The Colonnades At Reflection Bay
The Colonnades at Reflection Bay in Pearland, TX — inspection on May 1, 2026.
Found 6 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
could call 911.
She said the medication cup spilled which caused her medications to fall to the floor.
open her mouth to show that she took them.
She said taking medications like that made her feel like
Resident #96, she answered the resident's call light when Resident #96 asked for her pain medications.
She said she told the nurse (name unknown) when the nurse returned from a break.
She said later, the nurse asked her to go in Resident #96's room as a witness to the nurse giving the resident her medications.
When asked by the surveyor how the medications were administered, CNA Y said the nurse asked the resident to open her mouth, then the nurse poured the medications in the resident's mouth, and then said, Let me see.
She said the resident opened her mouth to show that she took the medications. In an interview on 4/30/26 at 10:50am, MA T said Resident #96 reached for the medication cup and took her medications independently by mouth when MA T gave her medication. In an interview on 4/30/26 at 3:50pm, LVN U said she remembered caring for Resident #96.
She said she checked on Resident #96 around 4:00pm.
She said Resident #96's as-needed pain medications were due between 4:00pm and 6:00pm.
She said Resident #96 asked for them around 8:00pm or 8:30pm.
She said around 7:45pm, she was handling an emergency with another resident.
She said Resident #96 began yelling around that time, stating that she needed her medication.
She said around 8:00pm, Resident #96 was screaming bloody murder.
She said a few minutes later, she walked into Resident #96's room to give her medication.
She said she had a medicated cream and a cup of medications in her hand.
She said Resident #96 was seated upright at the end of the bed.
She said Resident #96 grabbed the nurse's shirt by the shoulder area, causing the cream to fall and hit the floor and caused the cup of medications to fall out of the cup and into the nurse's hand.
She said when she bent over to pick up the cream, Resident #96 grabbed the nurse's hand, grabbed the pills and threw the pills into her (Resident #96's) mouth.
She said she then backed away from the resident to the door, called for CNA Y, then gave her a beverage and asked her to open her mouth to make sure she swallowed her pills.
She said she asked CNA Y to witness Resident #96 take her medications because, I didn't want her to say she didn't take them. In a follow-up interview on 4/30/26 at 6:09pm, CNA Y confirmed that when she witnessed Resident #96's medication administration, the nurse poured the medication in the resident's mouth, then asked the resident to open her mouth to show that she took the pills. In an interview on 5/1/26 at 1:20pm, the Administrator discussed the incident regarding Resident #96.
She said she thought it was a concern that LVN U had a witness come into the room to watch medication administration.
She said she thought it would be appropriate that LVN U checked to see if Resident #96 took her medication.
She said she could see both sides.
The Administrator said, I can see why the nurse asked to see that she took the meds, and I see why the resident would be upset.
Record review of the facility's policy regarding Resident Rights dated 2/21/26 read, Employees shall treat all residents with kindness, respect and dignity.
Federal and state laws guarantee certain basic rights to all residents of this facility.
These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness and dignity.
676207 05/01/2026
The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584
caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is
Orientation for transfer or discharge will be provided and documented to ensure safe and orderly
Depending on the circumstances, this orientation may be provided by various members of the interdisciplinary team. d.
Facility will assist with transportation arrangements to the new facility and any other arrangements as needed.
676207 05/01/2026
The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584
Findings included:Review of Resident #9's face sheet, dated 5/1/26 revealed a [AGE] year-old male admitted to the facility on [DATE].
His diagnoses included: ileus (a condition in which the bowel does not work correctly), hemiplegia (complete paralysis) and hemiparesis (weakness) following cerebral infarction (a type of ischemic stroke), epilepsy (a brain condition that causes recurring seizures), dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), and schizophrenia (a serious mental health condition that affects how people thing, feel, and behave).
Record review of the PASRR level 1 screening dated 3/27/26 revealed he was negative for mental illness, intellectual disability, and developmental disability.
Record review of Resident #9's Comprehensive MDS, dated [DATE] revealed a BIMS score of 1 which indicated severe cognitive impairment. Resident #9 had an active diagnosis of schizophrenia and was taking an antipsychotic.
Record review of Resident #9's physician's orders with a start date of 4/21/26 indicated he was prescribed Quetiapine Fumarate (atypical antipsychotic) oral tablet 50 mg, via g-tube two times a day.
Record review of Resident #9's care plan dated 3/27/26 indicated he had a behavior problem, removing colostomy (an opening in the colon that lets stools pass from the body without going through the anus) bag and throwing it on the floor.
Interventions included: anticipate and meet the resident's needs, assist the resident to develop more appropriate methods of coping and interacting, encourage the resident to express feelings appropriately, caregivers to provide opportunity for positive interaction/attention, stop and talk with him as passing by.During an interview and observation of Resident #9 on 4/28/26 at 8:20 a.m. revealed he was lying in bed wearing a hospital gown and watching tv.
When questioned about the food Resident #9 repeated I'm alright or It's alright.
During an interview with the MDS Coordinator on 5/1/26 at 10:55 a.m., she said she would upload the PASSR Level 1 in system within 72 hours.
She said she did not check if the PASRR Level 1 was accurate; the Regional MDS Coordinator was responsible for checking the accuracy of the PASRRs.
The MDS Coordinator said she was not sure if Resident #9 was referred to a psychiatrist.
She said she was from a different state and the current state did things differently.
She said she did not know the risk to the resident when an inaccurate PASRR was completed for the resident.
Record review of the facility's policy titled Resident Assessment-Coordination with PASRR Program dated 12/20/25 revealed in part .
This facility coordinates assessments with the preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs .
676207 05/01/2026
The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584
bags every shift as stated in the residents' clinical orders. In an interview on 05/01/2026 at 12:31
the nurse.
She acknowledged she was trained on Foley care and how to empty the Foley bag but did
unsuccessful telephone call to LVN D who provided care to Resident # 28 on 04/30/2026 from 6a.m. to 2 p.m.
The facility's policy titled Catheter Care revised on 12/01/2025, revealed: It is the policy of the facility to ensure that all residents with indwelling catheters receive appropriate catheter care.
Catheter care will be performed every shift.
Empty drainage bag routinely.
Document care and report and concerns noted to the nurse on duty.
676207 05/01/2026
The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584
complications or deterioration in respiratory status.
The RRT stated the goal of therapy was to
considered acceptable for Resident #93.
The RRT stated the typical O2 setting for Resident #93 was
rate settings were not outlined in the physician order; however, licensed nursing staff should be aware of the appropriate O2 range the resident could tolerate via nasal cannula.Interview and observation on 5/1/2026 at 10:02am revealed Resident #93 was lying in bed with a nasal cannula in place and the oxygen concentrator set at 3 lpm. Resident #93 stated she had used O2 consistently for the past several years and did not go without it.
She reported there was a time in the past when she did not require continuous oxygen; however, she stated that had been a long time ago. Resident #93 stated she was unsure what would occur if she did not have her oxygen but believed she would have difficulty breathing without it.Follow-up phone interview attempted with RN C on 5/1/2026 at 11:27am.
Two calls were placed with no answer, and a voicemail was left requesting a return phone call. A text message was also sent to the number at this time requesting a return phone call.Follow-up interview on 5/1/2026 at 1:29pm revealed the surveyor asked the NP to clarify the risk posed to Resident #93 if she were without O2.
The NP stated she would not respond to hypothetical questions regarding residents and reiterated she could not confirm whether Resident #93 had been without oxygen.
The NP stated that without direct assessment, she was unable to determine the clinical impact or how the resident would have been affected.Follow-up interview on 5/1/2026 at 2:20pm revealed the Unit Manager stated nurses were expected to round on residents at a minimum of every 2 hours and continue rounding throughout the shift.
The Unit Manager stated during rounds, staff should assess whether residents were stable, identify any changes in condition, and ensure equipment was present and functioning properly.
The Unit Manager stated most equipment had alarms to alert staff if it was not functioning properly.
She further stated the same expectations applied to CNA staff, and if any issues were identified, they should be reported to the nurse.
The Unit Manager stated that if it was brought to the nurse's attention that equipment was not functioning, the nurse should immediately assess both the resident and the equipment.
The Unit Manager stated she had not spoken with RN C on 4/28/2026 after being informed by the surveyor that the oxygen concentrator was not functioning and reported she was unsure who ultimately replaced Resident #93's oxygen concentrator.
Record review of the facility oxygen administration policy implemented on 10/2025 revealed in part, .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. 1.The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: a.
The type of oxygen delivery system. b.
When to administer, such as continuous or intermittent and/or when to discontinue. c.
Equipment setting for the prescribed flow rates. d.
Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. e.
Monitoring for complications associated with the use of oxygen.
Record review of the facility oxygen concentrator policy implemented on 11/1/2025 revealed in part, .An oxygen concentrator is a medical device that extracts oxygen from room air by filtering out or separating the nitrogen from the oxygen.
The oxygen passes through a filter system and is then stored within the device for delivery based on the flow meter setting. 4.
Use of the Concentrator: a.
The nurse shall verify physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula etc.).
Based on observation and interview, the facility failed to ensure drugs and biologicals used in the
medication carts (halls 100, 300, 600) reviewed for labeling and expired medications.
The facility failed to label a Lantus vial and a mupirocin ointment tube with resident specific information in the medication cart located on the 300 hall.
The facility failed to label a Nuedexta bottle with resident specific information in the medication cart located on the 600 hall.
The facility failed to label Tetrahydrozoline HCL 0.05% with resident specific information in the medication cart located on the 100 hall.
These failures had the potential to result in medication administration errors.An observation of the medication cart for hall 300 on 4/30/2026 at 10:00 a.m. revealed 2 medications not labeled with resident specific information. A vial of Lantus 100 units/ml insulin was not labeled located in a Lantus box. A tube of mupirocin ointment usp 2% was not labeled. In an interview on 4/30/20206 at 10:05 a.m., LVN A said the medication should be labeled with the resident's name/date of birth .
She said she checked the medication before administration. An observation of the medication cart for hall 600 on 4/30/2026 at 10:45 a.m. revealed a bottle of Nuedexta 20mg/10mg not labeled with resident specific information. In an interview on 4/30/20206 at 10:50 a.m. with LVN D, she said the Nuedexta bottle should have been labeled with resident's name and date of birth .
She said without it being labelled they could not know who it belonged. An observation of the medication cart for hall 100 on 4/30/2026 at 12:49 p.m. revealed a bottle of tetrahydrozoline HCL 0.05% eye drops not labeled with a resident specific information. In an interview on 4/30/20206 at 12:50 p.m. with MA T, she said the eye drops should be labeled with resident information.
She said if it was not labeled, they could not be sure who it belonged to. In an interview on 4/30/2026 at 1:00 p.m. with the Unit Manager, she said medications should always be labeled with resident information or they could not administer it.
The facility's policy titled Medication Administration revised on 12/1/2025, stated in the policy: Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.
The facility's policy titled Pharmacy Services dated 12/1/2025, revealed in the policy: Pharmaceutical Services refers to: The process (including documentation, as applicable) of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling, reconciling, compounding, dispensing, packaging, labeling, distributing, administering, monitoring responses to, using and/or disposing of all medications, biologicals, chemicals (e.g., povidone iodine, hydrogen peroxide); Compliance Guidelines: The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
676207 05/01/2026
The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.