Rennes Health And Rehab Center-rhinelander

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

long? Why was I not given more information about this incident? Surveyor suggested to FM T that FM T should contact hospital to check on Resident R1. On 10/06/25 at 9:03 AM, Surveyor interviewed Registered Nurse (RN) J who was the RN who found Resident R1 in Resident R1's condition in the spa room. Surveyor asked if RN J notified physician on call or Resident R1's emergency contact. RN J reported that RN J did not because in a situation like this Resident R1 is his own person and that we usually just ask the resident, but since Resident R1 was unresponsive that RN J usually just makes that nurse judgement on her own. RN J reported that RN J contacted Emergency Department (ED) Physician S in the ED to report the incident but did not call Resident R1's emergency contact, FM T. On 10/07/25 at 9:45 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked why Resident R1's emergency contact, FM T, was not contacted about the incident on 09/29/25. NHA A reported that NHA A spoke with Resident R1's emergency contact, FM T. Surveyor asked NHA A when NHA A spoke with Resident R1's emergency contact FM T. NHA A reported that NHA A spoke with FM T on 10/03/25 and answered all of FM T's questions. Surveyor asked if NHA A notified FM T that Resident R1 had an incident on 09/29/25 and was transferred to hospital after the incident. NHA A reported that NHA A contacted Resident R1's POA on 10/02/25 which was activated on 10/02/25 in hospital. Surveyor asked NHA A if Resident R1's emergency representative, FM T, was contacted the same day of Resident R1's incident on 09/29/25 at that time. NHA A reported to Surveyor that NHA A does not know if anyone else contacted FM T.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rennes Health and Rehab Center-Rhinelander

1970 Navajo St Rhinelander, WI 54501

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the

interview and record review, the facility did not report 1 of 1 (Resident R1) potential misconduct incidents to the State's Office of Caregiver Quality (OCQ) via the State's Misconduct Incident Reporting (MIR) system immediately upon learning of the incident.Findings include: Facility policy titled, Abuse Prevention, dated reviewed on November 23, 2016, states in part: .Neglect Definition-Means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.*Facility will immediately report all alleged violations involving mistreatment, neglect, of abuse, including injuries of unknown source to the facility administration and to the Division of Quality Assurance. CMS defines immediately to be as soon as possible but not to exceed 24 hours after discovery of the incident. Resident R1 was admitted to the facility

on [DATE REDACTED] with diagnoses including, in part, chronic obstructive pulmonary disease, left bundle branch block, bipolar disorder with moderate depression, COVID-19 respiratory disease, urinary tract infection, hypertensive chronic kidney disease stage 1-4, epigastric pain chronic, flaccid neuropathic bladder, anxiety, hyperlipidemia, insomnia, peptic ulcer, benign prostatic hyperplasia, right artificial hip and knee joint. Resident R1's Minimum Data Set (MDS) assessment, dated 09/05/25, identified on admission that Resident R1 had a Brief

Interview for Mental Status (BIMS) score of 14. This indicated Resident R1 had intact cognition. The MDS assessment also identified Resident R1 required partial/moderate assist with bathing/showering self. Resident R1 was partial/moderate assist with bathing/shower transfers. On 10/02/25 at 2:25 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked for any type of incidents that require an investigation that may have been reported or were in the process of being reported. NHA A stated to Surveyor, If it is reportable then it would be obviously reportable. Surveyor asked NHA A again if there were any incidents that NHA A is working on that have not been reported. NHA A reported that any of those incidents would be considered in our Quality Assurance QI department for PIPs and that it is confidential. On 10/02/25 at 3:14 PM, Surveyor interviewed Director of Nursing (DON) B and asked if DON B had any other incidents or investigations that DON B is working on. DON B explained DON B's process for managing incidents like falls, med errors, etc. is that they are kept in a binder, reviewed at daily meetings, and then new interventions are implemented. DON B reported to Surveyor that NHA A and Assistant Director of Nursing (ADON) C have been working on an incident with Resident R1 and the spa room from 09/29/25 where Resident R1 was left unsupervised and found unresponsive. DON B and Surveyor then went to NHA A's office for investigation documents. On 10/02/25 at 3:17 PM, Surveyor entered NHA A's office. In attendance were NHA A, DON B, and regional resource staff. Surveyor asked NHA A why Resident R1's incident was not reported to OCQ. NHA A reported to Surveyor that through investigation NHA A found there was no willful intent and did not report

the incident pertaining to Resident R1 being left in the spa room unsupervised and becoming unresponsive requiring EMS transport to a higher level of care. NHA A stated to Surveyor, I did not feel it was necessary to report

the incident, therefore I did not.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rennes Health and Rehab Center-Rhinelander

1970 Navajo St Rhinelander, WI 54501

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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

around 9:15 PM to check crash cart and to ask Resident R1 to please get out of spa bath. RN J stated RN J took CNA Q in the spa room as well. RN J stated RN J could see something was wrong as Resident R1 had his head lying back, shallow breathing, gurgling, and he was not submerged but water was pretty high. RN J stated

she gave Resident R1 a hard sternal rub, checked pulse which was 128, and CNA Q was trying to shake his left arm to wake him up. Resident R1 was unresponsive. RN J stated RN J needed to check to see if he was a full code, so RN J asked CNA Q to stay in spa room with Resident R1. Another nurse called 911. RN J stated they could not get

the water to drain and then noticed washcloths at the bottom of the tub covering the drain. CNA G came in and pulled the washcloths out and stated, The water was very hot. Shortly after that, EMS arrived, and it took 4 guys to get Resident R1 out of tub. Oxygen was then placed on Resident R1 when EMS arrived. On [DATE REDACTED] at 9:27 AM, Surveyor interviewed CNA G and asked what involvement CNA G had with Resident R1's incident on [DATE REDACTED]. CNA G reported he was called to the 100-wing spa. Staff asked CNA G to unplug the spa tub. CNA G reported he stuck his hand and arm in the spa bath and the water was hot. CNA G stated, It was too warm and unpleasant to submerge my hand in, but I needed to get the drain unplugged. I pulled out 4 washcloths.

Surveyor asked CNA G if the drain was closed once the washcloths were pulled up. CNA G reported the drain was open and must have been slow to drain due to the washcloths plugging it. CNA G stated Resident R1 was not responsive, gurgling like secretions were in his airway, and there were 5 different staff members in the spa room at that time standing and watching Resident R1 until CNA G unplugged the drain. Surveyor asked CNA G what Resident R1's skin looked like. CNA G stated, Well I am not good with colors, but kind of like red tinged from chest level down. Surveyor asked if CNA G has ever been trained on the spa usage or how to use the spa controls. CNA G reported he did not receive

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rennes Health and Rehab Center-Rhinelander

1970 Navajo St Rhinelander, WI 54501

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 0919

Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or potential for actual harm

Based on observation and interview the facility did not provide adequate equipment to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member, or to a centralized staff work area, for 1 resident (Resident R1) out of 6 sampled residents. This had the potential to affect all 6 residents. * Resident R1 did not have access to a call light while Resident R1 was left in spa room unsupervised.

Findings include: On 10/02/25 at 10:29 AM, Surveyor observed spa room down 400-wing. Surveyor did not observe a call light in the spa tub room. Surveyor did not observe a call light cord long enough to reach to

the spa tub room from the shower room. On 10/02/25 at 10:36 AM, Surveyor observed spa room down 100-wing. Surveyor did not observe a call light in the spa tub room. Surveyor did not observe a call light cord long enough to reach to the spa tub room from the shower room. On 10/02/25 at 3:14 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B's expectation for call lights in the spa room and staff utilizing the call light. DON B reported that if staff leave a resident in the spa room, DON B would expect that a call light is in reach. Surveyor asked DON B if there was a reachable call light in the spa room.

DON B reported that DON B knows there is one near the shower area. On 10/02/25 at 5:15 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked NHA A if it was facility practice to leave Resident R1 alone in the spa tub. NHA A stated Resident R1 is his own person and can have privacy in the tub. Surveyor asked if NHA A knew there was no call light in the spa tub room. NHA A reported that NHA A was unaware there was no call light in spa room and there are call lights at the vanity and shower in each spa room. NHA A reported to Surveyor that Resident R1's preferences are to be left alone while taking a spa bath. Surveyor asked if Resident R1 was assessed to safely bathe on own in spa room. NHA A reported that Resident R1's preference had not been care planned, but everyone knew that he liked his privacy in spa room. Surveyor asked what the expectation is for staff leaving Resident R1 without a call light in reach. NHA A reported that NHA A didn't realize there was not a call light in reach. On 10/07/25 at 1:23 PM, Surveyor interviewed DON B and NHA A and asked if DON B and NHA A could walk with Surveyor to the 100-wing spa room. Surveyor asked NHA A to show Surveyor where call lights were in the spa room. NHA A grabbed a call light to show Surveyor in the entrance of the spa room. There were 3 call lights located near the vanity, again another about 5 feet and then another near the shower. Surveyor asked if the string to the call lights could reach into the other room where the spa tub is located. NHA A and DON B reported that call light does not reach to the spa tub.

Surveyor asked if there was a call light in the spa room. NHA A reported to Surveyor there was not a call light in the spa room. Surveyor asked why there was not a call light accessible to Resident R1 at the time of the event

on 09/29/25. NHA A stated, I don't know. I didn't build the building.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet