Inspection Reports for The Reutlinger Community

The visit was an unannounced case management inspection conducted in response to an incident report received on 2025-08-05 regarding a resident eloping from the facility.

The inspection found that a resident (R1) eloped from the facility unassisted after a staff member disabled the wander guard alarm, mistakenly believing the resident was being picked up by family. The resident was located unharmed and moved to memory care. A deficiency was cited for failure to maintain competent staffing and adequate safety measures.

The visit was triggered by a complaint incident report about a resident eloping. The deficiency was substantiated and cited under California Code of Regulation, Title 22.

The visit was an unannounced case management inspection conducted in response to an incident report received on 2025-06-20 regarding a resident taking another resident's medications.

The investigation found that resident R1 took resident R2's medications, and the facility failed to administer the correct medications, posing a potential health and safety risk. The resident was monitored for three days with no ill effects observed. The facility provided additional training to the medication technician and held meetings with residents, family, and staff about medication administration and regulatory requirements.

The visit was triggered by a complaint/incident report received on 2025-06-20 concerning a resident taking another resident's medications. The resident was monitored for adverse effects and none were observed. The medication technician received additional training. The deficiency was cited and a plan of correction was required.

The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.

The facility was toured and inspected with no deficiencies cited. All safety equipment was operational, environmental conditions were adequate, and records for residents and staff were reviewed and found compliant.

The visit was an unannounced case management inspection conducted due to receiving an eviction notification for resident R1.

No deficiencies were cited during the visit. The Executive Director explained that the eviction notice was issued because the facility could not meet R1's needs without agreement from the responsible party on medication adjustments and care changes.

The visit was conducted as a case management investigation due to a self-report of suspected verbal abuse of a resident by staff.

The facility and Licensing Program Analyst were unable to confirm any verbal abuse by staff towards the resident. The resident was hard of hearing and unable to identify the staff involved. No deficiencies were cited.

The complaint involved a resident alleging verbal abuse by staff. The resident could not identify the staff member, and interviews with other residents and staff did not substantiate the claim. The resident has a history of making false claims against caregivers.

The visit was conducted due to a self-report of suspected abuse involving a resident who fell in their room and caregivers not appropriately assessing the situation.

The investigation found that staff member S1 promptly checked on the resident after the fall but failed to wake the resident for a full assessment. Both staff members S1 and S2 received verbal warnings and additional training. No deficiencies were cited at this time.

The complaint involved a resident fall on 03/03/2025 with delayed injury discovery. Staff S1 and S2 were suspended pending investigation and received verbal warnings and in-service training. The resident is currently back at the facility and in physical therapy.

The visit was an unannounced complaint investigation conducted in response to allegations received on 07/18/2024 regarding staff mistreatment of a resident and prevention of resident access to food.

The investigation found no substantiated evidence to support the allegations. Interviews with staff and review of records did not confirm the claims, and no deficiencies were cited during the visit.

The complaint was unsubstantiated. Allegations included staff mistreating a resident and preventing access to food. Interviews with staff raised credibility concerns, and no evidence was found in resident charts or incident reports. Residents could not be interviewed due to dementia and memory care status.

The inspection was an unannounced continuation of the 1-Year Annual Required inspection to assess compliance with licensing requirements.

The Licensing Program Analyst toured the facility with the Skilled Nursing Administrator and found adequate lighting, appropriate temperatures, proper food supplies, and secured medications. No deficiencies were cited during the visit.

The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.

No deficiencies were cited during the visit. The inspection was not complete and will be continued at a later date. Fire clearance was approved, smoke detectors and sprinklers were observed, and staff training was current.

An unannounced complaint investigation was conducted in response to allegations that staff violated residents' personal rights by not allowing visitors.

The investigation found the allegations substantiated based on interviews and documentation showing that the Executive Director temporarily suspended a visitor's visitation rights due to harassment, which posed a potential personal rights risk to residents.

The complaint was substantiated. The allegation was that staff violated residents' personal rights by not allowing visitors. The Executive Director temporarily suspended a visitor's visitation rights due to harassment.

The visit was an unannounced case management inspection conducted in response to incident reports received on 11/17/2023, 11/29/2023, and 12/11/2023 involving medication errors and resident-staff interactions.

The inspection found that a resident was given incorrect medication due to a mix-up involving another resident's medication in food, resulting in a technical violation. Additional incidents involved staff yelling at a resident and a resident choking a visitor; appropriate staff training and reassignment were implemented, and no ill effects were noted for the residents involved.

The visit was complaint-related based on incident reports involving medication errors and resident-staff interactions. The medication error incident was substantiated with corrective actions taken including staff training and labeling improvements. Staff yelling incident resulted in reassignment and training. The choking incident involved a resident on hospice with dementia and was managed with care plan review and visitor notification.

The inspection visit was an unannounced complaint investigation triggered by allegations received on 01/25/2022 concerning staffing levels, caregiver to resident ratios, administrator performance, and planned activities at the facility.

The investigation involved record reviews, interviews, and document collection. The allegations were found to be unsubstantiated due to lack of preponderance of evidence, with findings showing efforts to maintain staffing, communication during COVID-19, and activities delivered during isolation.

The complaint involved multiple allegations including insufficient staffing levels, false claims about caregiver to resident ratios, inadequate administrator duties, and failure to carry out planned activities. The investigation concluded all allegations were unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 08/24/2022 regarding resident injury, medical attention delays, staffing issues, financial crisis, food service adequacy, and response to family council concerns.

The investigation found that the resident injury occurred but first aid was provided and the resident was hospitalized and later transferred to skilled nursing. Staffing was generally adequate according to resident interviews. The facility is experiencing a financial crisis linked to occupancy decline due to COVID-19 restrictions. Food service was reported adequate by most residents. The facility's response to family council concerns was timely. All allegations were ultimately unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included resident injury, failure to seek timely medical attention, insufficient staffing, financial crisis, inadequate food service, and delayed response to family council concerns. Evidence did not prove violations occurred.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-03-23 alleging improper incontinence care, unkempt facility conditions, inadequate meals, and questionable death.

The investigation found no substantiated violations. Staff interviews and observations confirmed residents received proper incontinence care, the facility was sanitary and well kept, residents were provided adequate meals, and the questionable death allegation was unfounded based on review of hospice care and death certificate.

The complaint was unsubstantiated or unfounded for all allegations including improper incontinence care, unkempt facility, inadequate meals, and questionable death.

Unannounced 1-Year Annual Required visit to evaluate facility compliance with licensing regulations.

The facility was found to be in compliance with no deficiencies cited. Safety measures, staff training, resident records, and environmental conditions met regulatory standards.

The visit was an unannounced Case Management inspection conducted following multiple incident reports submitted to the Community Care Licensing Division (CCLD). The purpose was to investigate incidents involving resident care and staff conduct.

The investigation reviewed multiple incidents including a resident with low oxygen levels, allegations of rough handling by staff, and multiple reports concerning a staff member accused of causing bruising and skin tears to residents. An internal investigation was conducted, resulting in suspension and reassignment of staff. No deficiencies were cited during the visit.

The visit was complaint-related, triggered by multiple incident reports involving resident injuries and staff conduct. The internal investigation of one staff member was terminated without determination of substantiation. The licensing analysts requested submission of the internal investigation report by 09/08/2023.

An unannounced complaint investigation was conducted in response to an allegation that facility staff were interfering with resident sleeping by slamming doors in the middle of the night.

The investigation included interviews with staff and residents. Four residents stated that staff do not disturb residents during their sleep. There was insufficient evidence to prove the allegation, so it was determined to be unsubstantiated.

The complaint alleged that facility staff were interfering with resident sleeping by slamming doors at night. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced complaint investigation conducted due to an allegation that the facility was not preventing the spread of COVID-19.

The investigation included interviews with staff and residents and a review of the facility's COVID-19 mitigation plan. Staff reported that COVID-19 positive residents were isolated in private rooms and redirected from common areas. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that the facility was not preventing the spread of COVID-19. The allegation was unsubstantiated after investigation.

An unannounced case management visit was conducted as a result of receiving residents from Grand Lake Gardens (GLG) and to check on residents.

Adequate food, paper, and PPE supplies were observed, staffing was stable, and there were no imminent health or safety concerns on the date of the visit.

The visit was an unannounced case management visit conducted as a result of receiving residents from Grand Lake Gardens and to check on residents.

During the visit, the Licensing Program Analyst met with residents and staff, observed adequate supplies and stable staffing, and found no imminent health or safety concerns.

An unannounced complaint investigation was conducted in response to an allegation that residents' care plans were increased without an updated plan.

The investigation found that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur, resulting in the allegation being unsubstantiated.

The complaint alleged that residents' care plans were increased without an updated plan. The investigation included interviews and record reviews, and concluded the allegation was unsubstantiated.

An unannounced complaint investigation was conducted in response to allegations received on 10/02/2020 regarding rough handling of a resident during COVID testing and violation of resident's personal rights.

The investigation included interviews with residents and staff and review of resident files. Findings indicated that staff used a shorter swab to minimize discomfort and residents did not report bad experiences. There was no preponderance of evidence to substantiate the allegations, and the complaint was determined to be unsubstantiated.

The complaint was unsubstantiated due to lack of sufficient evidence to prove the alleged violations occurred.

The inspection was conducted as an unannounced complaint investigation following a complaint alleging that the facility was not taking precautions to mitigate risks of spreading COVID-19.

The investigation found that the complaint was unfounded; the facility was not responsible for the valet parking service infection control issues, and no evidence supported the allegation that the facility failed to mitigate COVID-19 risks.

The complaint alleged that the facility was not taking precautions to mitigate risks of spreading COVID-19. The complaint was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.

The visit was an unannounced Infection Control Inspection conducted as a required one-year routine inspection.

The facility was found to have adequate infection control measures including proper PPE use, sufficient food supply, visitor screening policies, and posted hygiene protocols. No deficiencies were cited during the visit.

The visit was a Case Management call conducted by telephone due to the State's shelter in place order, discussing an Incident Report involving two residents.

The Licensing Program Analyst learned that the facility appropriately intervened in the incident and separated the two residents involved.

The inspection was an unannounced complaint investigation visit conducted due to a complaint received on 2020-10-21 regarding failure to adhere to local infectious disease control and failure to report to the Responsible Party.

The complaint regarding failure to adhere to local infectious disease control was substantiated based on interviews and photographic evidence showing staff not properly wearing face coverings. The complaint regarding failure to report to the Responsible Party about COVID-positive individuals was found to be unfounded based on interviews and documentation provided by the facility.

The complaint investigation was substantiated for failure to adhere to infectious disease control due to improper mask use by staff. The complaint regarding failure to report to the Responsible Party about COVID-positive individuals was unfounded.