Colonnades at Reflection Bay: Trach Care Gaps - TX
That resident was Resident 3. The ADON's name was on the admission assessment. She said she may have helped out the charge nurse.
A tracheostomy is a surgically created opening in the throat that allows a person to breathe when the natural airway is blocked or compromised. Without consistent suctioning and wound care around the stoma, secretions accumulate, the airway can become obstructed, and the tissue around the opening can break down. The administrator at the facility put the stakes plainly when inspectors asked: a resident not receiving tracheostomy care could experience respiratory distress or death.
Federal inspectors arrived at The Colonnades at Reflection Bay, a nursing home at 12001 Shadow Creek Parkway in Pearland, on October 24, 2025, following a complaint. What they found was a facility where a resident had been admitted with a tracheostomy and the orders needed to guide that resident's care had not been entered into the system as they should have been, leaving nurses without formal direction for suctioning schedules, dressing changes, or the routine airway management that keeps a trach patient stable.
The ADON told inspectors that orders for tracheostomy care should be put in the same day a resident is admitted. She said it was important for those orders to be entered so nurses know to provide the care. She said that usually she checked admission orders when she arrived the next morning, but that she was not at the facility on weekends, and that RN H would check admissions on weekends.
She did not say which day Resident 3 arrived, or how long the orders were missing. She said she did not recall the resident at all.
The facility's own staff described, in consistent terms, what the standard was supposed to look like. RN ZZ told inspectors that tracheostomy care was normally done every shift and at minimum assessed each shift. If the dressing was soiled, it would be changed. Suctioning was completed every four hours and as needed. There were standing orders that the director of nursing could put in place for new admissions who arrived with a tracheostomy, and doctors provided orders as well, particularly for new admissions.
LVN Y said the same thing in slightly different words: when a resident admitted with a tracheostomy, the nurse was supposed to place all tracheostomy orders into the computer, including suctioning orders and tracheostomy care orders. Discharge paperwork and a report from the hospital were supposed to arrive with the resident so staff knew what they were dealing with before the person even came through the door.
The administrator confirmed that batch orders existed for exactly this situation, a set of standing orders that could be pulled up and applied to any resident admitted with a tracheostomy, covering everything the resident would need. New admissions were reviewed daily during the interdisciplinary team meeting. The administrator said a resident should have had tracheostomy care the day of admission, and the nurse should have verified those orders.
None of that happened for Resident 3, at least not in the way it was supposed to.
The ADON said a potential risk for a resident not receiving tracheostomy care was aspiration or shortness of breath. The administrator said the risk was respiratory distress or death. Both of them described the same gap in care. Neither of them described what had actually been done for Resident 3 during the period when orders were not in place.
The Director of Nursing did not participate in the inspection. Inspectors attempted to reach the DON by phone on October 23, 2025, at 11:39 in the morning and again at 1:03 in the afternoon. A voicemail was left. The call was not returned.
Inspectors also reviewed the facility's in-service training records going back to February 2025. In the eight months before the inspection, the facility had conducted no in-service training on tracheostomy care. None. The most recent policy on tracheostomy care that inspectors could locate carried a revision date of August 2013, more than twelve years before Resident 3 was admitted.
There was a respiratory therapist who came to the facility a few times a week to provide tracheostomy care, change out supplies, and assess residents. The ADON mentioned this. RN ZZ mentioned this. It was presented, in both conversations, as part of the care structure. A respiratory therapist coming a few times a week is not a substitute for shift-by-shift nursing orders that tell staff when to suction, when to change a dressing, and what to watch for. It is a supplement to that structure, not a replacement for it.
The facility's own administrator acknowledged there was no time limit on when orders could be verified with a doctor. That framing, offered apparently to describe flexibility in the process, also describes the gap: if there is no deadline, there is no urgency, and a resident with a surgical airway can sit in a facility bed while the question of who is responsible for their care remains, in the system at least, unanswered.
The in-service training record from April 18, 2025, covered admission assessments. It reflected that nurses were trained to complete admission assessments within 24 hours. That training did not appear to have closed the gap that inspectors found six months later, when a resident arrived with a tracheostomy and the ADON reviewed the discharge paperwork during the inspection and said it looked like the resident had one.
Resident 3 had since been discharged from the facility by the time inspectors reviewed the case. The inspection report does not say where the resident went, or what their condition was when they left, or whether they experienced any complications during their stay. The ADON said she did not recall the resident at all.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Colonnades At Reflection Bay from 2025-10-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 9, 2026 · Our methodology
The Colonnades at Reflection Bay in Pearland, TX was cited for violations during a health inspection on October 24, 2025.
The ADON's name was on the admission assessment.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.