Columbus Health and Rehab: Infection Control Failures - WI
That sequence of events, documented during a March 2025 inspection, captured what federal surveyors described as an infection control breakdown affecting many residents.
The CNA, identified in inspection records as CNA I, had been providing pericare, the intimate hygiene care that involves contact with a resident's genital and rectal area. After finishing, the CNA pushed the mechanical lift device out of the room and asked the surveyor whether anything else was needed before moving on to the next resident. The surveyor noted the hand sanitizer dispenser was empty.
When the surveyor asked CNA I about infection control practices, the aide showed a clear understanding of what should have happened. Gloves are contaminated after pericare and should be removed, CNA I said, and hands should be cleansed before touching any resident items. When the surveyor asked what to do if hand sanitizer isn't available, CNA I gave the correct answer: use soap and water at the sink inside the resident's room.
CNA I knew the right answer. CNA I had not done it.
The surveyor then went to the Director of Nursing, identified as DON B, and walked through the same scenario. DON B confirmed that hand hygiene is expected before a task begins, when changing gloves, when moving from a dirty site to a clean one, and when a task is complete. The surveyor asked whether a staff member should switch gloves without performing hand hygiene in between. DON B said no. The surveyor asked whether it was acceptable to touch a resident's clothing, supplies, a mechanical transfer device, a wheelchair, or a door without cleaning hands first. DON B said no.
What the Director of Nursing described as unacceptable is precisely what the surveyor had just watched happen.
The inspection was conducted on March 12, 2025. The deficiency was classified as causing minimal harm or potential for actual harm, and surveyors noted it affected many residents, not just the one whose care was observed.
That classification, minimal harm, reflects the regulatory threshold for what was documented, not a reassurance about what the lapse could produce. Pericare involves contact with areas of the body that harbor bacteria capable of causing urinary tract infections, skin infections, and gastrointestinal illness. A mechanical lift used to transfer one resident is then used to transfer others. A door handle touched with contaminated gloves is touched again by staff, residents, and visitors. The chain of potential transmission doesn't end in one room.
The facility's own leadership drew that chain clearly when the surveyor asked. DON B's answers were unambiguous. The problem was not a gap in policy or a misunderstanding of expectations. The problem was that none of those expectations were met in the room the surveyor happened to walk into, on an ordinary morning, during a routine task.
CNA I moved on to the next resident.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
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 surveyor noted the hand sanitizer dispenser was empty.
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.