Tyler, TX

Reunion Plaza Healthcare & Rehabilitation

5-star overall rating with 5-star inspections with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

1401 Rice Rd, Tyler, TX

(903) 561-6060

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

99

Certified beds

Average residents

73

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

Southwest Ltc

Operator or chain grouping

Approved since

2001-09-25

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

13 facilities

Chain averages 3 overall / 4 health / 2 staffing / 3 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.35

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.07

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.10

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.52

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.42

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.16

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.15

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.40

CMS adjusted RN staffing hours

Adjusted total hours

3.99

CMS adjusted total nurse staffing hours

Case-mix index

1.21

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

64%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,491

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

4.56

Composite VBP score used to determine payment impact.

Payment multiplier

0.9805

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Performance 21.33% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

0

Baseline 6.79% · Performance 8.88% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

0

Baseline 79.75% · Performance 77.91% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

1.82

Baseline 3.79 hours · Performance 3.60 hours · Measure score 1.82 · Achievement 1.82 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.06%	10.72% 0.3 pts worse	No Different than the National Rate · Eligible stays 79 · Observed rate 12.66% · Lower 95% interval 7.96%
Discharge to community	40.82%	50.57% 9.8 pts worse	No Different than the National Rate · Eligible stays 52 · Observed rate 30.77% · Lower 95% interval 28.88%
Medicare spending per beneficiary	1.03	1.02 About the same
Drug regimen review with follow-up	57.78%	95.27% 37.5 pts worse	Numerator 52 · Denominator 90
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 90
Discharge self-care score	66.67%	53.69% 13 pts better	Numerator 36 · Denominator 54
Discharge mobility score	68.52%	50.94% 17.6 pts better	Numerator 37 · Denominator 54
Pressure ulcers or injuries, new or worsened	3.33%	2.29% 1 pts worse	Numerator 3 · Denominator 90 · Adjusted rate 3.01%
Healthcare-associated infections requiring hospitalization	8.88%	7.12% 1.8 pts worse	No Different than the National Rate · Eligible stays 54 · Observed rate 14.81% · Lower 95% interval 4.92%
Staff COVID-19 vaccination coverage	12%	8.2% 3.8 pts better	Numerator 12 · Denominator 100
Staff flu vaccination coverage	5.26%	42% 36.7 pts worse	Numerator 9 · Denominator 171
Discharge function score	72.22%	56.45% 15.8 pts better	Numerator 39 · Denominator 54
Transfer of health information to provider	98.28%	95.95% 2.3 pts better	Numerator 57 · Denominator 58
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	1.75%	25.2% 23.4 pts worse	Numerator 1 · Denominator 57

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.2	2.1 1.1 pts worse	1.9 1.3 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.4 · Expected 2.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.0	2.1 0.1 pts better	1.8 0.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	97.1% 2.9 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.5%	97.9% 0.6 pts better	95.5% 3 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5%
Percentage of long-stay residents experiencing one or more falls with major injury	3.4%	3.3% 0.1 pts worse	3.3% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.2% · Q3 3.4% · Q4 3.3% · 4Q avg 3.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.5%	2.7% 1.2 pts better	11.4% 9.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.9% · Q3 0.0% · Q4 1.9% · 4Q avg 1.5%
Percentage of long-stay residents who lose too much weight	7.3%	3.3% 4 pts worse	5.4% 1.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 10.4% · Q3 8.5% · Q4 2.2% · 4Q avg 7.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.0%	18.9% 0.1 pts worse	19.6% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 23.5% · Q3 16.3% · Q4 12.8% · 4Q avg 19.0%
Percentage of long-stay residents who received an antipsychotic medication	10.2%	10.8% 0.6 pts better	16.7% 6.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 9.5% · Q3 9.5% · Q4 15.0% · 4Q avg 10.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	23.6%	15.4% 8.2 pts worse	16.3% 7.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q3 37.1% · 4Q avg 23.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	24.7%	16.1% 8.6 pts worse	14.9% 9.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 29.2% · Q3 30.4% · Q4 12.8% · 4Q avg 24.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	3.6%	0.8% 2.8 pts worse	1.7% 1.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 0.0% · Q3 3.5% · Q4 5.1% · 4Q avg 3.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	23.7%	15.0% 8.7 pts worse	19.8% 3.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 21.4% · Q3 26.2% · Q4 27.1% · 4Q avg 23.7%
Percentage of long-stay residents with pressure ulcers	5.0%	4.2% 0.8 pts worse	5.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 5.0% · Q3 4.8% · Q4 6.8% · 4Q avg 5.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.7%	89.7% 8 pts better	81.7% 16 pts better	Short Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 98.6% · Q3 96.8% · Q4 96.6% · 4Q avg 97.7%
Percentage of short-stay residents who had an outpatient emergency department visit	9.9%	12.0% 2.1 pts better	12.0% 2.1 pts better	Short Stay · 20240701-20250630 · Adjusted 9.9% · Observed 10.1% · Expected 11.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.3%	1.5% 1.2 pts better	1.6% 1.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	98.7%	88.0% 10.7 pts better	79.7% 19 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 98.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	32.9%	25.9% 7 pts worse	23.9% 9 pts worse	Short Stay · 20240701-20250630 · Adjusted 32.9% · Observed 32.6% · Expected 23.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-07 · Fire 2025-08-07

5 health deficiencies

Top issue: Resident Rights (2 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2024-07-17 · Fire 2024-07-17

0 health deficiencies

No concentrated health issue counts in this cycle.

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2023-05-17 · Fire 2023-05-17

0 health deficiencies

No concentrated health issue counts in this cycle.

1 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-08-07

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-09-15

F · Potential for more than minimal harm 2025-08-07

K343 · Smoke Deficiencies

Fire Safety

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Corrected 2025-09-15

F · Potential for more than minimal harm 2025-08-07

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2025-09-15

F · Potential for more than minimal harm 2025-08-07

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-09-15

E · Potential for more than minimal harm 2025-08-07

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-09-15

E · Potential for more than minimal harm 2025-08-07

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-09-15

D · Potential for more than minimal harm 2025-08-07

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2025-09-15

D · Potential for more than minimal harm 2025-08-07

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2025-09-15

D · Potential for more than minimal harm 2025-08-07

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-09-15

F · Potential for more than minimal harm 2024-07-17

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-09-27

E · Potential for more than minimal harm 2024-07-17

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-07-17

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-07-17

K929 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

Corrected 2024-09-27

D · Potential for more than minimal harm 2023-05-17

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-09-01

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-08-07

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-09-01

E · Potential for more than minimal harm 2025-08-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-09-01

D · Potential for more than minimal harm 2025-08-07

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2025-09-01

D · Potential for more than minimal harm 2025-08-07

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-09-01

D · Potential for more than minimal harm 2025-08-07

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-09-01

Penalties and ownership