Reo Vista Healthcare Center

In the surveyor’s words

From the most serious findings on record at Reo Vista Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 23, 2026

  Based on observations, interviews, and record reviews, the facility failed to ensure staff provided necessary supervision (1:1 supervision to monitor continuously and not left unattended) according to the care plan to prevent falls for one of six sampled residents (Resident 1) who had a known history of falls, impaired safety awareness, and an identified need for ongoing staff presence to prevent unsafe self-transfers and falls. As a result, Resident 1 fell in her room, sustained bruises to the forehead, facial swelling, and bruising on arms associated with pain. Resident 1 was subsequently transferred to the hospital for medical evaluation and treatment. […]

• Actual harm, isolatedF689Oct 26, 2023

  Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1), who was frail and had cognitive impairment, was free from an avoidable fall with injury when: 1. Certified nursing assistant (CNA) 2 placed Resident 1 in a wheelchair, who was agitated and was left alone unattended, in the hallway around 2 A.M. 2. Resident 1's written care plan was not followed related to locomotion (how the resident moves between locations including self-sufficiency in a wheelchair) that was required to be provided by at least one staff. As a result, Resident 1 fell out of the wheelchair and hit her head on the floor. […]

• Actual harm, isolatedF689May 19, 2023

  Based on observation, interview, and record review, the facility failed to ensure three of three residents (Resident 1, 2, and 3) were transferred (how a resident moved from one surface to another) in a safe manner using the mechanical lift, when: 1. Resident 1 and Resident 2 were transferred from the bed with only one certified nursing assistant (CNA) present to operate the mechanical lift. 2. CNAs transferred Resident 3 from the bed manually without using a mechanical lift. In addition, the facility failed to develop and implement a process that ensured slings (devices a resident sits in that attach to the mechanical lift) were verified to support resident ' s weight and maintained in a safe working order. […]

• No harm, potential for more than minimal, patternF842Apr 17, 2025

  Based on record review and interview, the facility did not maintain a complete Physician Orders for Life Sustaining Treatment (POLST- a medical form used to communicate a resident's wishes during a life-threatening emergency) for eight of 32 residents reviewed for complete and accurate medical records. (Residents 2,15, 45, 57, 58, 59, 245, 111) This failure did not provide an accurate representation of the care provided and had the potential to cause confusion amongst care providers. Findings: 1. […]

• No harm, potential for more than minimal, patternF580Oct 2, 2024

  Based on observation, interview, and record review the facility failed to notify the attending physician and resident representative on four of five residents (Resident 2, 3, 5 and 7) reviewed for changes in condition when: 1. Resident 2 ' s representative was not notified of a wound deterioration. 2. Resident 3 ' s attending physician was not notified of a significant weight loss. 3. Resident 5 ' s attending physician was not notified of a significant weight loss. 4. Resident 7 ' s representative was not notified of a wound deterioration. These failures had the potential for a delay in care in treatment. In addition, the residents ' representatives were not aware of the change in condition. 1. […]