant CNA J perform personal care for Resident 236. After helping the resident stand from the toilet and cleaning their perineal area from front to back, CNA J adjusted the resident's clothing without removing her gloves or washing her hands. Only after dressing the resident did she remove the contaminated gloves and perform hand hygiene.
When questioned 8 minutes later, CNA J acknowledged she should have cleaned her hands before touching the resident's clothes.
The violation represents one of six documented cases where nursing assistants at the facility failed to follow basic infection control protocols during intimate care procedures. Federal inspectors observed staff repeatedly touching clean surfaces, medical equipment, and resident belongings with gloves contaminated by bodily fluids.
On February 24, CNA G performed front and back perineal care for Resident 16 while touching the person's bed linens, clothing, and wipes package without changing gloves. The assistant also applied barrier cream with the same contaminated gloves used for cleaning.
CNA G later told inspectors that gloves become contaminated after performing intimate care and should be removed before touching resident items or applying cream.
The same day, CNA H threw a mechanical transfer sling onto the floor before beginning perineal care for Resident 7. During the procedure, the assistant touched bed linens, clothing, and wipes packages with contaminated gloves. When the resident complained of discomfort, CNA H grabbed her walkie talkie from her waistband with the same gloves, called for a nurse, then gathered wipes from the bed and stored them in the bedside cabinet.
CNA H acknowledged to inspectors that floors are contaminated and transfer equipment should not be placed there. She also confirmed that contaminated gloves should be removed and hands cleaned before touching resident items.
The most complex violation occurred February 26, when CNA I performed intimate care for Resident 22, then attempted to change just one glove while keeping the other contaminated glove on. The assistant removed one glove, touched the glove box with the still-gloved hand, removed a new glove with the ungloved hand, then put on the new glove using the contaminated glove.
CNA I then dressed the resident and transferred them to a wheelchair using a mechanical sit-to-stand device, all while wearing one contaminated glove. After removing both gloves, the assistant tried to use wall-mounted hand sanitizer but found it empty. Instead of washing hands at the room's sink, CNA I opened the bedroom door, pushed the mechanical device into the hallway, and asked inspectors if anything else was needed before moving to the next resident.
The assistant later confirmed to inspectors that contaminated gloves should be removed and hands cleaned before touching resident items, and that soap and water at the room sink could substitute for empty hand sanitizer.
Director of Nursing DON B told inspectors on February 26 that hand hygiene is required before tasks, when changing gloves, when moving from contaminated to clean areas, and when tasks are complete. She confirmed that staff should not touch resident clothing, linens, supplies, walkie talkies, or medical equipment without proper hand hygiene.
DON B also confirmed that floors are considered contaminated surfaces and that transfer slings should not be placed on them.
The infection control violations affected multiple residents across different days and involved various nursing assistants. Each case demonstrated staff understanding of proper protocols when questioned, yet consistent failure to follow them during actual care.
The facility also faced scrutiny over pneumococcal vaccine guidance. On February 26, inspectors questioned DON B about current vaccination schedules for adults over a certain age. While DON B correctly identified three available vaccines - Prevnar 13, Pneumovax 23, and Pneumococcal conjugate 20 - she was unaware of updated guidance following the introduction of the newest vaccine option.
The inspection report does not indicate whether any residents developed infections as a result of the contamination incidents. However, the repeated failures across multiple staff members and different dates suggest systemic problems with infection control training and enforcement at the facility.
Federal inspectors classified the infection control violations as causing minimal harm or potential for actual harm, affecting many residents. The facility received citations under federal tag F880, which governs infection prevention and control programs in nursing homes.
The violations occurred during routine care procedures that happen multiple times daily at nursing facilities. Perineal care involves cleaning residents' most private areas and requires strict attention to preventing the spread of bacteria and other pathogens to clean surfaces, medical equipment, and other residents.
Each documented case showed staff members who understood proper procedures when asked directly by inspectors but failed to implement them during actual resident care. The gap between knowledge and practice suggests potential issues with supervision, enforcement, or workplace culture around infection control.
The empty hand sanitizer dispenser in Resident 22's room highlights additional facility maintenance issues that can compromise infection control efforts, even when staff attempt to follow proper procedures.
Columbus Health and Rehab's infection control failures come as nursing homes nationwide face increased scrutiny over prevention protocols. The facility's violations demonstrate how basic lapses in hand hygiene and glove changing can potentially expose vulnerable residents to preventable infections during their most intimate care moments.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
COLUMBUS HEALTH AND REHAB in COLUMBUS, WI was cited for violations during a health inspection on March 12, 2025.
Only after dressing the resident did she remove the contaminated gloves and perform hand hygiene.
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.