The Colonnades At Reflection Bay

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

gone. During an interview on 10/22/2025 at 11:05 AM, ADM stated that there was no elopement reported to her on 06/05/2025 or 06/06/2025. The ADM stated had it been reported to her that Resident #2 tried to cross the street Resident #2 would have been put on 1:1 supervision and discharged much sooner. ADM stated that she would have expected any elopement to be reported to her or the DON. The ADM stated an investigation would have been conducted with interview from Resident #2 to try and figure out what caused

the elopement. The ADM stated during investigation normally she talked to the resident staff, find out the last time the resident was seen and put the resident on 1:1 and get with family to start the discharge process. The ADM stated there were no incident reports for 06/05/2025, 06/06/2025 or 06/21/2025 elopements, or witness statements. Review of TULIP from June 2025 through 10/22/2025 reflected no reports for elopements. Review of in-service dated 06/27/2025 titled Elopement reflected in-service was completed with staff and reviewed the policy Elopement Response Protocol. Review of Adhoc QAPI Plan dated 07/01/2025 reflected the ADM was notified on 06/21/2025 at 12:30 PM the facility that a resident was missing. Review reflected there were no staff or witness statements included in the meeting notes. Review reflected inconsistencies among staff on Resident #2's 06/21/2025 elopement. Review reflected there was no investigation or information regarding a 06/05/2025 or 06/06/2025 elopement. Review of facility policy dated March 2012 titled Elopement Response Protocol reflected to Notify Department of Aging and Disability in accordance with guidelines for reportable incidents and based on elopement risk patient may be discharged . Head-to-toe nursing assessment must be completed upon return in addition the physician and responsible party must be notified and document. Review of facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating with revision date of September 2022 reflected if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Review also reflected:2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a. The state licensing/certification agency responsible for surveying/licensing the facility.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Colonnades at Reflection Bay

12001 Shadow Creek Parkway Pearland, TX 77584

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

care would be different. She said refusals to take medication should be care planned because staff could know about the refusals and follow the interventions and goals for that resident outlined in the residents' care plan. She said a possible negative effect of not care planning for medication refusals was lack of care for that resident and lack of interventions. Interview on 10/24/25 at 9:04 a.m., the Administrator reflected a care plan should tell you everything you need to know about how to are for the resident. She said it was necessary because you need to know what might or might not work for that resident. She said medication refusals should be care planned because it was a behavior and any behavior should be care planned and

the facility needs to have interventions to address issues. She said medication refusals could be life threatening. She said everyone was responsible for a care plan. She said the MDS Coordinator was responsible because they did the charts. She said the nurse management team were responsible for making sure resident information was properly documented and the Administrator was ultimately responsible for making sure things were done. She said a possible negative effect of not documenting was that you are not going to fix the problem and in an extreme situation the resident could die. Interview on 10/24/25 at 11:44 a.m., the DON reflected it was her expectation that nurses document changes of condition and resident medication refusal was a change of condition. She said a care plan was an overall summary of how a resident should be cared for and how and what the staff would do to provide care for that resident. She said medication refusals should be care planned. She said the MDS Coordinator was responsible for the resident care plan, but nurses added to the resident care plan. She said that CNAs and MTs do not have any responsibility for care plans. A possible negative effect of not documenting medication refusals in a care plan would be that there would be no documentation that the resident did not get the therapeutic benefits of the medication. A refusal of medication in the care plan would trigger everyone to know that they needed to intervene in a different way when a resident refused to take the medication. She said that medication refusals could have been discussed in the facility morning meetings and resident care plans could be updated. Record review of facility policy Care Plan, Comprehensive Person-Centered dated March 2022 reflected a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan reflects currently recognized standards of practice for problem areas and conditions. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Colonnades at Reflection Bay

12001 Shadow Creek Parkway Pearland, TX 77584

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

confused quite a bit and she tried to leave the facility a couple of times. LVN FF stated she was not working when Resident #2 eloped from the facility and had only heard the staff looked for Resident #2 at she was not on the premises. LVN FF stated she knew someone brought Resident #2 inside the facility one time because she tried to go across the street. LVN FF stated the only interventions she recalled for Resident #2 was to keep an eye on her. LVN FF stated if a resident was missing the first thing to do was search everywhere and if the resident cannot be found to notify the DON and have all staff start to look for the resident. During an interview on 10/22/2025 at 12:42 PM MD G stated he recalled Resident #2 and she used to refuse dialysis. MD G stated that he did not recall her cognition level, but did believe she had a cognitive decline because she did not always understand the importance of going to dialysis. MD G stated if Resident #2 eloped from the facility and had been without dialysis there was a risk to develop uremia and cause confusion, but he was unsure if that is what Resident #2 experienced. Review of facility policy dated March 2012 titled Elopement Response Protocol reflected to Notify Department of Aging and Disability in accordance with guidelines for reportable incidents and based on elopement risk patient may be discharged . Head-to-toe nursing assessment must be completed upon return in addition the physician and responsible party must be notified and document. The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 06/05/2025 and ended on 07/06/2025. The facility had corrected the noncompliance before the survey began. The facility took the following actions to correct

the non-compliance:-Review of in-service dated 06/21/2025 titled elopements reflected in-service was completed with staff with no additional information included.-Review of in-service dated 06/27/2025 titled Elopement reflected in-service was completed with staff and reviewed the policy Elopement Response Protocol. -Review of Adhoc QAPI Plan dated 07/01/2025 reflected the ADM was notified on 06/21/2025 at 12:30 PM the facility that a resident was missing. Interview with charge nurse found resident refused medications an dialysis and was missing for approximately 20 minutes. Interview with weekend supervisor indicated patient asked another family member to take her across the street because she wanted to go get food. Family member took resident to the restaurant and then she wanted to go to the other side of the parking lot. RN H went across the street to get the resident and she was at the apartments. In-service on elopement was conducted and facility updated 100 % of elopement risk assessments. Review reflected there were no staff or witness statements included in the meeting notes. Review reflected inconsistencies among staff on Resident #2's 06/21/2025 elopement. Review reflected there was no investigation or information regarding a 06/05/2025 or 06/06/2025 elopement.-Review of Resident #2's monitoring sheet dated 06/21/2025 reflected Resident #2 was on 1:1 supervision -Review of Resident #2's monitoring sheets dated 06/28/2025 through 07/06/2025 reflected Resident #2 was on 1:1 supervision throughout each shift.-Review of facility elopement risk assessments dated 07/01/2025 reflected no residents were at risk for elopement.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Colonnades at Reflection Bay

12001 Shadow Creek Parkway Pearland, TX 77584

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and 01:00 PM revealed eight of eight residents that received enteral nutrition with the head of their bed elevated greater than 30 degrees.Review of facility audit, dated [DATE REDACTED], reflected orders for and observation of head of bed elevated for eight of eight residents that received enteral nutrition was completed by the RDRC.Review of facility audit, dated [DATE REDACTED]-[DATE REDACTED], reflected daily audits were conducted for observations of enteral feeding for of eight of eight residents that received enteral nutrition by either the ADM or the RDRC.Review of 20 post-tests and 20 skills check-off sheets, dated [DATE REDACTED], reflected licensed nurses demonstrated proper skills and demonstrated knowledge on performing respiratory assessments, suctioning and respiratory care. Review of 107 post-tests, dated [DATE REDACTED]-[DATE REDACTED], reflected staff demonstrated knowledge of competency for enteral feeding. Review of in-service spread sheet reflected 98 of 103 staff had completed in-services as of [DATE REDACTED]. During an interview on [DATE REDACTED] at 1:30 PM, the ADM stated more than 90% of their staff had been in-serviced on safe positioning for residents receiving enteral feeding, aspiration precautions and timely intervention. She stated that no one would work until they were in-serviced. The ADM was notified the IJ was removed on [DATE REDACTED] at 2:20 PM. However, the facility remained out of compliance at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.During an interview, after exit, on [DATE REDACTED] at 05:04 PM, Ex-DON stated she previously worked at the facility, but quit on

the last week in February 2025. She ac

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Colonnades at Reflection Bay

12001 Shadow Creek Parkway Pearland, TX 77584

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm

reflected there were no in-services conducted on tracheostomy care. Review of in-service dated 04/18/2025 titled admission Assessments was completed with nursing staff and reflected nurses are to complete admission assessment within 24 hours. Review of policy titled Tracheostomy Care with revision date of August 2013 reflected procedure included to check the physician order.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Colonnades at Reflection Bay

12001 Shadow Creek Parkway Pearland, TX 77584

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

start/stop/adjust/silence the feeding pump, signs and symptoms of aspiration, and what to do if they observe a resident aspirating. Review of LVN D's employment file, on [DATE REDACTED], revealed she was suspended

on [DATE REDACTED] and involuntarily terminated on [DATE REDACTED] for misconduct. Review of CNA E's employment file, on [DATE REDACTED], revealed she was suspended on [DATE REDACTED] and involuntarily terminated on [DATE REDACTED] for misconduct.Review of the DON's employment file, on [DATE REDACTED], revealed she was suspended on [DATE REDACTED] and involuntarily terminated on [DATE REDACTED] for unprofessional behavior.Review of facility-reported incident reflected,

a formal complaint to regulatory authorities with intake number 1045259 was initiated and submitted on [DATE REDACTED] at 10:23 PM.Review of the facility's AD HOC QAPI Plan, dated [DATE REDACTED], reflected the medical director, the ADON, the ADM, and other facility and corporate staff were in attendance. Review of statement written by the ADM reflected: Medical Director.was notified of immediate jeopardy on [DATE REDACTED] at approximately 9:00 PM. Review of electronic health records for eight of eight residents who received enteral nutrition revealed medical orders to ensure the head of the bed was elevated were in place.Observations

on [DATE REDACTED] between 11:50 AM and 4:45 PM revealed eight of eight residents that received enteral nutrition with the head of their bed elevated greater than 30 degrees. Observations on [DATE REDACTED] between 09:30 AM and 01:00 PM revealed eight of eight residents that received enteral nutrition with the head of their bed elevated greater than 30 degrees.Review of facility au

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Colonnades at Reflection Bay

12001 Shadow Creek Parkway Pearland, TX 77584

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

prescribed, only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Medications must be administered in accordance with the orders, including any required time frame. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. As required or indicated for a medication,

the individual administering the medication will record in the resident's medical record: a. The date and time

the medication was administered;b. The dosage;c. The route of administration;d. The injection site (if applicable);e. Any complaints or symptoms for which the drug was administered;f. Any results achieved and when those results were observed; andg. The signature and title of the person administering the drug.

Review of facility Refusal of Treatment policy dated May 2013 reflected Our facility shall honor a resident's request not to receive medical treatment as prescribed by his or her physician, as well as care routines outlined on the resident's assessment and plan of care. The resident is not forced to accept any medical treatment and may refuse specific treatment even though it is prescribed by a physician. Treatment is defined as care provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms. If a resident refuses treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will interview the resident to determine what and why the resident is refusing in order to try to address the resident's concerns and explain the consequences. The Care Plan Team will assess the resident's needs and offer the resident alternative treatments, if available and pertinent, while continuing to provide other services outlined in the care plan. If the resident's refusal brings about a significant change, a reassessment will be made and such information will be incorporated into the resident's care plan. Should

the resident refuse to accept treatment, detailed information relating to the refusal must be entered into the resident's medical record.Documentation pertaining to a resident's refusal of treatment shall include at least

the following:The date and time the staff tried to give a medication or treatment was attempted;The medication or treatment refused;The resident's response and reason(s) for refusal;The name of the person attempting to administer the treatment;That the resident was informed (to the extent of their ability to understand) of the purpose of the treatment and the consequences of not receiving the medication/or treatment;The resident's condition and any adverse effects due to such refusal;The date and time the physician was notified as well as the physician's response;All other pertinent observations; andThe signature and title of the person recording the data.The Attending Physician must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of

the refusal. For example, a resident's refusal to take a diuretic while experiencing acute congestive heart failure should be reported immediately, while a refusal to take a blood pressure medication while the blood pressure is well controlled can be reported within 24 hours.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Colonnades at Reflection Bay

12001 Shadow Creek Parkway Pearland, TX 77584

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited The Colonnades at Reflection Bay in Pearland, TX for a deficiency under regulatory tag F-F0842 during a complaint investigation conducted on 2025-10-24.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of The Colonnades at Reflection Bay.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2025-12-19.