Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Reutlinger Community during CMS and state inspections, most recent first.
A resident with stroke-related hemiplegia, dementia, and anxiety experienced multiple unexplained fingernail detachments with significant bleeding, including a completely detached middle fingernail and later bleeding and loss of the index and small fingernails, with blood noted on clothing, in the mouth, and on the opposite hand. CNAs and LVNs observed these injuries and documented bleeding and missing nails, and photos showed progressive loss of fingernails and torn surrounding skin. Despite these being injuries of unknown origin, the administrator acknowledged the first incident was not reported because fingernail loss was viewed as not unusual, and the facility only considered reporting after multiple similar incidents, contrary to its policy requiring immediate reporting of suspected abuse and injuries of unknown source.
A resident with severely impaired cognition and total-assist feeding needs experienced emotional distress when a family representative repeatedly yelled at the resident during a meal, expressing frustration about the resident’s inability to self-feed and then leaving the room angrily. Documentation of an acute change in mental status noted the emotional distress and verbal abuse but indicated that the care plan was not reviewed. The DON reported that no care plan was initiated after the incident because the abuse did not involve staff or another resident, despite facility policy requiring the IDT to develop and revise comprehensive care plans based on identified problems and changes in condition. A psychosocial care plan was only initiated later and addressed psychosocial issues in general terms, without specifically addressing the incident of verbal abuse and the resident’s psychosocial needs related to that event.
A resident who required continuous IV antibiotic therapy following recent spinal surgery was admitted after the DON assured the Admissions Coordinator that the facility could meet the care needs. However, no RN was scheduled for the night shift, leaving only an LVN on duty, who was not permitted to administer IV antibiotics. This resulted in the resident experiencing discomfort and an unplanned discharge back to the hospital after three days, contrary to the facility's assessment tool and admission policy.
The facility failed to complete and maintain competency records for all 17 Licensed Nurses, including LVNs and RNs, as required by their policy. Only wound care competencies were documented, leaving other areas unchecked. The DSD and DON confirmed the absence of comprehensive competency assessments, which are crucial for ensuring safe and competent care for residents.
The facility failed to act on the Consultant Pharmacist's monthly Drug Regimen Reviews for two residents, leading to unaddressed medication safety issues. One resident received Doxycycline without a stop date, and another was given Protonix without a "Do Not Crush" note, contrary to recommendations. The DON did not receive or follow up on the DRR documents from June to October 2024.
A resident's Lantus insulin was found in the medication cart beyond the 28-day usage period, making it expired. The insulin, which was also discontinued, was not destroyed as per facility policy. The resident had multiple diagnoses, including diabetes, and the expired medication posed a risk due to potential reduced effectiveness.
A resident experienced frustration and discomfort due to ill-fitting dentures that were not addressed by the facility for over a month. Despite being at high risk for nutrition and hydration issues, the resident's dental needs were not properly assessed or followed up on by staff, leading to ongoing discomfort and potential health risks.
Two residents on mechanical soft diets received incorrect meal textures, risking choking. A resident received a whole piece of meat instead of ground meat, and another received regular snap peas instead of finely chopped vegetables. Staff failed to check meal trays for accuracy before serving, contrary to facility policy.
The facility failed to maintain sanitary conditions in food storage and preparation. Plant-based patties in the freezer were defrosted and past their use-by date, and a can opener had brownish matter. Additionally, the ice machine used for residents had black matter, potentially contaminating the ice. The Director of Dietary Services acknowledged these issues, which violated the facility's policies and FDA guidelines.
A resident with severe cognitive impairment and nutritional risks was not promptly assisted during a meal, despite facility policies requiring such assistance. Staff interviews revealed a lack of awareness of the resident's needs, leading to a delay in providing necessary help, which could have impacted the resident's nutrition and dignity.
A resident with essential hypertension experienced an eight-hour delay in the completion of a stat blood draw ordered by a physician. The order was placed for a complete blood count, basic metabolic panel, urinalysis, and culture & sensitivity. Despite contacting the lab, no technician was available, and the order was canceled as the resident was taken to the hospital. Interviews revealed that stat labs should be completed within four to six hours, but the facility failed to ensure this timely completion.
A resident was transferred to a hospital with incorrect medical records, as the Unit Manager failed to verify the transfer packet contents. The resident, admitted with a UTI and atrial fibrillation, was lethargic and had low blood pressure when transferred for Covid evaluation. The facility's policy requires accurate information for continuity of care, which was not followed.
A facility failed to notify a resident's family member of a COVID-19 outbreak due to missing email contact information. The resident, with a history of UTI and atrial fibrillation, tested positive for COVID-19 and was hospitalized. Notifications were sent via email, but the family member was not informed as their email was not on file.
Failure to Timely Report Repeated Unexplained Fingernail Injuries
Penalty
Summary
The deficiency involves the facility’s failure to timely report an injury of unknown origin for a resident whose fingernails repeatedly came off without an identified cause. The resident, who had a history of stroke with left-sided hemiplegia, dysphagia, dementia, and anxiety, was admitted in late March and was found on one occasion with the entire left middle fingernail detached, dried blood on the finger, and blood on the nightgown. Staff interviews indicated that a CNA discovered the bleeding finger and blood on the nightgown and immediately notified the charge nurse, who then observed the detached nail on the resident’s chest and dried blood but no active bleeding. Another CNA reported seeing a baseball-sized amount of blood on the resident’s nightgown and did not know what had happened. The unit supervisor acknowledged that the incident, involving a fingernail coming off for an unknown reason, should have been reported as required by policy. Subsequent events showed additional unexplained fingernail injuries that also were not promptly reported as suspected abuse or injury of unknown origin. A picture taken on 3/6/26 showed the middle fingernail missing with a dark blood clot and surrounding redness, while the index fingernail appeared intact; a later picture, taken on an unknown date, showed the index and small fingernails missing with torn surrounding skin. On another date after dinner, an LVN found the resident’s left index finger bleeding, with blood in the resident’s mouth and on the right hand, and later, during a midnight medication round, another LVN noted the left small finger bleeding with the fingernail off. Despite multiple incidents of fingernails coming off without a known cause, the administrator stated that the facility did not initially report the first incident because it was considered not unusual for a resident’s fingernail to come off, and only after multiple incidents did the facility feel it needed to report, contrary to the facility’s abuse and reporting policy requiring immediate reporting of alleged violations, including injuries of unknown source, within two hours.
Failure to Care Plan Psychosocial Needs After Verbal Abuse by Family Representative
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan to assess and maintain the psychosocial well-being of a resident following an incident of verbal abuse by the resident’s family representative. The resident had a severely impaired cognitive status, with a BIMS score of 3/15, and required total assistance with food and fluid intake, with encouragement to self-feed with the left hand. The resident’s physician orders included a pureed diet with mildly thick liquids and 1:1 feeding. On the date of the incident, an acute change in mental status event record documented that the resident was seen tearing up around 6 p.m. while the family representative repeatedly yelled at the resident, expressing frustration that the resident could not feed herself, insisting she use her arms, and stating he was tired of helping her, before storming out of the room visibly angered. The acute change in mental status documentation indicated that the care plan was not reviewed. The DON stated that no care plan was initiated after the verbal abuse was observed because the abuse was not committed by staff or another resident, and acknowledged that there should have been a care plan initiated after the incident to serve as a blueprint for the resident’s care. Although the facility’s policy on the Interdisciplinary Team/Care Plan Process requires that an IDT develop and maintain a comprehensive care plan incorporating identified problem areas, risk factors, and changes in medical condition, the resident’s care plan addressing psychosocial well-being did not start until a later date and only generally stated that the resident had potential for psychosocial issues due to living in the facility. The record review and interviews showed that, despite documented emotional distress and verbal abuse, the facility did not review or revise the care plan at the time of the incident to address the resident’s psychosocial needs related to the event.
Failure to Ensure RN Staffing for Resident Requiring Continuous IV Antibiotic Therapy
Penalty
Summary
The facility failed to follow its Facility Assessment Tool and did not ensure the necessary resources were available to care for a resident requiring continuous intravenous antibiotic therapy (IV ATB) prior to admission. The Admissions Coordinator, after consulting with the Director of Nursing (DON), accepted the resident for admission based on the DON's assurance that the facility could manage the resident's need for continuous IV ATB therapy. However, the facility did not have a Registered Nurse (RN) scheduled to cover the night shift, which was required for the administration and monitoring of IV ATB therapy, as Licensed Vocational Nurses (LVNs) were not permitted to perform this task according to facility policy and scope of practice. The resident, who had recently undergone a third elective spinal surgery with hardware revision and was ordered to receive 12 grams of Ampicillin Sodium Injection intravenously every shift, was admitted to the facility. Despite the resident's complex care needs, the facility's staffing records showed that no RN was present during the night shift, and the DON had approved the staffing schedule. The LVN on duty expressed discomfort with the situation and ultimately requested the resident's physician to transfer the resident back to the hospital due to the inability to provide the required IV therapy. The resident experienced discomfort and frustration as a result of the facility's inability to provide the necessary care, leading to an unplanned and avoidable discharge back to the hospital after only three days. The family was initially assured that the facility could meet the resident's care needs, but was later informed otherwise, causing additional distress. The facility's own policies and assessment tool required that only residents who could be adequately cared for should be admitted, and that an RN should be available each shift to assist with IV therapy, but these requirements were not met in this case.
Failure to Maintain Competency Records for Licensed Nurses
Penalty
Summary
The facility failed to complete annual performance reviews and maintain competency/skills records for all 17 sampled Licensed Nurses (LNs), which included nine Licensed Vocational Nurses (LVNs) and eight Registered Nurses (RNs). During an interview and record review with the Director of Staff Development (DSD), it was revealed that the facility only had competency checks completed for skin and wound care, dated 7/11/24. The DSD was unable to locate any other competency checks for the LNs, despite searching the facility's storage and her office. The facility's policy required competency checks to be conducted upon hiring, after 90 days, and annually, to ensure LNs possess the necessary skills and knowledge to provide competent care. The Director of Nursing (DON) confirmed that no competency/skills assessments had been completed for any LNs in the past year. The facility's policy, titled 'Competency of Nursing Staff,' emphasized the importance of ensuring all nursing staff possess the competencies and skill sets necessary to meet resident needs safely and promote their well-being. The lack of completed competency checks placed residents at risk of receiving care from potentially incompetent LNs, as acknowledged by the DSD.
Failure to Implement Consultant Pharmacist's Recommendations
Penalty
Summary
The facility failed to ensure that Drug Regimen Reviews (DRR) by the Consultant Pharmacist (CP) were acted upon on a monthly basis for two residents. The DRR binder did not include the CP's monthly recommendations for several months, from June through October 2024. The Director of Nursing (DON) stated she did not receive these documents from the CP, although the CP claimed they were emailed to both the DON and the Administrator. The CP noted that some recommendations were not addressed, requiring repeated reminders. For Resident 4, the DRR for August and September 2024 indicated that the resident was receiving Doxycycline for a chronic right arm infection without a specified stop date, which is necessary under the Antibiotic Stewardship program guidelines. The order summary for Resident 4 showed an active status for the medication without an end date, which could lead to continuous administration and potential side effects. The DON acknowledged the importance of reviewing the DRR monthly to ensure correct medication indications and special instructions. For Resident 34, the DRR for the same months highlighted that the resident was receiving Protonix, a long-acting medication that should not be crushed due to its protective enteric coating. However, the order summary did not include a "Do Not Crush" note as recommended by the CP. The DON admitted to an oversight in not following up with the CP when the DRR documents were not received, which led to the failure to implement the CP's recommendations and ensure medication safety for the residents.
Improper Storage of Medications for a Resident
Penalty
Summary
The facility failed to properly store medications for one resident, identified as Resident 18, which had the potential to lead to the administration of expired, less effective, and discontinued medication. During an observation and interview, it was found that the medication cart contained Resident 18's Lantus insulin, which was opened beyond the 28-day period recommended for use, rendering it expired. The Registered Nurse acknowledged that the insulin was expired and should have been destroyed. Resident 18 was admitted to the facility with multiple diagnoses, including pneumonitis and Type 2 diabetes mellitus with diabetic chronic kidney disease. The facility's policy required the destruction of insulin 28 days after opening, and the Assistant Director of Nursing confirmed that expired insulin posed a risk to the resident due to its potential reduced effectiveness. Additionally, a review of Resident 18's doctor's orders revealed that the Lantus insulin had been discontinued, yet it remained in the medication cart, contrary to the facility's policy of not using discontinued or outdated drugs.
Failure to Address Ill-Fitting Dentures
Penalty
Summary
The facility failed to address the issue of ill-fitting dentures for Resident 34, who had been without properly fitting dentures for over a month. Despite being aware of the problem, the facility did not take timely action to resolve it. Resident 34, who was edentulous and on a mechanical soft diet, expressed frustration and discomfort due to the lack of properly fitting dentures. The resident's Minimum Data Set (MDS) assessment indicated a high risk for nutrition and hydration issues related to the ill-fitting dentures, yet the MDS Coordinator did not physically assess the resident's oral cavity or ensure the dentures were fitted correctly. Interviews with staff revealed a lack of communication and follow-up regarding the resident's dental needs. The Social Services Director acknowledged contacting the dentist about the issue but found no documentation of follow-up actions until over a month later. The Director of Nursing stated that staff should address denture-related issues within 72 hours, but this was not done. The facility's policy required timely referrals for dental services, which were not adhered to in this case, leading to the resident's ongoing discomfort and risk for further health issues.
Failure to Follow Therapeutic Diet Orders
Penalty
Summary
The facility failed to ensure that therapeutic diets ordered by the physician were followed for two residents during dining observations. Resident 35, who was on a mechanical soft diet with ground meats, received a piece of meat that was not in bite size as indicated on the meal ticket. The Certified Nurse Assistant (CNA) serving the meal acknowledged that the meat was not prepared according to the diet order and removed the tray for replacement. The Registered Nurse (RN) and Assistant Director of Nursing (ADON) confirmed that the meal tray was not checked for accuracy before being served, which placed Resident 35 at risk for choking. Resident 7, who was also on a mechanical soft diet, received regular texture snap peas instead of finely chopped vegetables as required by the diet order. The CNA feeding Resident 7 was unaware of the need for finely chopped vegetables, despite the meal ticket indicating this requirement. The Director of Dietary Services (DDS) admitted that the meal tickets should have been checked accurately before the trays were placed in the meal delivery cart, and the nursing staff should have verified the meal tickets before serving. The facility's policy and procedure for therapeutic diets and texture alterations require that nursing personnel ensure residents are served the correct diet by checking the diet card before serving. The policy also states that any errors should be reported to the dietary supervisor for correction. However, in these instances, the policies were not followed, leading to the potential risk of choking or aspiration for the residents involved.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to ensure food was stored and prepared under sanitary conditions, as observed during a survey. The kitchen freezer contained a bag of plant-based patties that were soft to touch and had a label indicating they were defrosting with a use-by date that had already passed. The Director of Dietary Services (DDS) confirmed that the patties were completely defrosted, which was against the facility's policy that required frozen foods to be held solidly frozen. Additionally, a tabletop can opener was found with an accumulation of brownish matter, which the DDS acknowledged should have been kept clean. Furthermore, the ice machine used to provide ice for residents had black matter on the ice sweep part, which could potentially contaminate the ice. The DDS admitted that the ice machine should not have had black matter inside, as it could have made the residents sick. The facility's policy and procedure for food and supply storage emphasized the importance of preventing contamination and maintaining the safety and wholesomeness of food for human consumption. The Food and Drug Administration (FDA) Federal Food Code also requires that equipment and utensils be clean to sight and touch.
Failure to Assist Resident During Meal
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 7, was treated with respect and dignity by not providing prompt assistance during a meal. Resident 7, who was admitted in October 2024 with diagnoses including sepsis and metabolic encephalopathy, had a severely impaired mental status as indicated by a BIMS score of 3 out of 15. The resident's care plan noted a risk for nutrition and hydration issues due to chewing and swallowing difficulties, requiring occasional to frequent assistance with feeding. On the day of the incident, Resident 7 was observed sitting with a meal tray but not eating, and it was noted that no staff were assisting her, despite her need for supervision or touching assistance during meals. Interviews with staff revealed that there was a lack of awareness regarding Resident 7's need for assistance. CNA 1, who eventually assisted the resident, was unaware of her requirements, while CNA 6 and the ADON confirmed that Resident 7 needed cueing and prompting to eat. The facility's policy on supervision of resident nutrition emphasized the need for prompt assistance for residents requiring help with eating, which was not adhered to in this case. The Director of Nursing acknowledged that the CNAs should have engaged with Resident 7 to encourage her to eat, as per the facility's policies on necessary care and services for activities of daily living.
Delay in Stat Lab Draw for Resident
Penalty
Summary
The facility failed to ensure the timely completion of a physician's order for a stat blood draw for a resident, resulting in an eight-hour delay. The resident, who was admitted in November 2022 with a diagnosis of essential hypertension, had a physician's order placed on November 16, 2022, at 3:00 p.m. for a stat blood draw to conduct a complete blood count, basic metabolic panel, urinalysis, and culture & sensitivity. However, the laboratory was contacted at 4:18 p.m., and by 11:45 p.m., it was noted that no lab technician was available to perform the draw. The order was eventually canceled at 12:44 a.m. on November 17, 2022, as the resident was taken to the hospital. Interviews with the Director of Nursing and a Licensed Vocational Nurse revealed that stat labs are expected to be completed within four to six hours, and if not done within three hours, the lab should be contacted again to expedite the process. The facility's policy and procedure for diagnostic services, dated May 24, 2013, states that all diagnostic service requests must be ordered by a physician and completed timely. Despite these guidelines, the facility did not ensure the timely completion of the stat lab order, potentially impacting the resident's treatment and well-being.
Failure to Provide Accurate Transfer Records
Penalty
Summary
The facility failed to provide accurate patient records during the transfer of a resident to a hospital. The resident, who was admitted in August 2024 with diagnoses of a urinary tract infection and unspecified atrial fibrillation, was transported to the hospital for further evaluation after testing positive for Covid. At the time of transfer, the resident was lethargic, had poor oral intake, and low blood pressure. However, the transfer packet accompanying the resident contained incorrect information, which was not verified by the Unit Manager before the transfer. The Unit Manager admitted to not checking the contents of the envelope containing the transfer documents, which included an incorrect face sheet. This oversight was discovered when the hospital notified the facility about the incorrect transfer packet. The facility's policy and procedure for transfers, dated October 1999, requires that all pertinent medical and other information be provided to the receiving community to ensure continuity of care. The failure to adhere to this policy resulted in the resident not having the correct records at the hospital, potentially delaying identification and treatment.
Failure to Notify Family of COVID-19 Outbreak
Penalty
Summary
The facility failed to notify a resident's emergency contact family member of a COVID-19 outbreak, resulting in a deficiency. The resident, admitted in August 2024 with a urinary tract infection and unspecified atrial fibrillation, tested positive for COVID-19 and was subsequently hospitalized. During interviews, the Infection Preventionist stated that family notifications were made via mass email, and the Administrator confirmed that the facility used face sheets to obtain email contact information. However, the resident's family member was not notified due to the absence of an email address on file, as the Administrator assumed all family members had email addresses.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Danville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Danville Post-acute Rehab | 5.7 mi | ★★★★★ | 0 | 0 |
| Creekview Skilled Nursing | 7.7 mi | ★★★★★ | 0 | 0 |
| Pleasanton Nursing And Rehabilitation Center | 9.9 mi | ★★★★★ | 11 | 0 |
| Tice Valley Post Acute | 10.7 mi | ★★★★★ | 14 | 0 |
| The Vineyards Healthcare Center | 10.7 mi | ★★★★★ | 2 | 0 |
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