The Colonnades At Reflection Bay

expectation that nurses document changes of condition and resident medication refusal was a change

should be care planned.

She said the MDS Coordinator was responsible for the resident care plan, but

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.

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The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

identified as Past Noncompliance (PNC).

The noncompliance began on 06/05/2025 and ended on

jeopardy to resident health or the following actions to correct the non-compliance:-Review of in-service dated 06/21/2025 titled safety 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

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.

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The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

Review of LVN D's employment file, on [DATE], revealed she was suspended on [DATE] and involuntarily terminated on [DATE] for misconduct.

Review of CNA E's employment file, on [DATE], revealed she was suspended on [DATE] and involuntarily terminated on [DATE] for misconduct.

Review of the DON's employment file, on [DATE], revealed she was suspended on [DATE] and involuntarily terminated on [DATE] 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] at 10:23 PM.

Review of the facility's AD HOC QAPI Plan, dated [DATE], 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] 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] at 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] at 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 audit, dated [DATE], 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]-[DATE], 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], reflected licensed nurses demonstrated proper skills and demonstrated knowledge on performing respiratory assessments, suctioning and respiratory care.

Review of 107 post-tests, dated [DATE]-[DATE], 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].

During an interview on [DATE] 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] 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] at 05:04 PM, Ex-DON stated she previously worked at the facility, but quit on the last week in February 2025.

She ac

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The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

During an interview and observation on 10/22/2025 at 3:48 PM, ADON stated she did not recall Resident #3 at all and that her name was on the assessment because she may have helped out the charge nurse. ADON reviewed Resident #3's discharge information and stated that based on the hospital discharge paperwork it looked like Resident #3 had a tracheostomy.

ADON stated that charge nurses completed tracheostomy care and there was a respiratory therapist that came out a few times a week and would provide tracheostomy care as well and change out supplies and assess residents. ADON stated orders for tracheostomy care were provided by doctors and there were standing orders in place for resident who admitted with a tracheostomy that the nurse could put in. ADON stated there were also orders from discharge records from the hospital. ADON stated orders should be put in the same day the resident admitted to the facility. ADON stated it was important for orders to be put in so nurses know to provide tracheostomy care. ADON stated tracheostomy care was performed each shift and suctioning was provided according to how much secretion the resident had. ADON stated a potential risk for a resident not receiving tracheostomy care was risk of aspiration or shortness of breath. ADON stated usually she checked admission orders when she arrived the next morning, but she was not at the facility on weekends and the RN H would check the admissions on the weekends. An attempted telephone interview was conducted on 10/23/2025 at 11:39 AM and 1:03 PM with the DON a voicemail was left but the call was not returned.

During an interview on 10/23/2025 at 12:02 PM, LVN Y stated that if a resident admitted with a tracheostomy the nurse was supposed to place all tracheostomy orders into the computer and that included the suctioning orders and tracheostomy care. LVN Y stated that tracheostomy care was provided each shift and suctioning was done as needed and when the care was performed. LVN Y stated that the doctor providers the orders and they are put into the system. LVN Y stated that there are existing orders that can be put in place for new admissions with tracheostomy. LVN Y stated that discharge orders were received and report is received form the hospital to ensure that information is received on whether or not the resident has a tracheostomy to ensure everything is put into place.

During an interview on 10/23/2025 at 3:49 PM, the ADM stated there are standing orders that can be put into place for residents who admit with tracheostomies.

The ADM stated there are batch orders that can be put in and reviewed with everything the residents needs for tracheostomy care.

The ADM stated new admission orders are reviewed daily during the IDT which included significant changes and admissions.

The ADM stated a resident should have had tracheostomy care the day of admission and the nurse should have verified those orders.

The ADM stated if the hospital did not provide orders, staff can reach out to the hospital and once the orders were verified they can be put in.

The ADM stated there was no time limit as to when orders could be verified with the doctor.

The ADM stated a potential risk to a resident not having tracheostomy care orders could be respiratory distress or death.

Review of in-services for February 2025 through October 2025 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.

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The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

Review of LVN D's employment file, on [DATE], revealed she was suspended on [DATE] and involuntarily terminated on [DATE] for misconduct.

Review of CNA E's employment file, on [DATE], revealed she was suspended on [DATE] and involuntarily terminated on [DATE] for misconduct.

Review of the DON's employment file, on [DATE], revealed she was suspended on [DATE] and involuntarily terminated on [DATE] 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] at 10:23 PM.

Review of the facility's AD HOC QAPI Plan, dated [DATE], 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] 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] 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] 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

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The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

request not to receive medical treatment as prescribed by his or her physician, as well as care

Treatment is defined as care provided for purposes of maintaining/restoring health, improving

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.

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The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

resident refused medications the nurse was expected to notify the NP or MD and RP and document

have an opportunity to address the problem. To not document when a resident refused medication

the charge nurse and the nurse administering the medication.

Interview on 10/20/25 at 1:36 pm with LVN C reflected it was common knowledge that Resident #1 refused his medication, and she notified the doctor and the RP and said, Lord I hope I did when asked if she documented the refusal and the notification in the progress notes.

She said if Resident #1 did not have enough of his seizure medications, he could have had a seizure, and the doctor should have been notified and it should have been in the progress notes.

She said if something was not documented, it was not done and if you did not document it did not take place.

She said it was the responsibility of the charge nurse to make sure documentation was taken care.Interview on 10/23/25 at 1:11 pm with the ADON reflected if a resident refused mediation the refusal should be documented in the resident's progress notes and the notification to the MD and family of the refusal should be documented and the progress notes.

She said it should be documented every time a resident refused medication.

She said documenting was important to residents for the residents' ongoing patient care.

Interview on 10/21/24 at 4:27 pm with the MD G reflected he knew that Resident #1 refused his medications, and it was his understanding that nursing staff would have to notify the RP. He said there was no notification that Resident #1's refusal of his seizure medication was that extensive. He said missing the doses could have caused a seizure, but they were monitoring his levels of seizure medications, and the labs did not indicate his levels were abnormal.

Interview on 10/24/25 at 9:04 am with the Administer reflected the management and nursing team are responsible for making sure things are properly documented.

Nurses should notify the MD, family when a resident refuses medication and this communication should be documented in the residents' progress notes. A possible negative effect of not documenting was that you were not going to fix the problem and a resident could die with the case of this, because Resident #1 refused his seizure medication, he could have had a seizure.Interview on 10/24/25 at 11:44 am with the DON reflected that it was her expectation that nurses documented in the progress notes for a change of condition and said a resident's refusal to take medication was a change of condition.

She said medication refusal should be documented and notification of the refusal to the MD, family, and supervisor should be documented.

She said that every time a resident refused medication it should be documented.

She said the possible negative effect of not documenting medication refusals would be MDs would not be able to have the information to try a different route or different treatment.

She said documentation was very important and was the verification of how you cared for the resident.

She said if you did not document, it stated you did not care for your resident.

She said you could not confirm that the MD or RP were contacted if it was not documented.

She said if it was not documented it was not done.

She said it was the responsibility of the nurse managers to make sure staff were documenting properly.

The facility was unable to provide a policy on documentation.