Federal inspectors found the facility failed to report or investigate three separate resident elopements between June 5 and June 21, 2025. The unreported incidents violated the facility's own policies requiring immediate notification to administrators and state agencies.
Resident #2 escaped on three occasions. On June 5 and June 6, the resident left the facility undetected. On June 21, the resident again left the building and attempted to cross a street before being found.
The administrator learned about the June 21 incident at 12:30 PM that day when notified a resident was missing. But she never heard about the earlier escapes on June 5 and 6.
During an October 22 interview at 11:05 AM, the administrator said no elopement was reported to her on June 5 or June 6. Had she been told that Resident #2 tried to cross the street, she said the resident "would have been put on 1:1 supervision and discharged much sooner."
The administrator said she would have expected any elopement to be reported to her or the director of nursing. She said an investigation would have been conducted with an interview of Resident #2 "to try and figure out what caused the elopement."
Her normal investigation process included talking to resident staff, finding out the last time the resident was seen, putting the resident on one-to-one supervision, and working with family to start the discharge process.
None of that happened.
There were no incident reports for the June 5, June 6, or June 21 elopements. No witness statements were taken. Federal inspectors reviewed the facility's TULIP reporting system from June 2025 through October 22, 2025, and found no reports for any elopements.
The facility held an in-service training on June 27, 2025, titled "Elopement" that was completed with staff and reviewed the Elopement Response Protocol policy. But this training came after all three incidents had already occurred.
An Adhoc QAPI Plan dated July 1, 2025, documented that the administrator was notified on June 21 at 12:30 PM that a resident was missing. But the meeting notes included no staff or witness statements. The review revealed inconsistencies among staff regarding Resident #2's June 21 elopement.
The plan contained no investigation or information regarding the June 5 or June 6 elopements.
The facility's own Elopement Response Protocol, dated March 2012, required staff to notify the Department of Aging and Disability in accordance with guidelines for reportable incidents. The policy stated that based on elopement risk, a patient may be discharged.
The protocol required a head-to-toe nursing assessment upon the resident's return. It also mandated that the physician and responsible party be notified and that all actions be documented.
None of these requirements were followed for the June 5 and June 6 incidents.
The facility's policy on "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," revised in September 2022, required that suspected incidents be reported immediately to the administrator and to other officials according to state law.
The policy specifically stated that the administrator or the individual making the allegation must immediately report suspicions to the state licensing and certification agency responsible for surveying and licensing the facility.
Federal inspectors determined that the facility's failure to report and investigate the elopements represented minimal harm or potential for actual harm affecting some residents.
The inspection findings highlighted a breakdown in the facility's reporting system. Staff who witnessed or discovered the elopements failed to follow established protocols for documenting and reporting the incidents to supervisors.
The administrator's statement that she would have immediately placed Resident #2 on one-to-one supervision and expedited discharge if informed of the street-crossing attempt underscored the serious safety implications of the unreported incidents.
Elopements pose significant risks to residents with cognitive impairments who may become disoriented, lost, or injured when they leave a secured environment without supervision. The risk increases dramatically when residents attempt to cross streets or enter traffic areas.
The facility's March 2012 protocol recognized these dangers by requiring comprehensive assessments, immediate notifications, and potential discharge for residents who demonstrate elopement behaviors. The protocol's emphasis on involving families in discharge planning reflected the understanding that some residents may require more restrictive care settings.
The June 27 training session on elopement procedures, conducted after all three incidents, suggested the facility recognized problems with staff compliance. However, the training occurred too late to prevent the policy violations that had already taken place.
The July 1 QAPI meeting's documentation of staff inconsistencies regarding the June 21 elopement indicated ongoing confusion about what actually happened during that incident. The absence of witness statements and formal investigation procedures left critical questions unanswered about how and why the resident was able to leave the facility undetected.
Federal regulations require nursing homes to provide a safe environment and to report incidents that could affect resident health and safety. The facility's failure to document, investigate, or report three elopements over a 16-day period represented a systemic breakdown in safety protocols.
The administrator's acknowledgment that she never learned about two of the three elopements revealed gaps in the facility's internal communication system. Her statement about normal investigation procedures contrasted sharply with what actually occurred when Resident #2 repeatedly left the building.
The inspection findings were part of a complaint investigation conducted on October 24, 2025. The deficiency was classified under federal tag F609, which addresses the facility's responsibility to protect residents from accidents and provide adequate supervision.
Resident #2's three escapes, including the attempt to cross a street, remained undocumented in incident reports and uninvestigated by facility leadership for months after they occurred.
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
- View all inspection reports for The Colonnades At Reflection Bay
- Browse all TX nursing home inspections