Reunion Plaza Healthcare & Rehabilitation

Inspection findings

1. Aug 7, 2025 Health · 14 findings
   • Not serious Scope/severity D

     F0585 Resident Rights Deficiencies

     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 Sep 1, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0628 Resident Rights Deficiencies

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

     Corrected Sep 1, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

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

     Corrected Sep 1, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0842 Resident Assessment and Care Planning Deficiencies

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

     Corrected Sep 1, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 1, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0222 Egress Deficiencies

     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 Sep 15, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0281 Egress Deficiencies

     Install proper backup exit lighting.

     Corrected Sep 15, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0321 Smoke Deficiencies

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

     Corrected Sep 15, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Sep 15, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0343 Smoke Deficiencies

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

     Corrected Sep 15, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0345 Smoke Deficiencies

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

     Corrected Sep 15, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0916 Gas, Vacuum, and Electrical Systems Deficiencies

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

     Corrected Sep 15, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

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

     Corrected Sep 15, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Sep 15, 2025 · CMS fire safety

2. Jul 17, 2024 Fire Safety · 4 findings
   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Sep 27, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

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

     Corrected Sep 27, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Sep 27, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0929 Gas, Vacuum, and Electrical Systems Deficiencies

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

     Corrected Sep 27, 2024 · CMS fire safety

3. May 17, 2023 Fire Safety · 1 finding
   • Not serious Scope/severity D

     K0222 Egress Deficiencies

     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 Sep 1, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BAUDER, KELLY — adp of the snf, NOT APPLICABLE, since 10/01/2025
• BAUDER, MADISON — adp of the snf, NOT APPLICABLE, since 10/01/2025
• BAUDER, PARKER — adp of the snf, NOT APPLICABLE, since 10/01/2025
• BAUDER, WILLIAM — adp of the snf, NOT APPLICABLE, since 10/01/2025
• BOULWARE, DOUGLAS — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 03/24/2026
• BOULWARE, SANDRA — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 03/24/2026
• BOULWARE, STEVEN — adp of the snf, NOT APPLICABLE, since 10/01/2025
• BOULWARE, THOMAS — adp of the snf, NOT APPLICABLE, since 10/01/2025
• DAVIS, KENT — operational/managerial control, NOT APPLICABLE, since 10/01/2025
• DAVIS, KENT — adp of the snf, NOT APPLICABLE, since 10/01/2025
• KOEHLER, KEITH — operational/managerial control, NOT APPLICABLE, since 10/01/2025
• KOEHLER, KEITH — adp of the snf, NOT APPLICABLE, since 10/01/2025
• SPEER, GENA — corporate officer, NOT APPLICABLE, since 01/01/2025
• WALKER, KATIE — adp of the snf, NOT APPLICABLE, since 10/01/2025
• BAUDER FAMILY INVESTMENTS, LLC — adp of the snf, NOT APPLICABLE, since 10/01/2025
• BOULWARE ST JAMES LLC — adp of the snf, NOT APPLICABLE, since 10/01/2025
• PMG OPCO-TYLER LLC — operational/managerial control, NOT APPLICABLE, since 10/01/2025
• PMG REALCO-TYLER LLC — adp of the snf, NOT APPLICABLE, since 10/01/2025
• STEPHENS MEMORIAL HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 04/01/2022
• STEVEN BOULWARE FAMILY INVESTMENTS LLC — adp of the snf, NOT APPLICABLE, since 10/01/2025