Columbus Health And Rehab
Columbus Health and Rehab in Columbus, WI — inspection on March 12, 2025.
Found 11 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Daily weight in the morning related to ACUTE ON CHRONIC SYSTOLIC (CONGESTIVE) HEART
R8's Weight Documentation indicates, in part: 2/13/25 at 10:35 AM: 172.2 lbs. (Standing) 2/14/25 at 1:57 PM: 176.4 lbs. (Standing) On 2/15/25 at 6:10 PM, a Progress Note states, in part: Resident's weight increased from 172.2 to 176.2 from 2/13- 2/14.
Unclear if MD was notified.
Weight this AM was 175.2.
Resident's breathing labored and tachypneic (High respiratory rate) in the 40s, O2 (Oxygen) saturation of 85% on 2.5 L (Liters) via NC (Nasal Cannula) .
A fax, with an illegible date in February 2025, indicates a general update on the resident was provided including the weight increase.
However, no response was documented.
There is a mark on the bottom of the page that may be a signature that is dated 2/17/25.
The response fax is dated 2/17/25 at 3:26 PM.
On 2/26/25 at 3:42 PM, Surveyor interviewed LPN O (Licensed Practical Nurse) and asked what situations she would immediately notify a physician. LPN O indicated she would immediately notify a physician for a change in condition, urinary tract infection symptoms, a fall, significant bleeding, or high or low blood sugars.
Surveyor asked LPN O what it means to immediately notify a physician. LPN O indicates she would call a physician within a couple of hours after she was able to assess the resident.
Surveyor asked LPN O what standard of practice the facility uses for change in condition.
LPN O indicates she references binders at the nurses' station to determine what requires notification.
Surveyor asked LPN O if a resident is acutely coughing up sputum and reporting emesis, does this require immediate physician notification. LPN O indicates that would be pretty urgent and would call if as needed treatments were attempted and did not resolve the resident's symptoms.
On 2/26/25 at 5:02 PM, Surveyor interviewed DON B (Director of Nursing) and asked what it means to immediately notify a physician. DON B stated as soon as practicable.
Surveyor asked DON B in what situations should staff immediately notify a physician. DON B indicated with a change in condition or abnormal vital signs.
Surveyor asked DON B if a fax would be acceptable or if a physician should be called. DON B indicated that it depends on the situation.
Surveyor asked what change of condition standard of practice the facility follows. DON B stated the facility follows eINTERACT.
Surveyor asked DON B if a resident is acutely coughing up sputum to the point they are having emesis, is an immediate physician notification needed. DON B stated, yes.
Surveyor asked DON B if a resident who has CHF and has a weight change of 4 pounds in one day would require immediate physician notification. DON B indicated she would expect staff to call the physician immediately.
525445 03/12/2025
Columbus Health and Rehab 825 Western Ave.
Columbus, WI 53925
B indicates she does not know how to answer this question, but that she checks in with staff and
should call the wound care clinic.
Surveyor asked DON B if calling the wound care clinic should be a
part of the care plan but it usually is put int the special instructions section of the dashboard of the electronic medical record.
Surveyor asked DON B if those special instructions were included on the dashboard for R237. DON B indicates they were not.
525445 03/12/2025
Columbus Health and Rehab 825 Western Ave.
Columbus, WI 53925
The facility failed to implement aggressive pressure injury interventions; failed to complete
of R30 refusing repositioning.
Facility did not assess or measure R30's left gluteal pressure injury.
R30 developed two stage three, and one unstageable facility acquired pressure injury.
525445 03/12/2025
Columbus Health and Rehab 825 Western Ave.
Columbus, WI 53925
Irreversible but there is a potential for continence to be maintained or improved by reducing
urine.
Date initiated: 5/9/24.
Interventions: BRIEF USE: [Resident Name] uses disposable briefs.
Change daily and PRN (as needed).
Date initiated: 5/9/24.
Ensure unobstructed path to the bathroom.
Date initiated: 5/9/24. INCONTINENT: Wash, rinse, and dry perineum.
Change clothing PRN after incontinent episodes.
Date initiated: 5/9/24.
Monitor/document s/sx (signs and symptoms) of UTI (urinary tract infection).
Date initiated: 5/9/24. (Of note: R25's Comprehensive Care Plan does not note any type of habit training or scheduled toileting program).
On 2/26/25 at 4:53 PM, Surveyor interviewed RN L (Registered Nurse).
Surveyor asked RN L who completes the resident comprehensive care plans. RN L indicates that DON B (Director of Nursing) was, but recently RN L has taken over this responsibility.
Surveyor asked RN L who is responsible for setting up the bladder and bowel programs. RN L indicates all she does is set up the care plan and she does not do anything with the bowel and bladder program or management diaries.
On 2/26/25 at 5:06 PM, Surveyor interviewed DON B (Director of Nursing).
Surveyor asked DON B who is responsible for completing the resident comprehensive care plans. DON B indicates it is a shared responsibility between herself and RN L; however, RN L completes the bulk of initiating care plans and each specialty, such as dietary or therapy, works on their own section.
Surveyor asked DON B who is responsible for completing bladder and bowel diaries or managing the bowel and bladder program. DON B indicates she is unsure if the facility has been doing formal bladder and bowel diaries.
Surveyor advised DON B that R25's Bladder Incontinence Evaluation indicates the facility had a plan to conduct habit training or scheduled toileting to improve or maintain R25's urinary continence.
Surveyor asked DON B if those interventions should have been conducted. DON B indicates that if the facility said they were going to do those interventions, they should have done them and documented it.
525445 03/12/2025
Columbus Health and Rehab 825 Western Ave.
Columbus, WI 53925
According to <https://www.ncbi.nlm.nih.gov/books/NBK594495/> Before flushing the lumen with 0.9% sodium chloride, aspiration of blood should be attempted to ensure patency.
The volume of fluid used for flushing should be twice the volume of the lumen.
RN/MDS L was observed not following the policy and procedure for IV medications and does not have a competency check for administering IV medication.
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Columbus Health and Rehab 825 Western Ave.
Columbus, WI 53925
serve food in accordance with professional standards.
accordance with professional standards for food service safety.
This has the ability to affect all 38
Food items were observed to be spoiled.
Scoops were found in containers of sugar.
Nutritional supplements were found without use by dates.
Four Sysco Imperial Strawberry Shakes were found in the medication room refrigerator with no use by date.
Findings include Example 1 On 2/24/25 at 9:24 AM, Surveyor observed in the facility kitchen's refrigerator, along with DM C (Dietary Manager), an unoppened and unchopped bag of fresh parsley with a received date of 1/21/25.
Portions of the parsely were visbly brown and slimey.
Additionally, Surveyor observed a bag of unopened lettuce with a received date of 2/11/25 that appeared to be slimey and discolored. DM C stated at this time that the lettuce and parsley should be thrown away.
Example 2 On 2/24/25 at 9:42 AM, Surveyor observed in the facility kitchen, along with DM C, 3 containers, 1 each of flour, brown sugar and sugar with scoops in each container. DM C indicated to Surveyor at this time that the scoops should not be in the containers as it could be a cross contamination issue.
Example 3 On 2/25/25 at 1:31 PM, Surveyor observed four Sysco Imperial Strawberry Shakes (nutritional supplement) in the medication room refrigerator with no use by date.
Surveyor interviewed RN E (Registered Nurse) and asked when the shakes expire / when the shakes should be disposed of. RN E stated unable to tell as the shakes don't have labels.
On 2/26/25 at 10:09 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and DON B (Director of Nursing) and asked if there is no label on a supplemental shake, would the staff be able to accurately determine when it needs to be used by / disposed of. NHA A and DON B stated no.
Surveyor asked if there should be a use by date on supplemental shakes. NHA A and DON B stated yes.
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Columbus Health and Rehab 825 Western Ave.
Columbus, WI 53925
physical plan consideration that are necessary for this population, and e.
Any ethnic, cultural, or
buildings and/or other physical structures and vehicles; b.
Equipment (medical and non-medical); c.
emergent services; and f.
Health information services .
Surveyor reviewed the facility document titled Facility Assessment, dated January 2025.
Surveyor noted the document contained several categories, the first being Resident Population Profile, dated 12/21/23-12/20/24 that includes sections labeled number of admission/stays, % of admissions/stays, frequency relative to benchmark.
The actual benchmark is not listed for any category.
Other categories included are Diseases, Conditions & Treatments, Acuity-Frequency of Potentially High-Risk Treatments, Acuity-Care Requirements, Cognitive, Mental & Behavioral Status, Cultural, Ethnic, & Religious Factors.
None of these categories had a listed benchmark which the facility had assessed their facility to be capable of accepting.
Additionally, the staffing section is titled Staffing, Training, Services & Personnel, containing categories titled Overall Staffing, Staff/Training/Competencies, and Services.
All categories are marked Evaluated with no additional information or other staffing needs quantified.
Finally, the sections marked Physical Environment, Technology, Equipment have the same categories marked Physical Environment, Technology, and Equipment, and all sections are marked Evaluated with no actual benchmark or quantity of equipment or technology listed. (Of note: Quite often the Frequency Relative to Benchmark is indicated as High or Very High without any reference to the actual benchmark) On 2/26/25 at 11:15 AM, Surveyor asked NHA A (Nursing Home Administrator) for any additional information or documentation related to the facility assessment. NHA A indicated there was none, and that all information was provided.
On 2/26/25 at 11:30 AM, Surveyor advised NHA A that Surveyors were looking for documentation stating specific numbers of residents that can be accepted with different conditions, therapies such as IVs, and equipment needs. NHA A indicated she would look for additional documentation.
On 2/26/25 at 12:01 PM, NHA A provided Surveyor with the same documentation that was previously described and advised that the information Surveyor was looking for was contained in a paragraph within the previously provided documentation.
Surveyor reviewed the paragraph again and could find no additional information specifying the quantity of assessed resident population, staffing, or physical environment needs.
Another Surveyor also reviewed the documentation looking for the required information to ensure nothing was missed.
Another Surveyor confirmed the required information was not contained within the documents provided.
No additional information was provided as to why the facility did not conduct and document a complete facility-wide assessment to determine what resources are necessary for the care of its residents.
The facility assessment must reflect the resident population, and the resources needed to care for this population.
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Columbus Health and Rehab 825 Western Ave.
Columbus, WI 53925
facility.
Surveyor asked how the facility receives visit notes. RN D stated R7's hospice provider
RN D requested assist from DON B (Director of Nursing) with locating the binder. DON B was able to
for multiple residents receiving services from (provider name) hospice. R7's information included a plan of care for benefit period 11/9/24 through 1/7/25 and a skilled nursing visit summary dated 12/17/24.
On 2/26/25 at 9:33 AM, Surveyor interviewed RN D and asked how often there is facility collaboration with hospice. RN D stated one to two times weekly; more as needed.
Surveyor asked where this is documented. RN D stated there is mostly verbal discussion that is not documented.
Surveyor asked if the resident's most recent hospice documentation should be in the hospice binder. RN D stated yes.
Surveyor asked RN D to review the information in the hospice binder for R7. RN D stated that the date of the most recent plan of care was 12/19/24 and the date of the most recent visit note was 12/17/24.
Surveyor asked if there should be a current plan of care and visit notes for staff to reference. RN D stated yes, there is nothing here from 2025.
Surveyor asked how the facility ensures that the facility plan of care and the hospice plan of care match. RN D stated if we don't have a current plan of care, we can't.
On 2/26/25 at 10:21 AM, Surveyor interviewed DON B (Director of Nursing) and asked if there is a facility staff member who coordinates hospice. DON B stated their nurses handle communication with hospice on their own; there is no coordinator in house.
Surveyor asked if there should be a current hospice plan of care and visit notes in the hospice binder for staff to reference. DON B stated yes.
sanitizer was empty. CNA I opened R22's bedroom door, pushed the mechanical device out of the
pericare and should be removed and hands cleansed prior to touching resident items.
Surveyor asked
could be performed in the resident room with soap and water at the sink.
On 2/26/25 at 10:22 AM, Surveyor interviewed DON B (Director of Nursing) and asked about hand hygiene and pericare. DON B stated that hand hygiene is expected prior to task, when changing gloves, when moving from dirty to clean site, and when task is complete.
Surveyor asked if staff should remove one glove, obtain another glove, and apply without performing hand hygiene. DON B stated no.
Surveyor asked if resident's clothing, supplies, mechanical transfer device, wheelchair, and door should be touched without hand hygiene. DON B stated no.
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Columbus Health and Rehab 825 Western Ave.
Columbus, WI 53925
According to <https://www.ncbi.nlm.nih.gov/books/NBK594495/> Before flushing the lumen with 0.9% sodium chloride, aspiration of blood should be attempted to ensure patency.
The volume of fluid used for flushing should be twice the volume of the lumen.
RN/MDS L was observed not following the policy and procedure for IV medications and does not have a competency check for administering IV medication.
525445
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 525445 B.
Wing 03/12/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Columbus Health and Rehab 825 Western Ave Columbus, WI 53925
During this observation, CNA G performed pericare for R16's front, turned R16 to the side touching R16's bed linens and clothing, touched the wipes package and obtained more wipes, performed pericare for R16's backside, and applied barrier cream.
There was no removal of gloves with hand hygiene after contact with bodily fluids prior to touching bed linens, clothing, wipes package, or barrier cream.
Surveyor interviewed CNA G regarding infection control. CNA G stated that gloves are contaminated after performing pericare and should have been removed and hand hygiene performed prior to touching resident items and applying barrier cream.
On 2/26/25 at 10:22 AM, Surveyor interviewed DON B (Director of Nursing) and asked about hand hygiene and pericare. DON B stated that hand hygiene is expected prior to task, when changing gloves, when moving from dirty to clean site, and when task is complete.
Surveyor asked if resident's clothing, linens and supplies should be touched without hand hygiene. DON B stated no.
Example 5
On 2/24/25 at 1:51 PM, Surveyor observed CNA H assisting R7 with pericare.
During this observation, CNA H removed a mechanical device transfer sling from under the resident and threw the sling onto the floor. CNA H performed pericare for R7's front, turned the R7 to the side touching R7's bed linens and clothing, touched the wipes package and obtained more wipes, then performed pericare for R7's backside. R7 complained of discomfort to R7's bottom. CNA H took the walkie talkie from CNA H's waistband and called the nurse to the room. CNA H gathered the two packages of wipes from R7's bed, opened R7's bedside cabinet and put the wipes away.
There was not removal of gloves with hand hygiene after contact with bodily fluids prior to touching bed linens, clothing, wipes packages, walkie talkie, or bedside cabinet.
Surveyor interviewed CNA H regarding infection control.
Surveyor asked if the floor is contaminated. CNA H stated yes.
Surveyor asked if the mechanical device transfer sling should be on the floor. CNA H stated no.
Surveyor asked about infection control with pericare. CNA stated that gloves are contaminated after performing pericare and should have been removed and hand hygiene performed prior to touching resident items.
525445
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 525445 B.
Wing 03/12/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Columbus Health and Rehab 825 Western Ave Columbus, WI 53925
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.