Rennes Health and Rehab Center-De Pere

Inspectors wroteBased on observation, staff, resident, and resident representative interview, and record review, the facility did not ensure a hand splint, a compression sleeve, and passive range of motion (PROM) exercises were provided for 1 resident (R) (R83) of 1 sampled resident. R83's hand splint and compression sleeve were not applied as ordered. In addition, R83 did not receive PROM restorative therapy per therapy discharge recommendations, a physician's order, and R83's plan of care.

Inspectors wroteBased on observation, staff interview and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 3 residents (R) (R145, R21, and R71) of 8 sampled residents. Certified Nursing Assistant (CNA)-G did not wear a gown while emptying R145's catheter bag. In addition, R145 did not have an enhanced barrier precautions (EBP) sign on or near R145's door or a personal protective equipment (PPE) cart outside or near R145's room. CNA-C did not wear a gown while providing Foley catheter care for R21. In addition, R21 did not have an EBP sign on or near R21's door or a PPE cart outside or near R21's room. R71 was on droplet precautions due to a respiratory illness. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure a grievance was documented, thoroughly investigated, or resolved for 1 resident (R) (R1) of 5 sampled residents. R1 and R1's activated Power of Attorney for Healthcare ((POAHC)-C) reported a grievance involving staff. The facility did not document, investigate, resolve, or provide follow-up for the grievance.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure medications for 11 residents (R) (R36, R55, R51, R69, R52, R20, R75, R22, R213, R57, and R88) of 16 residents in 2 of 3 medication carts were stored, labeled, or dated appropriately. The facility also did not ensure expired medications and medical supplies were discarded in 2 of 2 medication storage rooms. Medication carts and storage rooms contained open, undated, and expired medications and medical supplies.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect more than 4 of the 109 residents residing in the facility. The facility did not ensure time/temperature control foods were labeled with open or use-by dates.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for 2 residents (R) (R54 and R317) of 7 sampled residents observed during the provision of cares. During an observation on 9/18/24, Certified Nursing Assistant (CNA)-F and CNA-G did not don gowns prior to the provision of care for R54 who was on enhanced-barrier precautions (EBP). During an observation on 9/16/24, CNA-H and CNA-I did not ensure R317's catheter bag was not in contact with the floor and was below the level of R317's bladder.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a vaccination was re-offered for 1 resident (R) (R18) of 5 sampled residents. R18 was not offered the 20-valent pneumococcal conjugate vaccine (PCV20) since R18 refused the vaccine upon admission on [DATE].

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure fall prevention interventions were implemented for 1 Resident (R) (R5) of 1 resident. R5 had a history of falls with injury at home and in the facility. R5's plan of care contained interventions for a body pillow while in bed and to place R5's wheelchair in an angled position at the foot of the bed. Those interventions were not consistently followed.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 103 residents residing in the facility. The facility did not monitor and document food cooling temperatures. The facility did not ensure time/temperature control foods were labeled with opened or use-by dates.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 5 Residents (R) (R84, R6, R18, R65, and R56) of 24 sampled residents were assessed to safely and accurately self-administer medication. R84 did not have a self-administration of medication assessment or physician order to self-administer Vitamin D 800 units which was observed at R84's bedside. R6 did not have a self-administration of medication assessment or physician order to self-administer Tucks pads and Preparation H ointment which were observed at R6's bedside. R18 did not have a self-administration of medication assessment or physician order to self-administer Vitamin B-12 1000 milligrams (mg) which was observed at R18's bedside. R65 did not have a self-administration of medication assessment or physician order to self-administer Systane eye drops which were observed at R65's bedside. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure all drugs and biologicals were stored in accordance with facility policy for 8 Residents (R) (R84, R6, R18, R14, R31, R60, R65, and R56) of 24 sampled residents. On 8/14/23, Surveyor observed unsecured oral medication at R84's bedside. On 8/14/23, Surveyor observed unsecured and unlabeled non-oral medication at R6's bedside. On 8/14/23, Surveyor observed unsecured and unlabeled oral and non-oral medication at R18's bedside. On 8/14/23, Surveyor observed unsecured non-oral medication with an illegible label at R14's bedside. On 8/14/23, Surveyor observed an unsecured non-oral medication labeled with another resident's name at R31's bedside. On 8/14/23, Surveyor observed unsecured and unlabeled non-oral medications at R60's at bedside. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure an as needed (PRN) psychotropic medication was not utilized more than 14 days unless an alternate duration with rationale was provided for 1 Resident (R) (R29) of 5 residents reviewed for unnecessary medications. The facility did not discontinue R29's PRN alprazolam (an anti-anxiety medication) order after 14 days or obtain an alternate duration with rationale.