The facility's administrator admitted he didn't know there was no call light accessible to residents using the spa tub rooms, despite allowing staff to leave residents unattended during baths.
When inspectors visited the spa room in the 400-wing on October 2nd, they found no call light in the tub area and no cord long enough to reach from the adjacent shower room. The same problem existed in the 100-wing spa room.
The violation came to light during an investigation of a September 29th incident involving a specific resident who was left unsupervised in the spa room without access to emergency communication.
Director of Nursing B told inspectors that if staff leave a resident in the spa room, she would expect a call light to be within reach. When asked if there was a reachable call light in the spa room, she said she knew there was one near the shower area.
But that wasn't accurate.
Administrator A initially defended the practice, telling inspectors the resident "is his own person and can have privacy in the tub." When asked if he knew there was no call light in the spa tub room, the administrator said he was unaware of the problem.
The administrator explained that this particular resident's preference was to be left alone while taking spa baths. But when inspectors asked if the resident had been assessed for safely bathing alone in the spa room, the administrator admitted the resident's preference "had not been care planned."
"Everyone knew that he liked his privacy in spa room," the administrator told inspectors.
Five days later, inspectors returned with both the administrator and director of nursing for a walkthrough of the 100-wing spa room. The administrator grabbed a call light to demonstrate the system, showing three call lights located near the vanity and shower areas.
When inspectors asked if the call light strings could reach into the separate room where the spa tub was located, both the administrator and nursing director confirmed they could not.
The administrator admitted there was no call light in the spa room itself.
When inspectors asked why there was no accessible call light for the resident during the September 29th incident, the administrator responded: "I don't know. I didn't build the building."
Federal regulations require nursing homes to provide adequate equipment allowing residents to call for staff assistance through communication systems that relay calls directly to staff members or centralized work areas. The violation affected all six residents inspectors sampled, though it specifically endangered the resident who was left unattended.
The spa room setup created a dangerous gap in emergency communication. Residents using the spa tubs were physically separated from call lights by walls and distance, with no way to summon help if they experienced a medical emergency, fall, or other crisis while bathing.
The facility's practice of leaving residents alone in spa tubs without accessible call systems violated basic safety protocols. While the administrator claimed to respect the resident's privacy preferences, the facility failed to conduct proper safety assessments or develop care plans addressing the risks of unsupervised bathing.
The administrator's response to inspectors revealed a troubling lack of awareness about his own facility's safety equipment. His claim that he "didn't build the building" deflected responsibility for ensuring residents had access to emergency communication systems required by federal law.
The inspection found the facility's leadership failed to recognize a fundamental safety hazard that put vulnerable residents at risk during one of the most dangerous activities in nursing homes. Bathroom falls and bathing-related injuries are among the leading causes of serious harm to elderly residents.
The violation received a minimal harm rating, but inspectors noted it had the potential to affect all residents using the spa facilities. Without accessible call lights, any resident left alone in the spa tubs would be unable to summon help in an emergency.
The facility's practice of allowing unsupervised spa baths without proper safety equipment continued until federal inspectors discovered the violation during their October investigation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rennes Health and Rehab Center-rhinelander from 2025-10-13 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Rennes Health and Rehab Center-rhinelander
- Browse all WI nursing home inspections