The Colonnades At Reflection Bay
The Colonnades at Reflection Bay in Pearland, TX — inspection on November 20, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on interviews and observations the facility failed to ensure the residents environment remained as free of accident hazards as possible for 2 (Rm#1 and Rm#2) of 6 bathrooms reviewed.
The facility failed to ensure that sharps containers were not past the full line in 2 resident bathrooms.
This failure could place residents at risk of being stuck by needles and cause infection.Finding included:During an observation on 11/20/25 at 9:30 am revealed RM#1 and RM#2 bathrooms sharps containers were observed above the full line.During an observation and interview on 11/20/25 at 10:05 am, the ADON and surveyor did a walk-through of RM#1 and RM#2.
The ADON stated housekeeping and nursing staff were responsible for emptying out the sharp containers.
During an interview on 11/20/25 at 11:10 am, LVN G stated the sharps container should be emptied once it got to the full line. LVN G stated the charge nurses had the key for the containers and sharps were disposed of in the red hazard bags.
During an interview on 11/20/25 at 11:30 am, RN F stated when sharps containers were at full line then it was time to replace the container. RN F stated residents were endangered with getting their fingers stuck.
During an interview on 11/20/25 at 11:10 am, LVN E stated the sharps containers should be eye balled daily and changed when the sharps were at the full line. LVN E stated the sharps container needed to be changed to prevent exposure to body fluids.
During an interview on 11/20/25 at 1:15 pm, the Housekeeping Supervisor stated they did not have the key to the sharps containers and were not responsible for changing them.
During an interview on 11/20/25 at 1:30pm, the Executive Director stated that she did not have a policy for emptying out the sharps containers.
The Executive Director stated the sharps container should be emptied before it was full to help prevent staff and residents from hurting themselves and possibly caused infection.
The Executive Director stated that infection control policy did not address sharps containers specifically, but nursing staff had been educated about the sharps container.
The Executive Director stated very few residents had sharps containers in their bathrooms.
The Administrator stated the LVNs were responsible for checking and changing those out.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
The Colonnades at Reflection Bay
12001 Shadow Creek Parkway Pearland, TX 77584
SUMMARY STATEMENT OF DEFICIENCIES
The facility failed to ensure the medication cart was free of expired insulin vial dated 09/07 on [DATE].
The failures could place residents at risk of poor insulin blood sugar control from expired insulin.
Finding included:During an observation on [DATE] at 5:34 am on MC#2, the surveyor observed 1-Insulin LSP Inje 100/ml was dated 09/07.
During an interview and observation on [DATE] at 5:35 am LVN C stated the insulins were supposed to be dated when opened. LVN C stated that he did not administer insulin during his shift and did not touch the insulin.
During an interview on [DATE] at 6:25 am, LVN E stated depending on the type of insulin it could stay on the cart for 28 days after being opened. LVN E stated expired medication should be properly exposed of by giving it to the ADON.
During an interview on [DATE] at 2:18 pm, the ADON stated expired medication should not be left on the medication cart.
During an interview on [DATE] at 6:40 am, LVN D stated insulin should be dated when opened. LVN D stated the insulin was good for 30 days depending on the type of insulin.
During an interview on [DATE] at 1:45 pm, the Executive Director stated she started in-servicing staff and completed the POC on [DATE] for locking the medication cart and dating the opened insulin vials and insulin injectable pens.
The Executive Directoristrator stated she had 14 medication carts and the carts were audited.Record review of facility policy titled Medication Labeling and Storage, revised 02/2023 reflected, medication storage.3. If the facility has discounted, outdated.medications and biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying medications.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
The Colonnades at Reflection Bay
12001 Shadow Creek Parkway Pearland, TX 77584
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited The Colonnades at Reflection Bay in Pearland, TX for a deficiency under regulatory tag F-F0761 during a complaint investigation conducted on 2025-11-20.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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 3 deficiencies cited during this inspection of The Colonnades at Reflection Bay.
Correction Status: Deficient, Provider has no plan of correction.