The Colonnades At Reflection Bay

12001 Shadow Creek Parkway
Pearland, TX 77584
Brazoria County
Phone: 713-434-3800
Provider Number: 676207
Last Inspection: 12/05/2014

About the Nursing Home About the Staff

Number of Beds
Number of
Beds
180
Number of Residents
Number of
Residents
133
Number of Beds Available
Beds Available
47
Percent Occupancy
Percent Occupancy
74%
Accepts Insurance
Insurance Accepted
Medicare & Medicaid
Types of Councils
Types of Councils
Both
Type of Ownership
Type of Ownership
For profit - Corporation
Within a Hospital?
Within Hospital?
NO

State Inspection Deficiencies About State Inspection Deficiencies

Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home. We suggest you use our Nursing Home Checklist to help evaluate the nursing homes you plan to visit.


Deficiency Ratings what is a deficiency rating?
By Region


  • Facility
  • County
  • TX
  • USA
  • 42
  • 22
  • 25
  • 20
Lower Numbers are Better

Deficiency Ratings what is a deficiency rating?
By Year


  • 2014
  • 2013
  • 2013
  • 42
  • 27
  • 41
Lower Numbers are Better

Details by Inspection Date

 

12/5/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Minimal 3 12/9/2014
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern : Minimal 4 12/9/2014
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Isolated : Minimal 3 12/9/2014
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 12/9/2014
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 12/9/2014
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 12/9/2014
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 12/9/2014
Failed To: Develop policies and procedures for influenza and pneumococcal immunizations. Pattern : Minimal 4 12/9/2014
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 12/9/2014
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 12/9/2014
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 12/9/2014
Failed To: Provide or obtain laboratory services only when ordered by the attending physician. Isolated : Minimal 3 12/9/2014
 

12/13/2013 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Minimal 4 12/20/2013
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 12/14/2013
Failed To: Provide proper discharge planning and communication, of the resident's health status and summary of the resident's nursing home stay. Isolated : Minimal 3 1/7/2014
Failed To: Ensure that residents are safe from serious medication errors. Pattern : Minimal 4 12/14/2013
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 12/18/2013
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 12/16/2013
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 12/16/2013
 

1/18/2013 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide residents with private access to a telephone. Isolated : Minimal 3 2/13/2013
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern : Minimal 4 2/13/2013
Failed To: Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. Isolated : Minimal 3 2/13/2013
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Minimal 4 2/13/2013
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 2/13/2013
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 2/13/2013
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 2/13/2013
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 2/13/2013
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Widespread : Minimal 5 2/13/2013
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 2/13/2013


 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

 

10/31/2014 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 12/5/2014
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Isolated : Actual 4 12/5/2014
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 12/9/2014
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 12/9/2014
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 12/5/2014
 

10/7/2014 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Pattern : Minimal 4 10/13/2014
 

5/15/2014 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Allow residents to have visitors. Isolated : Minimal 3 5/16/2014
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 5/16/2014
 

4/16/2014 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Isolated : Actual 4 4/30/2014
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Actual 4 4/30/2014
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 5/14/2014
 

3/13/2014 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Try to resolve each resident's complaints quickly. Pattern : Minimal 4 4/4/2014
 

1/17/2014 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 1/20/2014
 

8/28/2013 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 9/6/2013
Failed To: Try to resolve each resident's complaints quickly. Pattern : Minimal 4 9/6/2013
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 9/6/2013
 

7/18/2013 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 unknown
 

4/14/2012 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 4/27/2012

 

About The Staff About the Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg TX State Avg
Number of Residents 133 88.17 76.84
Registered Nurses 1.68 0.70 0.57
Licensed Practical / Vocational Nurses 0.48 0.92 0.90
Certified Nursing Assistants 2.54 2.57 2.20
Total Staff Hours 4.70 4.20 3.67

About the Residents About the Staff

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% TX State Avg%
High Risk Long Stay Residents With Pressure Ulcers 12 8 6
Long Stay Residents Experiencing One or More Falls with Major Injury 2 3 3
Long Stay Residents Who Have Depressive Symptoms 16 10 7
Long Stay Residents Who Lose Too Much Weight 19 8 5
Long Stay Residents Who Received an Antipsychotic Medication 23 28 25
Long Stay Residents Who Self Report Moderate to Severe Pain 2 7 8
Long Stay Residents Who Were NOT Assessed and Appropriately Given the Pneumococcal Vaccine 0 13 11
Long Stay Residents Who Were NOT Assessed and Appropriately Given the Seasonal Influenza Vaccine 1 15 8
Long Stay Residents Who Were Physically Restrained 0 1 0
Long Stay Residents Whose Need for Help with ADLs has Increased 20 19 20
Long Stay Residents with a Catheter Inserted and Left in Their Bladder 3 3 3
Long Stay Residents With a Urinary Tract Infection 11 5 6
Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder 55 44 44
Short Stay Residents Who Newly Received an Antipsychotic Medication 1 4 3
Short Stay Residents Who Self Report Moderate to Severe Pain 2 16 18
Short Stay Residents Who Were NOT Assessed and Appropriately Given the Pneumococcal Vaccine 2 30 27
Short Stay Residents Who Were NOT Assessed and Appropriately Given the Seasonal Influenza Vaccine 3 32 25
Short Stay Residents With Pressure Ulcers That Are New or Worsened 1 1 0