The September 29 incident at Rennes Health and Rehab Center-Rhinelander involved a resident with intact mental capacity who had been admitted with multiple serious conditions including chronic obstructive pulmonary disease, bipolar disorder with moderate depression, and COVID-19 respiratory disease.
When federal inspectors asked Nursing Home Administrator A on October 2 about incidents requiring investigation, the administrator initially deflected. "If it is reportable then it would be obviously reportable," Administrator A told the surveyor.
Pressed again about unreported incidents, Administrator A claimed any such matters "would be considered in our Quality Assurance QI department for PIPs and that it is confidential."
The resident, identified as R1 in inspection documents, had been admitted with diagnoses including left bundle branch block, urinary tract infection, chronic kidney disease, anxiety, insomnia, peptic ulcer, benign prostatic hyperplasia, and artificial right hip and knee joints. A September 5 assessment showed the resident had a Brief Interview for Mental Status score of 14, indicating intact cognition.
The resident required partial to moderate assistance with bathing and shower transfers.
Director of Nursing B revealed the cover-up during a separate interview with inspectors the same day. The nursing director explained the facility's process for managing incidents like falls and medication errors through a binder system, daily meetings, and new interventions.
But then Director of Nursing B disclosed that Administrator A and Assistant Director of Nursing C "have been working on an incident with R1 and the spa room from 09/29/25 where R1 was left unsupervised and found unresponsive."
The nursing director led the surveyor directly to Administrator A's office to examine investigation documents.
In that confrontation, with the nursing director, administrator, and regional resource staff present, the surveyor asked Administrator A directly why the incident hadn't been reported to the state's Office of Caregiver Quality.
Administrator A's response revealed a fundamental misunderstanding of reporting requirements.
"Through investigation NHA A found there was no willful intent and did not report the incident pertaining to R1 being left in the spa room unsupervised and becoming unresponsive requiring EMS transport to a higher level of care," inspectors documented.
Administrator A told the surveyor: "I did not feel it was necessary to report the incident, therefore I did not."
The facility's own policy, titled "Abuse Prevention" and reviewed on November 23, 2016, requires immediate reporting of all alleged violations involving mistreatment, neglect, or abuse to both facility administration and the Division of Quality Assurance.
The policy defines neglect as "failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."
Federal regulations define "immediately" as "as soon as possible but not to exceed 24 hours after discovery of the incident."
Wisconsin requires nursing homes to report potential misconduct incidents to the Office of Caregiver Quality through the state's Misconduct Incident Reporting system immediately upon learning of such incidents.
The administrator's decision to withhold the report violated both state and federal requirements. The incident involved a resident being left without supervision in a spa room and subsequently found unresponsive, requiring emergency medical services and transport to a higher level of care.
The resident's condition was serious enough to warrant hospital-level treatment, yet the administrator concluded no reporting was necessary based on a personal determination about staff intent.
State inspectors found the facility failed to report one of one potential misconduct incidents to the proper authorities. The violation affected few residents but represented minimal harm or potential for actual harm.
The inspection occurred after a complaint was filed about the facility's practices.
Administrator A's reluctance to discuss incidents with inspectors initially, followed by the revelation that a serious incident had gone unreported for days, highlighted gaps in the facility's compliance with mandatory reporting requirements.
The resident involved had been dealing with multiple serious medical conditions requiring ongoing care and assistance. Being left unsupervised in a spa room represented a clear departure from the level of supervision such a resident would require.
The fact that the resident became unresponsive and required emergency transport suggests the incident had serious consequences that warranted immediate medical attention.
Yet the administrator's investigation focused on determining staff intent rather than recognizing the incident as potential neglect requiring state notification.
The facility's approach of handling the matter internally through quality assurance processes, while keeping it confidential, directly contradicted state reporting requirements designed to ensure proper oversight of resident care.
Director of Nursing B's disclosure to inspectors ultimately exposed the unreported incident, leading to the federal citation for failing to comply with mandatory reporting requirements.
The administrator's statement that the incident didn't feel necessary to report demonstrated a concerning gap in understanding regulatory obligations that exist regardless of personal judgments about staff intentions or incident severity.
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
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