The Colonnades At Reflection Bay
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
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
11/20/2025
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-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for 1 (MC#2) out of 14 medication carts. The facility failed to ensure the medication cart was free of expired insulin vial dated 09/07 on [DATE REDACTED]. The failures could place residents at risk of poor insulin blood sugar control from expired insulin. Finding included:During an observation on [DATE REDACTED] 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 REDACTED] 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 REDACTED] 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 REDACTED] at 2:18 pm, the ADON stated expired medication should not be left
on the medication cart. During an interview on [DATE REDACTED] 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 REDACTED] at 1:45 pm, the Executive Director stated she started in-servicing staff and completed
the POC on [DATE REDACTED] 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.
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
11/20/2025
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-Tag F0761
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.
The Colonnades at Reflection Bay in Pearland, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Pearland, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from The Colonnades at Reflection Bay or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.