The Reutlinger Community

In the surveyor’s words

From the most serious findings on record at The Reutlinger Community, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF726Nov 21, 2024

  Based 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. Findings: During a concurrent interview and record review with Director of Staff Development (DSD) on 11/20/24, at 12:17 p.m., an untitled, undated facility's document with facility's active employee names, date of hire, job title, employee ID was reviewed. […]

• No harm, potential for more than minimal, patternF756Nov 21, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF761Nov 21, 2024

  Based 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. Findings: During a review of Resident 18's Admission Record, printed [DATE], indicated, Resident 18 was admitted to the facility in 2024 with multiple diagnosis which included, Pneumonitis (swelling and irritation of lung tissue) due to inhalation of food and vomit, and Type 2 diabetes mellitus (a long-term disease in which the body cannot regulate the amount of sugar in the blood) with diabetic chronic kidney disease (when diabetes damages the kidneys, causing them to filter waste less effectively). […]

• No harm, potential for more than minimal, patternF790Nov 21, 2024

  Based 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. Findings: During a review of Resident 34's Admission Record (a document used to communicate basic information about a resident) printed on 11/20/24, the record indicated Resident 34 was admitted to the facility on [DATE] and was readmitted on [DATE]. A review of Resident 34's Minimum Data Set (MDS, an assessment used to plan care), dated 11/8/24, indicated, Resident 34 was able to understand others and was able to make himself understood. […]

• No harm, potential for more than minimal, patternF808Nov 21, 2024

  Based 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). Findings: 1. […]