The Colonnades at Reflection Bay

Inspectors wroteBased on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 3 of 6 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. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to be treated with respect and dignity for 1 of 31 residents (Resident #96) reviewed for resident rights. The facility failed to ensure Resident #96's right to be treated with respect and dignity on 4/15/26 when LVN U asked CNA Y to witness medication administration. A staff member poured medications in her mouth and LVN U asked her to open her mouth to ensure she swallowed them. Resident #96 had the ability to take medications independently. The failure could place residents at risk of emotional distress, embarrassment, and loss of dignity.

Inspectors wroteThe facility failed to ensure a post-discharge plan of care was developed with the participation of the resident and ensure post-discharge medical and non-medical services were arranged for 1 of 4 residents (CR #1) reviewed for discharge process. The facility failed to review discharge instructions with CR #1 upon her discharge from the facility. The facility failed to provide CR #1 with a copy of the discharge summary at the time of discharge which caused delay in receiving her motorized wheelchair. The facility failed to provide CR #1 with a reconciled medication list upon discharge, resulting in CR #1 being discharged home without her medications, including prescribed pain medications. CR #1 did not receive her medications until the following morning after discharge. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately submit a PASRR Level 1 Screening screening when a resident admitted with a diagnosis of Mental Illness, Intellectual Disability or Developmental Disability for (1 Resident #9) of 4 residents reviewed for PASRR screenings. The facility did not correctly identify Resident #9 as having mental illness in their PASRR Level 1 Screening. This failure could place residents with documented mental illness diagnoses at risk of not receiving needed care and services in the appropriate setting.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 10 residents (Residents #33 and #28) reviewed for incontinent care. -Resident #1's Foley catheter bag was observed more than half full and was not emptied as needed during observation on 04/29/2026 at 11:22 a.m.- Resident #2's Foley catheter bag was observed more than half full and was not emptied as needed during observation on 04/30/2026 at 5:00 p.m. This failure could place residents with indwelling Foley catheter at risk of infection, sepsis, hospitalization and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care was provided care consistent with professional standard of practice, the comprehensive person-centered care plan, and the residents goals and preferences for 1 of 31 resident (Resident #93) reviewed for respiratory care. The facility failed to ensure Resident #93, who had COPD and required oxygen via nasal cannula, had a functioning oxygen concentrator for approximately 5 hours. Resident #93 was found to have oxygen saturation level below her baseline and complaints of not getting enough air. This failure placed the resident at risk for hypoxia (critical condition where body tissues are deprived of sufficient oxygen), respiratory distress, and deterioration of health.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure drugs and biologicals were secure and labeled for 7 (MC#1, MC#2, MC#3, MC#4, MC#5, MC#6, and MC#7) out of 14 medication carts. The facility failed to ensure medication carts were:1. Locked and secured when not in use.2. Drugs and biologicals were labeled. The failures could place residents at risk of drug diversion, use of expired medication and harm.

Inspectors wroteBased 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.

Inspectors wroteBased 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]. The failures could place residents at risk of poor insulin blood sugar control from expired insulin.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #2) of 4 resident reviewed for accidents and hazards. The facility failed to ensure Resident #2 did not leave the facility without supervision and/or staff knowledge on 06/06/2025 when she was found trying to cross the street and on 06/21/2025 when Resident #2 was found across the street at an apartment complex. The noncompliance was identified as PNC (past noncompliance). The Immediate Jeopardy (IJ) began on 06/05/2025 and ended on 07/06/2025. This failure could place residents at risk of unsafe elopements, injuries, hospitalization and/or death.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one of eight residents (Resident #4) reviewed for enteral nutrition. The facility failed to ensure Resident #4 was not laid in a flat position while her feeding tube was actively flowing by CNA E on [DATE]. The facility failed to ensure LVN D provided timely nursing care/interventions in response to Resident #4's possible aspiration on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 10:39 AM. [...]

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques and ensure that all licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for one of eight (Resident #4) residents. The facility failed to ensure Resident #4 was not laid in a flat position while her feeding tube was actively flowing by CNA E on [DATE]. The facility failed to ensure LVN D provided timely nursing care/interventions in response to Resident #4's possible aspiration on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 08:04 PM. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving, abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegations involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in seriously bodily injury to the state survey agency for 1 of 4 residents (Resident #2) reviewed for abuse and neglect reporting. 1. The facility failed report to the SSA when Resident #2 eloped from the facility on 06/05/2025. 2. The facility failed report to the SSA when Resident #2 eloped on 06/21/2025 when she was found across the street at an apartment complex. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of five residents reviewed for care plans, in that:The facility failed to care plan Resident #1's history of refusal of medication from 05/06/2025 until 06/16/25. This failure could place residents at risk of not receiving services and interventions for the residents' individual needs for person-centered care.

Inspectors wroteBased on record review and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs for one (Resident #3) of six residents review for pharmacy services. The facility failed to administer the following medication to Resident #1: [...]

Inspectors wroteBased on interviews and records review, the facility failed to ensure that medical records were accurately documented for one (Resident #1) of five residents reviewed for accurate clinical records, in that:The facility failed to document in Resident #1's EMR progress notes from 05/13/25 through 06/16/25 that the NP or MD and RP were notified of Resident #1's medication refusals. This failure put residents at risk for inaccurate medical records, decreased quality of care and decline in quality of life.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice, for 1 of 4 residents (Resident #3) reviewed for quality of care. The facility failed to ensure Resident #3 had orders for tracheostomy care and that tracheostomy care was completed on 03/14/2025 and 03/15/2025. This failures could place residents at risk of inadequate care, respiratory distress and hospitalization.

Inspectors wroteBased on interview, and record review the facility failed to provide care consistent with professional standards of practice promoting healing and prevent new pressure ulcers from developing for 1 (CR#1) of 7 residents reviewed for pressure ulcers. -The facility failed to ensure CR #1 received the care and services to prevent a stage 2 pressure wound on her sacral from deteriorating to a Stage 4 measuring 7 (L) x 13 (W) x 3 (D). CR#1 was sent to a local hospital after family intervention and was diagnosed with fever and Sepsis. -The facility failed to immediately begin treatment after CR #1 was admitted on [DATE], a referral made by primary Physician on 3/14/2025 and the first visit by the wound care doctor/NP was on 3/26/2025. -The facility failed to implement new interventions when the sacral wound was not healing and required debridement for necrotic tissue. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 of 9 residents (CR#1, Resident #4 and Resident #5) reviewed for ADL's. -The 2:00 p.m.-10:00 p.m. shift failed to consistently provide showers for Resident #4 who was physically impaired, for at least 11 days causing body odor. She was scheduled to have showers on Tuesdays, Thursdays, and Saturdays. She filed a grievance concerning staff not showering her. - The facility failed to provide CR#1 bed baths on Monday, Wednesdays, Fridays on the 2:00-10:00pm shift. -The facility failed to provide Resident #5 with showers on Monday, Wednesdays, Fridays on the 6a-2pm shift causing him to formerly file two grievances with the facility concerning not getting showers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 1 of 3 residents (Resident#6) reviewed for incontinent care and for indwelling urinary catheters. -Resident #6 Foley catheter bag was lying in the bed near his left calf on 6/4/2025 and hanging to the floor on 6/6/2025. This failure could place residents at risk for accidental dislodgement of the catheter and trauma to the bladder and urethra Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objective and time frames to meet a resident's medical, nursing, mental and psychosocial needs for 1 (Resident #23) of 6 residents reviewed for care plans. The facility failed to ensure that Resident #23's care plan included information regarding his tube feedings that were ordered on 4/17/2025. The failure could place residents at risk of not receiving appropriate care and interventions to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 10 residents (CR #1 and Resident #440) reviewed for pharmaceutical services 1. The facility failed to ensure accurate administering of all drugs and biological to meet the needs of Resident #440, who was administered morphine more frequently than prescribed by the physician on [DATE] and who was administered with the incorrect dosage on [DATE]. 2. The facility failed to acquire, dispense, and timely administer all medications to meet the needs of CR#1, who missed 4 doses of Posaconazole (antifungal) 100mg delayed release tablet between [DATE] and [DATE]. An Immediate Jeopardy was identified on [DATE] at 1:28 PM, and on [DATE] at 9: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain clinical records that were complete and accurately documented for two residents (CR #2 and Resident #10) in accordance with accepted professional standards and practices, reviewed for resident records, in that: -A nurse had documented pre- and post- nebulizer oxygen saturation percentage levels for CR #2 and later said she did not provide a nebulizer treatment. -LVN T did not document CR #2's vital signs at the time they were obtained. -Resident #10 was provided a nebulizer treatment. The nurse documented a post-nebulizer oxygen saturation level without checking the resident's oxygen saturation. These failures could result in delay or omission of necessary interventions due to inaccurate data.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, reviewed for infection control, in that: -Staff entered a room with Enhanced Barrier Precautions and transferred Resident #44 with no PPE except gloves. -The staff removed the Enhanced Barrier Precautions sign from Resident #44's door and exited the area without performing hand hygiene. -Two staff provided incontinent care for Resident #92, who had Enhanced Barrier Precautions, without any PPE except gloves. These failures could place the residents receiving care at risk for cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 residents (CR #2 and Resident #10 ) were provided with respiratory care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, in that: -CR #2 had an order for continuous oxygen but was documented several times as being on room air. -CR #2 had changes of condition regarding his breath sounds that were not reported to the physician. -CR #2 had a documented O2 saturation of 84%, and the physician was not notified. -Staff did not provide continuous supervision with CR #2's nebulizer treatment as was policy. -Staff did not properly assess Resident #10's O2 saturations following a nebulizer treatment, then documented a 98% O2 saturation. These failures could place both residents at risk for respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 3 residents (Resident #1) reviewed for quality of care. -The facility failed to ensure Resident #1's treatment orders for left distal/medial foot were followed as ordered by the NP (Nurse Practitioner) on 11/11/24. -The Wound Care Nurse failed to cover Resident #1's left distal/medial foot with kerlix bandage on 12/31/24 after applying betadine (topical antiseptic and germicide that contains povidone iodine). This failure could affect all residents and place them at risk of decline in health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 5 (Resident #1) reviewed for resident rights, in that: The facility failed to ensure Resident #1's call light was within reach. This failure could place residents at risk of not able to call for assistance.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the resident had a right to and the facility provided a safe, clean, comfortable, and homelike environment for 1 (Resident #3) of 5 resident rooms reviewed for cleanliness. The facility failed to ensure soiled sheets and urine odor was removed from Resident #3's room. This failure could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so the facility is free of pests for 1 of 1 facility in that: The facility failed to keep resident rooms free from roaches. Observed a cockroach in Resident #2's room. This deficient practice could place residents at risk of residing in an environment with pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 9 residents (Resident #1) reviewed for ADL's. The 2:00 p.m. - 10:00 p.m. shift failed to consistently provide showers/bed baths and daily clothing changes for Resident #1, who was physically impaired, for at least two months and resulted in body odors. This failure could place ADL dependent residents at risk of experiencing embarrassment from odors, infection, and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 1 of 3 residents (Resident#1) reviewed for incontinent care and for indwelling urinary catheters. -The facility failed to ensure Resident #1's catheter stabilizer was in place on 09/20/2024. This failure could place residents with urinary catheters at risk for accidental dislodgement of the catheter and trauma to the bladder and urethra.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 3 residents (Resident #1) reviewed for infection. -The facility failed to ensure CNA B performed hand hygiene after removing soiled gloves and before applying new gloves while providing Resident #1 incontinence care. CNA B touched items in Resident #1's environment including the resident's bedside drawer, container of barrier cream, dress, clean brief, and sheets, while wearing soiled gloves. This failure could place residents at risk for the spread of infection

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (CR #1) reviewed for accidents. The facility failed to use an appropriate transfer for CR #1 from bed to wheelchair. This failure could place residents at risk for harm and further injuries.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 residents (Resident #2) reviewed for incontinent care. -The facility failed to ensure CNA J properly cleaned Resident #2 during incontinent care. This failure could place residents at risk for urinary tract infections (UTI), urethral erosions, discomfort, skin breakdown, and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 4 residents (Resident #2) reviewed for infection. -The facility failed to ensure CNA J performed hand hygiene during incontinent care on Resident #2. This failure could lead to the spread of infection to residents, resident illness, and/or resident distress.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pest control. The facility failed to ensure the kitchen was free from roaches and gnats. The facility failed to ensure four resident rooms and kitchen were free from roaches . The facility failed to ensure the dining area near the front lobby was free of two flies. This failure placed residents at risk of infection and food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, based on the comprehensive assessment of the resident, 1 resident (Resident #6) of 5 residents reviewed for wound care received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan. -Resident #6 had a blackened area on her right great toe. -Facility staff did not assess the toe prior to surveyor intervention. -Facility staff did not report the toe issue to the physician prior to surveyor intervention. -Facility staff did not provide treatment to the toe prior to surveyor intervention. The deficient practice could place residents at risk for worsening of the wound and possible pain associated with the wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (CR #10) of 6 residents reviewed for resident rights was treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of his quality of life. -The facility failed to ensure CR #10 was covered and unexposed with the door open to the hallway during incontinent care. -The facility failed to ensure CR #10 was covered and unexposed with the door open to the hallway during wound care. These failures placed residents at risk for other residents, staff, and visitors to observe exposed residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including hand hygiene procedures to be followed by staff involved in direct resident contact for 1 resident (CR #10) of 5 residents reviewed for wound care and incontinent care. The facility failed to ensure the following: -CNA C demonstrated appropriate hand hygiene when providing incontinent care for CR #10. -RN D demonstrated approriate hand hygiene when providing wound care for CR #10. -CNA demonstrated appropriate hand hygiene when handling bloody linens. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments for one (Nurse 900 hall even rooms /1000 hall) of 12 medication carts observed for storage of medications. The facility failed to ensure the nurse 900 hall even rooms /1000 hall medication cart was secured when unattended. This failure could place residents at risk for loss of medications, resident's safety, and drug diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse and neglect for 1 (Resident #1) of 5 residents reviewed for abuse and neglect. CNA A yelled at Resident #1, slapped her left arm three times, and forcefully grabbed her arm, which caused a skin tear on her left arm on [DATE]. The noncompliance was identified as past noncompliance (PNC). The noncomplilance began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began. This failure could place residents at risk of physical or emotional distress, and injury.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 of 5 residents (Resident #1) reviewed for abuse and neglect. The facility failed to appropriately implement written abuse policy which resulted in CNA A hitting and forcefully grabbing Resident #1 left arm which resulted in a skin tear during care. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began. This failure placed residents at risk of physical or emotional distress, and injury.