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The Colonnades At Reflection Bay

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About The Colonnades At Reflection Bay

General Information

Legal Business NameSweeny Hospital District
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsYes
First Accepted MedicareFebruary 26, 2009 (8 years)
Capacity180
Residents133
Percent Occupied74%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsBoth
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for The Colonnades At Reflection Bay

The Colonnades At Reflection Bay
was reviewed by Medicare to have a rating of 2 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Texas Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Note that this facility has changed ownership within the past 12 months.

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

May 4, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
HSomeActual HarmComplaintProtect each resident from mistreatment, neglect and misappropriation of personal property.
HSomeActual HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
FManyPotential for HarmComplaintHave enough nurses to care for every resident in a way that maximizes the resident's well being.
ESomePotential for HarmComplaintAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
ESomePotential for HarmComplaintProvide care by qualified persons according to each resident's written plan of care.
ESomePotential for HarmComplaintDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
DFewPotential for HarmComplaintMake sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.

February 17, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaint1) 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.

December 5, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmFire Safety InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.
ESomePotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
ESomePotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
ESomePotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmHealth InspectionProvide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible.
ESomePotential for HarmFire Safety InspectionProperly located and lighted "Exit" signs.
ESomePotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
ESomePotential for HarmFire Safety InspectionExits that are free from obstructions and can be used at all times.
ESomePotential for HarmHealth InspectionDevelop policies and procedures for influenza and pneumococcal immunizations.
DFewPotential for HarmHealth InspectionProvide or obtain laboratory services only when ordered by the attending physician.
DFewPotential for HarmHealth InspectionEnsure each resident receives an accurate assessment by a qualified health professional.
DFewPotential for HarmHealth InspectionLet residents refuse treatment, refuse to take part in an experiment, or formulate advance directives.
DFewPotential for HarmHealth InspectionReview or revise the resident's care plan after any major change in physical or mental health.
DFewPotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmHealth InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.

October 31, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
GFewActual HarmComplaintProtect each resident from mistreatment, neglect and misappropriation of personal property.
GFewActual HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .
ESomePotential for HarmComplaintDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
DFewPotential for HarmComplaintImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
DFewPotential for HarmComplaintProvide care by qualified persons according to each resident's written plan of care.

October 7, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Payment DenialPayment denial for 7 days
ESomePotential for HarmComplaintAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.

May 15, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
DFewPotential for HarmComplaintAllow residents to have visitors.

April 16, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$1,625 fine
---Fine$1,625 fine
GFewActual HarmComplaintDevelop 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.
GFewActual HarmComplaintProtect each resident from mistreatment, neglect and misappropriation of personal property.
DFewPotential for HarmComplaintGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

March 13, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintTry to resolve each resident's complaints quickly.

January 17, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmComplaintStore, cook, and serve food in a safe and clean way.

December 13, 2013 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
---Payment DenialPayment denial for 2 days
ESomePotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
ESomePotential for HarmComplaint+InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
ESomePotential for HarmHealth InspectionEnsure that residents are safe from serious medication errors.
ESomePotential for HarmComplaint+InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
ESomePotential for HarmHealth InspectionImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
DFewPotential for HarmHealth InspectionProvide proper discharge planning and communication, of the resident's health status and summary of the resident's nursing home stay.

December 12, 2013 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.
ESomePotential for HarmFire Safety InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.
CManyPotential for Minimal HarmFire Safety InspectionPortable fire extinguishers.
CManyPotential for Minimal HarmFire Safety InspectionEmergency lighting that can last at least 1 1/2 hours.
DFewPotential for HarmFire Safety InspectionProper stairway enclosures and vertical shafts.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of The Colonnades At Reflection Bay require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 30min
2hr 30min
ReportedExpected
CNA
30min
50min
ReportedExpected
LPN
1hr 40min
1hr 25min
ReportedExpected
RN
4hr 40min
4hr 45min
ReportedExpected
Total Nursing

This facility also provides approximately 1hr 10min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

91.4%
57.9%
58.4%
90.7%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Seasonal Influenza Vaccine
100.0%
100.0%
100.0%
87.9%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
67.4%
45.9%
65.7%
46.9%
Q1 2015Q2 2015Q3 2015TX
Low Risk Residents Who Lose Control of Their Bowel or Bladder
23.1%
20.6%
18.2%
22.3%
Q1 2015Q2 2015Q3 2015TX
Received an Antipsychotic Medication
15.3%
24.6%
13.8%
19.6%
Q1 2015Q2 2015Q3 2015TX
Need for Help with ADLs has Increased
0.0%
1.3%
1.6%
8.8%
Q1 2015Q2 2015Q3 2015TX
Self Report Moderate to Severe Pain
14.4%
9.4%
12.2%
6.3%
Q1 2015Q2 2015Q3 2015TX
Lose Too Much Weight
12.5%
14.1%
10.5%
6.6%
Q1 2015Q2 2015Q3 2015TX
High Risk Residents With Pressure Ulcers
4.9%
1.0%
8.3%
6.1%
Q1 2015Q2 2015Q3 2015TX
Have Depressive Symptoms
1.0%
3.0%
1.1%
5.1%
Q1 2015Q2 2015Q3 2015TX
With a Urinary Tract Infection
3.6%
3.0%
2.2%
3.5%
Q1 2015Q2 2015Q3 2015TX
Experiencing One or More Falls with Major Injury
2.7%
2.7%
5.0%
3.3%
Q1 2015Q2 2015Q3 2015TX
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.6%
Q1 2015Q2 2015Q3 2015TX
Were Physically Restrained

Quality Measures for Short Stay Residents

98.3%
95.9%
95.3%
71.4%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
95.2%
44.9%
44.7%
71.1%
Q1 2015Q2 2015Q3 2015TX
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
0.0%
0.0%
0.0%
16.5%
Q1 2015Q2 2015Q3 2015TX
Self Report Moderate to Severe Pain
1.7%
1.9%
1.7%
3.2%
Q1 2015Q2 2015Q3 2015TX
Newly Received an Antipsychotic Medication
0.4%
0.4%
0.0%
1.0%
Q1 2015Q2 2015Q3 2015TX
With Pressure Ulcers That Are New or Worsened