Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Reunion Plaza Healthcare & Rehabilitation during CMS and state inspections, most recent first.
A resident with GERD, AKI, dorsalgia, hyperkalemia, HLD, DM, and depression had an unplanned hospital transfer, but the chart contained no discharge summary or med reconciliation. The discharge MDS showed the BIMS could not be completed, and the SW, DON, and Administrator all acknowledged that no discharge summary was completed for the resident after the hospital transfer.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve grievances.
A resident who was dependent on staff for all ADLs and had diabetes did not receive complete hygiene care during a bath, as a CNA failed to clean the vaginal folds and feet despite facility policy and training. Staff interviews confirmed that these areas should have been cleaned, and facility policies required thorough perineal and foot care, especially for diabetic residents.
A resident with multiple complex medical conditions did not have their PASRR Level 1 screening or Level II evaluation uploaded to their medical record as required. The MDS Coordinator confirmed the documents were completed and available in the PASRR management system but had not been included in the resident's record, contrary to facility policy.
Missing discharge summary and medication reconciliation
Penalty
Summary
The facility failed to complete a discharge summary and medication reconciliation for a resident who had an unplanned discharge to the hospital. Resident #58 was admitted with diagnoses including GERD without esophagitis, acute kidney failure, dorsalgia, hyperkalemia, hyperlipidemia, diabetes, and depression. The discharge MDS reflected that the resident’s BIMS score was blank because the assessment could not be completed due to difficulty comprehending instructions, and the discharge assessment coded the discharge as unplanned. Record review showed no discharge summary in the resident’s clinical record and no discharge-related information in the care plan. The discharge summary was expected to include a recapitulation of the resident’s stay, a final summary of status, and reconciliation of pre-discharge and post-discharge medications, but none was found for this resident. The facility’s admission and discharge report reflected that the resident was sent to the hospital and discharged from the facility. During interviews, the SW stated she could not locate a discharge summary and reported that the DON was responsible for completing discharge summaries for residents discharged to the hospital. The DON acknowledged that there was not a discharge summary for Resident #58 and stated that discharge summaries were completed for each resident who discharged from the facility. The DON and Administrator both stated that residents sent to the hospital did not have discharge summaries completed at the facility, and the Administrator stated that this had been the practice during his time at the facility. The Administrator also stated that the Social Worker was responsible for discharge summaries except for hospitalizations, and he acknowledged that discharge summaries should be completed for each resident that discharged from the facility.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved in the deficiency.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address and resolve resident grievances in a timely and non-discriminatory manner.
Incomplete Hygiene Care During Bathing
Penalty
Summary
A resident with a history of diabetes, moderate cognitive impairment, and total dependence on staff for activities of daily living was observed not receiving complete hygiene care during a scheduled bath. The resident, who was always incontinent of bowel and bladder, required extensive assistance from two staff members for bathing as per her care plan. During the observed bath, CNA A cleaned the resident's arms, chest, abdomen, peri-area, and legs, but did not clean the vaginal folds or the feet. The CNA stated he did not clean the feet due to the presence of a small diabetic ulcer and did not clean the vaginal folds because the area was tight and he was unable to do so. Interviews with facility staff, including the ADON and DON, confirmed that staff are expected to wash residents' feet and thoroughly clean the vaginal area during bathing, especially for diabetic residents, to maintain hygiene and prevent complications. Facility policies reviewed also required perineal care and washing from head to toe during bathing. The failure to follow these procedures was directly observed and acknowledged by staff, constituting a deficiency in providing necessary services to maintain the resident's hygiene and skin integrity.
Failure to Maintain Complete PASRR Documentation in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not ensuring that the resident's preadmission PASRR Level 1 screening and subsequent evaluations were included in the medical record. Specifically, a review of the resident's electronic medical record revealed that the PASRR Level 1 screening was not uploaded, despite the resident having multiple complex diagnoses, including end stage renal disease, chronic respiratory failure with hypoxia, Type 2 Diabetes, dysphagia, and chronic diastolic heart failure. The absence of the PASRR documentation was confirmed during an interview with the MDS Coordinator, who stated that it was the responsibility of the MDS office to upload the PASRR Level 1 screening into the resident's medical record during admission, using the Simple software system. Further review with the MDS Coordinator confirmed that the PASRR Level 1 screening had been completed and was available in the Simple system, and that a PASRR Level II evaluation had also been completed. However, neither document had been uploaded to the resident's medical record as required by facility policy, which states that all assessments and services must be documented in the resident's medical record in accordance with state law and facility policy, and completed at the time of service or no later than the shift in which the service occurred.
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Illustrative
What surveyors actually found near you
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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 Tyler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Azalea Heights | 1.3 mi | ★★★★★ | 11 | 1 |
| Meadow Lake Health Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Briarcliff Health Center | 1.4 mi | ★★★★★ | 0 | 0 |
| The Heights Of Tyler | 1.5 mi | ★★★★★ | 7 | 0 |
| Providence Park Rehabilitation And Skilled Nursing | 1.8 mi | ★★★★★ | 1 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.