Columbus Health and Rehab: Care Plan Gaps Found - WI
That exchange, documented during a federal inspection on March 12, 2025, sits at the center of a deficiency finding at the facility located at 825 Western Ave.
The resident at the center of the finding is identified in inspection records only as R237. A wound care device was part of that person's treatment. When a surveyor asked the Director of Nursing, identified in records as DON B, whether information on how to troubleshoot the device should appear in R237's care plan, the director said she was "not in particular" sure that it should, adding that hospital documentation directed staff to call the wound care clinic if questions arose.
The surveyor pressed further. Should calling the wound care clinic be written into the care plan itself?
DON B said she was not sure. She said that typically, that kind of detail would not go into the care plan proper. It would go into what she described as the special instructions section of the electronic medical record's dashboard.
The surveyor asked whether those special instructions had been entered for R237.
They had not.
DON B's account of her own oversight role did not resolve the gap. She told the surveyor she checks in with staff and completes audits. When asked directly how to answer the surveyor's initial question about the care plan, she said she did not know.
The deficiency was rated at the lower end of the harm scale, classified as minimal harm or potential for actual harm, and identified as affecting a small number of residents. It does not carry the weight of an immediate jeopardy finding, the most serious classification federal inspectors can assign. But the classification reflects what inspectors observed, not what could have gone unobserved.
What the record shows is a resident receiving treatment involving a wound care device, a care plan that did not document how to handle problems with that device, an alternative location in the electronic record that staff described as the usual place for such instructions, and confirmation that those instructions were absent there too.
Wound care devices, depending on type, can require specific handling to function correctly. When something goes wrong with a device and the steps for addressing it are not written down anywhere staff are directed to look, the response depends on whoever happens to be present knowing what to do or thinking to call someone who does.
DON B indicated staff would call the wound care clinic. Whether that instruction was accessible to anyone caring for R237 on any given shift, the inspection record does not say.
Columbus Health and Rehab is a Medicare and Medicaid-certified facility. For information on the facility's plan to correct this deficiency, CMS directs inquiries to the nursing home or the state survey agency.
The inspection was completed March 12, 2025. R237's wound care device was still part of their treatment at the time inspectors were on site. Whether the documentation gap was corrected before, during, or after the inspection, and what happened in the meantime, the report does not say.
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.
That exchange, documented during a federal inspection on March 12, 2025, sits at the center of a deficiency finding at the facility located at 825 Western Ave.
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.