The Reutlinger Community

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of four sampled Residents (Resident 1) adequate notice of Medicare Non-Coverage. This failure had the potential to negatively impact Resident 1's right to an appeal process. During record review of Resident 1's admission record, printed on 5/21/26, Resident 1 was admitted on [DATE]. During record review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care), dated 4/14/26, indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool used to assess mental status) score was 15 out of 15, which indicated Resident 1's cognition was intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled Residents (Resident 1) had complete and accurate documentation recorded in the electronic health record regarding the Notice of Medicare Non-Coverage (NOMNC) document. This failure had the potential to negatively impact Resident 1's right to an appeal process. During record review of Resident 1's admission record, printed on 5/21/26, Resident 1 was admitted on [DATE]. During record review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care) dated 4/14/26, indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool used to assess mental status) score was 15 out of 15, and indicated Resident 1's cognition was intact. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to report an injury of unknown origin for one of three sampled Residents (Resident 1) in a timely manner when Resident 1's left middle fingernail came off on 3/6/26, and no staff knew what had caused it. This failure placed Resident 1 at risk of continued injury, as the lack of timely reporting could delay the investigation and the implementation of necessary protective measures. A review of Resident 1's Face Sheet (FS, a summary document in a resident's medical record that contains key identifying and administrative information), printed on 4/2/26, indicated Resident 1 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for Resident 1 to assess and maintain psychosocial well-being. This failure had the potential to negatively impact Resident's safety, psychosocial well-being and quality of life. During a record review of admission record, printed on 1/13/26, Resident 1 was admitted on [DATE]. During a record review of Resident 1's Minimum Data Set (MDS, an assessment used to guide care), dated 9/23/25, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 3 out of 15, which indicated Resident 1's cognition was severely impaired. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the Facility Assessment Tool (a document with facility-wide assessment to determine what resources are necessary to care for its residents competently during day-to-day operations), prior to accepting one of three sampled residents (Resident 1) at the facility. Facility did not ensure a Registered Nurse (RN) was available to care for Resident 1, who required continuous Antibiotic Intravenous Therapy (IV ATB- administration of antibiotic medications directly into the bloodstream through a vein to treat infection) for a period of three weeks. This failure resulted in Resident 1 to experience discomfort, frustration; an unplanned, and an avoidable discharge back to the hospital after three (3) days of being at the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete annual performance review and maintain competency/skills records for 17 of 17 sampled Licensed Nurses (LN's). A licensed nurse is a healthcare professional who has met requirements by state board of nursing to practice nursing skills within defined scope. This failure placed residents residing at the facility at risk to receive care from incompetent LN's.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Drug Regimen Reviews (DRR- review of all medications the residents were using in order to optimize therapy, identify any potential drug reactions, ineffective drug therapy or duplicate drug therapy) by the Consultant Pharmacist (CP, a pharmacist with specialized training to review safety aspects of medication use) were acted upon on a monthly basis for two of four sampled residents (Residents 4 and Resident 34). This failure had the potential to result in not addressing medication safety irregularities in a timely manner and/or help optimize the drug therapy for Resident 4 and Resident 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store drugs for one out of 12 sampled Residents (Resident 18). These failures had the potential for Resident 18 to take expired, less effective and discontinued medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to intervene for one of the sampled residents (Resident 34), when his dentures were not fitting properly for over a month. This failure resulted in Resident 34 feeling frustrated, awful, and placed him at risk for unintended weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the therapeutic diet ordered by the physician were followed for two of four sampled residents (Resident 7 and Resident 35) during a dining observation when: 1. Resident 35, who was on mechanical soft diet (a texture-modified diet that consists of foods that are easy to chew and swallow) with ground meats received a piece of meat, not in bite size as indicated on the meal ticket. 2. Resident 7, who was on a mechanical soft diet received a regular texture of snap peas vegetable. This failure had the potential for Resident 7 and Resident 35 to choke and/or aspirate (inhalation of a foreign object into the airway or lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared under sanitary conditions when: 1. Freezer had plant-based patties that were soft to touch and had beyond use date. 2. A tabletop can opener had brownish matter. 3. There was black matter on the ice sweep part of the residents' ice machine. These failures had potential to put residents at risk for food borne illness and cross-contamination (transfer of bacteria or other microorganisms from one substance to another) that could result in infection or spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 7) was treated with respect and dignity when Resident 7 was not promptly assisted during lunch on 11/18/24. This failure had the potential to affect Resident 7's psychosocial well-being and nutritional needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure completion of a physician ' s order of stat (immediate) lab draw for one of the residents (Resident 1) for eight hours. This failure resulted in Resident 1 having a delay in the completion of a physician ' s order of stat blood draw which potentially impacted Resident 1 ' s treatment and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide accurate patient records when one resident (Resident 1) was transferred to a hospital. This failure resulted in Resident 1 not having the correct records at the hospital which potentially delayed identification and treatment.

Inspectors wroteBased on interview and record review, the facility failed to notify one resident ' s (Resident 1) emergency contact family member of a Covid outbreak at the facility. This failure resulted in Resident 1 ' s family member not receiving Covid exposure status of Resident 1. Resident 1 subsequently tested Covid positive and was hospitalized .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food storage and preparation when: 1. Frozen fish products were stored on the same level as frozen poultry products. 2. Staff did not perform hand hygiene when switching between tasks. 3. Personal items were stored in the dried food storage area. These failures placed residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, for two of two sampled residents (Resident 22 and Resident 7), the facility failed to implement infection prevention and control practices when: 1. Licensed Vocational Nurse 2 (LVN 2) did not wear gloves prior to Resident 22's eye drop administration to both eyes. 2. LVN 1 did not perform hand hygiene and glove changes on two occasions; did not set up a clean area for the treatment supplies; did not sanitize reusable scissors after use; and did not dispose and/or sanitize contaminated supplies after performing Resident 7's wound care to top of head, right heel, and left heel. These failures created a risk for cross-contamination (transfer of bacteria or other microorganisms from one substance to another) that could result in infection or spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility stored 37 of 37 vials of various vaccines in an unlocked refrigerator with no method of monitoring temperature control, comingled with staff food items, and in a shared office with the social worker (SW) who was not a nurse, and was not licensed to have access to vaccines. These failures had the potential for the medications to become ineffective, contaminated, or diverted for unauthorized use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow food service safety measures by: 1. Cooking staff did not wash hands between glove changes during tray line service. 2. Ice machine filters had layers of gray particulate matter. 3. The nursing station ice machine drip tray had layers of foreign substances. These failures placed residents at risk to acquire food borne illness and infection.

Inspectors wroteBased on observation, interview and record review, for one (Resident 5) of four residents with pressure ulcers (A pressure ulcer develops when one or more layers of skin and tissue are damaged as a result of continuous pressure to the area.), the facility failed to follow Resident 5's care plan to turn and reposition to avoid further breakdown of Resident 5's Stage II pressure injury. This failure had the potential for Resident 5's Stage II pressure ulcers to worsen.

Inspectors wroteBased on interview and record review, nursing staff did not have readily accessible information for the treatment decisions documented in the Physician Order for Life-Sustaining Treatment (POLST, an approach to end-of-life planning where patients choose what treatments they do or do not want and their wishes are documented as physician orders) for one (Resident 201) of six sampled residents with POLST orders. For Resident 201, the failure to include her POLST in her medical record had the potential to result in provision of unwanted resuscitation (treatment to restore breathing and/or circulation) if her breathing and heart were to cease functioning.