Columbus Health And Rehab

F-F686 - Medical Director and/or Wound NP to review wound assessments weekly with facility nursing team either bedside at the facility or remotely to ensure thorough and accurate assessments, treatments remain appropriate, and standards of practice are maintained. Weekly reviews to continue x 4 weeks unless concerns are noted during reviews. After the Provider oversight DON/Designee will audit 4 wound assessments & care plans weekly x 4 weeks then 2 wound assessments weekly x 2 weeks. Audit result will be reviewed with the Medical Director during QAPI. Audits will be discontinued based on QAPI committee recommendations. Ad hoc QAPI held with Medical Director, Acting Administrator, DON, and Governing Body. Action plans reviewed, discussed and agreed upon at 1:55pm on 3.7.25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 31 525445 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49434

Residents Affected - Few Based on interview and record review, the facility did not ensure that residents who are continent of bladder and bowel, on admission, receive services and assistance to maintain continence, unless his or her clinical condition is or becomes such that continence is not possible to maintain for 1 of 1 resident's (Resident R25) reviewed for bowel and bladder.

The facility did not develop a toileting plan for Resident R25 after they assessed and concluded that Resident R25 would be a candidate for retraining.

This is evidenced by:

The facility's policy and procedure entitled Urinary Incontinence - Clinical Protocol/Guidelines, with an effective date of 10/2024, states, in part: Assessment and Recognition 1. As part of the initial assessment,

the nursing staff will attempt to identify individuals with impaired urinary continence, i.e., reduced ability to maintain urine in a socially appropriate manner .3. For incontinent individuals, the nursing staff will identify, and document circumstances related to the incontinence; for example, frequency, nocturia, dysuria, or relationship to coughing or sneezing .Treatment/Management .2. Assess for environmental interventions and assistive devices (e.g., grab bars, raised toilet seats, bedside commodes, urinals, bed rails, restraints, and/or walkers) that facilitate toileting. 3. As appropriate, based on assessment of the category and causes of incontinence, provide a scheduled toileting, prompted voiding, or other interventions to try to improve the individuals' continence status .

Resident R25 was admitted to the facility on [DATE REDACTED], with diagnoses that include, in part: polyosteoarthritis, atherosclerotic heart disease, type 2 diabetes, hypertension, and muscle weakness (generalized).

Resident R25's most recent Quarterly Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 2/12/25 states that Resident R25 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating that Resident R25 is cognitively intact. Section GG states Resident R25 requires partial/moderate assistance for toilet transfers and requires partial/moderate assistance for walking 10 feet. Section H states Resident R25 does not use any bladder and bowel appliances, has not had a trial of toileting program attempted since admission to the facility, and that Resident R25 is frequently incontinent, which is defined as 7 or more episodes of urinary incontinence, but a least one episode of continent voiding).

Resident R25's Physician Orders state, in part:

Furosemide Oral Tablet 20 MG (Furosemide) Give 1 tablet by mouth one time a day for edema (swelling). Order status: Active. Start Date: 5/7/24.

(Of note: Furosemide is a diuretic and often causes the need to urinate more frequently)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 31 525445 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Resident R25's evaluation titled, Bladder Incontinence Evaluation- V2, indicates it is unknown if Resident R25's incontinence has a recent onset, Resident R25 currently uses disposable continence products, specifically adult briefs at night only Level of Harm - Minimal harm or and adult underwear during the day only (Pull Ups). This document also indicates Resident R25 is taking a diuretic, potential for actual harm has decreased manual dexterity, requires physical assistance to access commode/urinal, and has decreased muscle strength in his lower extremities. Environmental factors identified include distance to toilet and Residents Affected - Few requires grab bars for support. Type of incontinence is identified as Functional (Normal function affected by environment or disease). A question that states, Irreversible but there is a potential for continence to be maintained or improved by reducing incontinent episodes through a bladder program is marked yes. The Approaches/Plan section has Habit Training/Scheduled Toileting and Incontinence Products/Garments both checked.

Resident R25's Comprehensive Care Plan, states, in part: Focus: [Resident Name] is incontinent at times of 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: Resident 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 Resident R25's Bladder Incontinence Evaluation indicates the facility had a plan to conduct habit training or scheduled toileting to improve or maintain Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 31 525445 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Level of Harm - Minimal harm or 49434 potential for actual harm Based on observation, interview, and record review, the facility did not ensure nursing staff followed Residents Affected - Few professional standards of practice when flushing a peripherally inserted central catheter (PICC) for 1 of 1 residents reviewed (Resident R237).

Staff did not check blood return prior to flushing Resident R237's PICC.

Evidenced By:

The Facility follows their Pharmacies Policy and Procedure entitled Central Vascular Access Device (CVAD) Flushing and Locking dated 6/1/24, it documents the following in part: .Considerations: 1. Central vascular access devices (CVADs) include: 1.1 Peripherally inserted central catheter (PICC) .4. Flushing/locking is performed to ensure and maintain catheter patency and to prevent the mixing of incompatible medications/solutions. 5. Needless connectors require vigorous cleansing with alcohol prior to accessing to reduce the risk of catheter related bloodstream infection .Guidance .5. Catheter patency must be verified prior to each medication administration. To assess patency, aspirate the catheter to obtain positive blood return. The aspirated blood should be the color and consistency of whole blood .Procedure: 1. Verify prescriber order. 2. Identify patient using appropriate identifiers. 3. Explain procedure to patient/significant other. 4. Perform hand hygiene. 5. Assemble equipment and supplies on clean work surface. 6. [NAME] gloves. 7. Vigorously cleanse needleless connector with alcohol. Allow to air dry .9. Attach syringe filled with prescribed flushing agent to needleless connector. Aspirate the catheter to obtain positive blood return to verify vascular access patency. 10. Flush while observing for signs and symptoms of complication/infiltration. 11. Disconnect syringe .12. Dispose of used supplies per facility policy. 13. Remove gloves. 14. Perform hand hygiene. 15. Documentation in the medical record .

Resident R237 is a recent short-term admission to the facility. Resident R237 has the following diagnoses: sepsis due to methicillin resistant staphylococcus aureus, infection following procedure deep incisional surgical site, type 2 diabetes mellitus, and morbid obesity due to excess calories.

Resident R237's Progress Note dated 2/15/24 at 21:50 (9:51 PM) documents: PICC flushed with NS and blood return noted. Wound vac and dressing in place. Ice for R (right) hand.

On 2/26/25 at 6:56 AM, Surveyor observed RN/MDS L (Registered Nurse/Minimum Data Set) perform Resident R237's PICC line medication initiation. RN/MDS L performed hand hygiene, donned appropriate personal protective equipment (PPE), knocked on Resident R237's door, announced herself and Surveyor, explained what she was there to do, and set up her supplies. RN/MDS L hung IV (intravenous- into or within a vein) medication bag on the IV pole, primed the IV tubing, and removed air bubbles. RN/MDS L cleaned the hub (end) of the PICC line with alcohol, removed NS (normal saline- solution) syringe from package and removed cap, attached NS syringe to hub of PICC line, she unclamped PICC line port and began flushing line with a pulsating (push/stop) motion until syringe was empty. RN/MDS L then took the end of the IV medication bag tubing and removed cap, she cleaned the PICC line hub with alcohol again, attached the IV medication bag tubing to the PICC line hub, set the pump to the correct setting, unclamped IV tubing and PICC line clamps, and monitored for medication to run appropriately. Once that was noted, RN/MDS L doffed PPE, performed hand hygiene, and exited room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 31 525445 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 It is important to note that RN/MDS L never aspirated (pulled back) to obtain blood return prior to administering medication per their policy and procedure. Level of Harm - Minimal harm or potential for actual harm On 2/26/25 at 4:26 PM, Surveyor interviewed RN/MDS L. Surveyor asked RN/MDS L to explain the flushing protocol for a PICC line, RN/MDS L said complete hand hygiene, alcohol cap, attach syringe, flush line in Residents Affected - Few pulsating motion, remove syringe, and re-apply clamp. Surveyor asked RN/MDS L should blood be aspirated

during flush prior to medication administration, RN/MDS L stated I was never taught that, I would for a peripheral line, I was not taught that with PICC line, not even when administering chemotherapy medication. Surveyor asked RN/MDS L if she had had any IV/PICC line training or education here at this facility, RN/MDS L replied skill checks annually but I just started in June, I had one of the nurses go through this with me so I would know how.

On 2/26/25 at 10:09 AM, Surveyor interviewed RN M. Surveyor asked RN M to explain the flushing protocol for a PICC line, RN M stated, Clean the hub for 30 seconds with alcohol, attach syringe, unclamp line, push

a little NS in, pull back for blood return, finish flush of NS, detach the syringe, and re-clamp line. Surveyor asked RN M how she knew to pull back for blood return, RN M stated that's the way she was taught in the hospital. Surveyor asked RN M if she had, had any IV/PICC line training or education here at this facility, RN M stated, No not since I've been here.

On 2/26/25 at 11:51 AM, Surveyor interviewed RN D. Surveyor asked RN D to explain the flushing protocol for a PICC line, RN D replied take the cap off, clean the hub with alcohol, unclamp. flush with NS, re-clamp, and put the cap back on. Surveyor asked RN D if she would aspirate blood, RN D said I don't. Surveyor asked RN D if she had had any IV/PICC line training or education here at this facility, RN D said the pharmacy has come out in the past but not recently. Surveyor asked RN D if LPN's (Licensed Practical Nurses) do IV therapy, RN D said no they do not.

On 2/26/25 at 4:55 PM, Surveyor interviewed DON/IP B (Director of Nursing/Infection Preventionist). Surveyor asked DON/IP B what standard of practice you use for PICC line flushing and maintenance, DON/IP B said the pharmacy guideline. Surveyor asked DON/IP B how you expect a PICC line to be flushed, DON/IP B explained they'd clean the hub with alcohol, flush out air bubbles from syringe, attach to needless connector, flush in pulsation motion until gone, and disconnect. Surveyor asked DON/IP B would you expect blood to be aspirated prior to medication administration, DON/IP B stated, No.

On 2/26/25 at 5:44 PM, Surveyor interviewed DON/IP B. Surveyor asked DON/IP B how you ensure nurses are competent when using a PICC line, DON/IP B said there is a list of tasks that need to be signed off within 30 days of hire. Surveyor asked DON/IP B who signs off the nurses, DON/IP B said DON/IP B. Surveyor asked DON/IP B how frequently competency is reviewed, DON/IP B said annually. Surveyor asked DON/IP B how competency is completed for PICC line care, DON/IP B replied I watch them do the task. Surveyor asked DON/IP B if that is documented, DON/IP B stated no. Surveyor asked DON/IP B would you expect staff to be able to perform PICC line skills competently, DON/IP B stated yes.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 31 525445 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 36253

Residents Affected - Many Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the ability to affect all 38 residents.

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.

50228

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 31 525445 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Level of Harm - Minimal harm or potential for actual harm 49434

Residents Affected - Many Based on interview and record review, the facility did not ensure the facility wide assessment developed by

the facility included all relevant details to ensure the facility provided care and services to residents to meet their individual needs within the facility's identified resources. This has the potential to affect all 38 residents residing in the facility.

The Facility Assessment did not indicate:

-the facility's resident capacity

-the care required by the resident population considering the types of disease, conditions, physical and cognitive disabilities, overall acuity

-Staff competencies that are necessary to provide the level and types of care needed for the resident population

-Physical environment, equipment services, and physical plant considerations that are necessary for care of

the population

-Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services

-The facilities resources, including but not limited to, all buildings and/or other physical structures and vehicles, equipment (medical and non-medical)

-Services provided, such as therapy, pharmacy, and specific rehabilitation therapies

-All personnel, including managers, staff (both employees and contracted employees), and volunteers as well as their education and/or training and competencies to provide resident care

-Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during normal operations

-Health information technology resources such as systems for electronically managing patient records and electronically sharing information with other organizations

This is evidenced by:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 31 525445 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 The facility's policy titled, Facility Assessment F 838, dated 10/2024, states, in part: Policy Statement: The community will conduct a facility wide assessment, review it periodically and update it annually. Policy Level of Harm - Minimal harm or Interpretation and Implementation: 1. Purpose - to determine what resources are necessary to care for our potential for actual harm residents during both day-to-day operations and emergencies. 2. Updates occur periodically and at least annually. 3. Include: a. The number of residents and the facility's resident capacity; b. The care required by Residents Affected - Many the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that apply to the current population, c. The staff competencies that are necessary to provide the level and types of care needed for the resident population, d. The physical environment, equipment, services and other physical plan consideration that are necessary for this population, and e. Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to activities and food and nutrition services. 4. List, at a minimum the following resources: a. All buildings and/or other physical structures and vehicles; b. Equipment (medical and non-medical); c. Services provided; d. Staff and their associated competencies required; e. Contracts for normal and 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 31 525445 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 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. Level of Harm - Minimal harm or potential for actual harm The facility assessment must reflect the resident population, and the resources needed to care for this population. Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 31 525445 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50228

Residents Affected - Few Based on interview and record review, the facility did not ensure hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 of 1 resident (Resident R7) reviewed for hospice.

Resident R7's current hospice plan of care and visit notes were not available to facility staff.

The facility did not designate a staff member to coordinate the plan of care with the hospice provider.

This is evidenced by:

The facility's Hospice Program policy, dated 10/2024, states, in part: .7. Identify a member of the IDT (interdisciplinary team) who is responsible for working with the hospice representative.This person's responsibilities include: .d. Ensuring the appropriate documents are readily available.If the hospice does not document in PCC (Point Click Care-the facility electronic health record), community may include selecting one personal to scan and upload hospice documents to the resident's electronic medical record no more than 5 days after documents are received as outlined below, to include: i. most recent hospice plan of care. viii. Visit notes from all hospice disciplines, nurse, chaplain, social services, and volunteer.9. The community retains the ultimate responsibility for the care plan. Coordinate the plan of care with the hospice provider, community staff and resident/family. 10. To promote continuity of care, collaborate with the hospice, nursing home and resident/representative on a coordinated care plan noted in the medical record . 14. Designate a member of the community staff to coordinate the plan of care with the hospice provider, specifically to ensure coordination, continuity of care and to resolve differences. Each provider should know how to review the other's care plan.

Resident R7 was admitted to the facility on [DATE REDACTED] and has diagnoses that include, in part: encounter for palliative care (care specializing in managing symptoms and improving quality of life); dementia with agitation (a condition characterized by impairment of brain function, such as memory loss and impaired judgement along with a state of restlessness, anxiety, or distress); diastolic heart failure (a condition where the heart muscle is unable to function properly resulting in reduced blood flow to the body).

Resident R7's physician orders include, in part: (provider name) Hospice services related to terminal prognosis. Order date: 3/15/24.

On 2/25/25 at 4:08 PM, Surveyor interviewed LPN F (Licensed Practical Nurse) and asked how the facility communicates with hospice. LPN F stated resident's receiving hospice services have a hospice binder for information to be kept. LPN F stated that there is not a facility contact person for hospice; all the nurses communicate with hospice as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 31 525445 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 On 2/26/25, at 9:00 AM, Surveyor asked LPN F for Resident R7's hospice plan of care. LPN F stated she was unable to locate Resident R7's binder in the nurse's station cupboard and stated that each hospice patient is handled Level of Harm - Minimal harm or differently. potential for actual harm

On 2/26/25 at 9:02 AM, Surveyor asked RN D (Registered Nurse) for Resident R7's hospice plan of care. RN D stated Residents Affected - Few that RN D was unable to locate Resident R7's binder in the nurse's station cupboard. Surveyor asked RN D how the facility gets information from hospice. RN D stated Resident R7's provider faxes new orders to the facility. Surveyor asked how the facility receives visit notes. RN D stated Resident R7's hospice provider doesn't necessarily send visit notes to the facility. Surveyor asked if there is a facility contact person for hospice coordination. RN D said there is no one person; all the nurses contact hospice as needed. RN D requested assist from DON B (Director of Nursing) with locating the binder. DON B was able to locate the binder in the nurse's station cupboard and provide to surveyor. Binder included information for multiple residents receiving services from (provider name) hospice. Resident 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 Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 31 525445 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38725 potential for actual harm Based on observation, interview and, record review, the facility did not establish and maintain an infection Residents Affected - Many prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. This has the potential to affect the census (38).

The facility is not monitoring the temperature of 3 of their 5 water heaters as part of their control measures for Water Management Program.

The facility's policy and procedure for Pneumococcal Vaccine is not up to date.

A breach in infection control was observed with Resident R236, Resident R16, Resident R7, and Resident R22.

This is evidenced by:

Example 1

Per Centers for Disease Control and Prevention (CDC), 3/15/24 documents, in part: .Cold water guidance: Store and circulate cold water at temperatures below 77 F, although Legionella may grow at temperatures as low as 68 F (20 C). Hot water guidance: Store hot water at temperatures above 140 F (60 C). Ensure hot water in circulation doesn't fall below 120 F (49 C) and recirculate hot water continuously, if possible .

The Facilities Water Management Program dated as reviewed 1/21/25 documents in part: Description of Building Water System .Cold water is heated to 140 degrees by two joined 120-gallon water heaters in the water heater utility room that serves shower and faucet fixtures in room on all three wings. Cold water is also delivered to a 120-gallon water heater in the water heater utility room that serves the kitchen. Cold water is also delivered to an 80-gallon water heater in the 300-wing janitor closet that serves the 300-wing spa. Cold water is also delivered to an 80-gallon water heater in the laundry room that serves the laundry room .

Logbook Documentation from 2025 includes the following, in part:

1/9/25- Laundry= 155.1 degrees, Kitchen= 147.1 degrees, 300 Spa= out of order, mixing valve temp= 132 degrees

1/15/25- Laundry= 155 degrees, Kitchen= 147.7 degrees, 300 Spa= closed for repairs, mixing valve temp= 131 degrees

1/24/25- Laundry= 150 degrees, Kitchen= 147.2 degrees, 300 Spa= out of order, mixing valve temp= 132 degrees

1/29/25- Laundry= 151 degrees, Kitchen= 146.2 degrees, 300 Spa= out of order, mixing valve temp= 131 degrees

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 31 525445 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 2/6/25- Laundry= 155 degrees, Kitchen= 145 degrees, 300 Spa= 112.1, mixing valve temp= 130 degrees

Level of Harm - Minimal harm or 2/13/25- Laundry= 150 degrees, Kitchen= 147.5 degrees, 300 Spa= 113.1, mixing valve temp= 133 degrees potential for actual harm 2/20/25- Laundry= 155 degrees, Kitchen= 146 degrees, 300 Spa= 113.2, mixing valve temp= 131 degrees Residents Affected - Many

On 2/26/25 at 10:19 AM, Surveyor interviewed Maintenance K. Surveyor asked Maintenance K what control measures are being monitoring routinely to prevent Legionella, Maintenance K said weekly water temperatures. Surveyor asked Maintenance K are the temperatures of the water heaters being check regularly, Maintenance K stated yes technically, the laundry and kitchen each have their own and the rest of

the building runs off of 3 other water heaters. Surveyor asked Maintenance K what those water heaters would be labeled on the temperature documentation received, Maintenance K said kitchen, laundry, mixing valve (has 2 water heaters) and the 300 spa (has 1 water heater). Surveyor asked Maintenance K if the temperatures recorded for the mixing valve and the 300 spa were at the water heaters themselves, Maintenance K replied no, those are not, the kitchen and laundry are. Surveyor asked Maintenance K what temperature water must heat to in order to prevent Legionella, Maintenance K stated, Minimum 130 degrees or is it 116 degrees.

Of note, 140 degrees is the temperature required to prevent Legionella.

On 2/26/25 at 3:28 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A would you expect the control measures for your Water Management Program to be documented, NHA A stated yes.

Example 2

The CDC's Pneumococcal Vaccine Recommendations dated 10/26/24 documents in part: .CDC recommends pneumococcal vaccination for children younger than 5 years and adults [AGE] years or older .

The Facilities Policy and Procedure entitled Pneumococcal Vaccine

F-F883 dated 10/24, documents in part: . Pneumococcal Vaccine Schedule for Adults greater than or equal to [AGE] years old .

On 2/26/25 at 3:31 PM, Surveyor interviewed DON/IP B (Director of Nursing/Infection Preventionist). Surveyor asked DON/IP B do you know the current guidance for pneumococcal vaccine, DON/IP B stated there's the Prevnar 13, Pneumovax 23, and Pneumococcal conjugate 20 for adults over [AGE] years old. Surveyor asked DON/IP B if she is aware of any new guidance after the new addition of the newest vaccine, DON/IP B said not that I am aware of.

49434

Example 3

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 31 525445 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 2/25/25 at 1:27 PM, Surveyor observed CNA J (Certified Nursing Assistant) performing Peri Care for Resident R236. Resident R236 was on a toilet at the start of the process. CNA J performed hand hygiene and donned gloves. Level of Harm - Minimal harm or CNA J then assisted Resident R236 into a standing position and ensured resident safety while standing. CNA J then potential for actual harm wiped the perineal area from front to back with several clean wipes. After CNA J, had finished cleaning the resident, she pulled Resident R236's brief and pants up without cleaning her hands or changing gloves. After the Residents Affected - Many resident's clothes were adjusted, CNA J then removed her gloves and performed hand hygiene.

On 2/25/25 at 1:35 PM, Surveyor interviewed CNA J. Surveyor asked CNA J if hand hygiene should be performed before touching the resident's clothes after performing peri-care. CNA J, states yes.

50228

Example 4

On 2/24/25 at 11:21 AM, Surveyor observed CNA G (Certified Nursing Assistant) assisting Resident R16 with pericare. During this observation, CNA G performed pericare for Resident R16's front, turned Resident R16 to the side touching Resident R16's bed linens and clothing, touched the wipes package and obtained more wipes, performed pericare for Resident 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 Resident 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 Resident R7's front, turned the Resident R7 to the side touching Resident R7's bed linens and clothing, touched the wipes package and obtained more wipes, then performed pericare for Resident R7's backside. Resident R7 complained of discomfort to Resident 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 Resident R7's bed, opened Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 31 525445 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 2/26/25 at 10:22 AM, Surveyor interviewed DON B 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 Level of Harm - Minimal harm or site, and when task is complete. Surveyor asked if resident's clothing, linens, supplies, and walkie talkie potential for actual harm should be touched without hand hygiene. DON B stated no. Surveyor asked if the floor is considered contaminated. DON B stated yes. Surveyor asked if a transfer sling should be placed on the floor. DON B Residents Affected - Many stated no.

Example 6

On 2/26/25 at 11:37 AM, Surveyor observed CNA I assisting Resident R22 with pericare. During this observation, CNA I performed pericare, then CNA I removed one glove, touched the box of gloves with the gloved hand and removed a new glove with the ungloved hand, then applied the new glove to the gloveless hand with the gloved hand. CNA I then assisted Resident R22 with adjusting clothing and transferred Resident R22 to the wheelchair with use of the mechanical sit to stand device. Resident R22 removed both gloves and attempted to cleanse hands with hand sanitizer mounted to the wall in Resident R22's room. CNA I stated the sanitizer was empty. CNA I opened Resident R22's bedroom door, pushed the mechanical device out of the room, and asked Surveyor if anything else was needed before going on to the next resident. Surveyor interviewed CNA I about infection control. CNA I stated that gloves are contaminated after performing pericare and should be removed and hands cleansed prior to touching resident items. Surveyor asked if hand sanitizer is not available is there another option for hand hygiene. CNA I stated hand hygiene 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 31 525445