Health inspection·October 24, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. This failure could place residents at risk of further abuse, physical harm, mental anguish, and/or unsafe elopements. Findings include: Review of Resident #2's face sheet reflected a [AGE] year-old-female admitted on initially admitted on [DATE] and discharged on 07/06/2025 with diagnoses of end stage renal disease (final stage of chronic kidney disease when the kidneys have deteriorated and no longer perform their functions), unspecified dementia (condition where a person experiences cognitive decline), unspecified convulsions (seizures where the specific cause cannot be determined), altered mental status (a change in a person's level of consciousness, alertness, and cognitive function), repeated falls, dependence on renal dialysis (medical necessity for a person to use a machine to filter their blood because their kidneys failed to do so), muscle weakness, and difficulty walking. Review of Resident #2 care plan dated 05/01/2025 with revision date of 07/07/2025 reflected Resident #2 had an ADL self-care performance deficit related to confusion, dementia impaired balance, and limited mobility. Further review reflected Resident #2 had a potential risk for elopement as evidenced by history of attempt to leave facility unattended. Review reflected Resident #2 was found in the front parking lot on 06/06/2025 and attempted to leave premises, trying to cross the street with revision date of 07/07/2025 with interventions to assess for alternative placement frequent monitoring, and provide 1:1 sitter at bedside. Review reflected Resident #2 has impaired cognitive function, difficulty making decisions, short term memory loss with revision date of 07/07/2025 with interventions to cue reorient and supervise as needed. Review of Resident #2 quarterly MDS dated [DATE] reflected Resident #2 had not exhibited wandering behavior. Resident #2 had a BIMS of 12. Review of Resident #2 elopement risk assessment dated [DATE] reflected Resident #2 was at risk and was cognitively impaired, able to ambulate and has intentionally or unintentionally attempted to leave the community. Review of both PCC (electronic health record) and MyUnity (electronic health record) reflected there were no elopement assessments completed prior to 06/21/2025. Review of nursing progress notes dated 06/05/2025 by LVN BB reflected Resident #2 was noticed by staff wheeling herself outside the facility trying to cross the road. Resident was approached by staff and brought back to the facility. [Resident #2] said she was trying to get to her family. Resident was brought back to her room and monitored Page 1 of 42 676207 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some continuously till end of shift. Oncoming nurse notified of [Resident #2's] elopement behavior. Review of nursing progress notes dated 06/06/2025 by LVN BB reflected Resident #2 was found wandering outside the street trying to cross the road. She was brought back into the building and helped to her room. Review of nursing progress note dated 06/21/2025 at 12:34 PM reflected Resident #2 was last seen at about 10:58 [am] when she refused to get her blood sugar checked, at about 11:18 [am], RN H came state someone saw a woman across the street with her head tied, message related to supervisor by the receptionist. The description looks like resident. RN H and other staff members also searched neighborhood, resident could not be seen at this time. [LVN CC] and another nurse crossed the street walked through the apartment complex resident was not seen. [LVN CC] notified 911, on call MD. DON aware. Review of nursing progress note by LVN CC dated 06/21/2025 at 1:40 PM, reflected head to toe assessment was done with no physical injury noted. During an interview on 10/21/2025 at 3:08 PM, the DON stated that she worked as the DON of the facility since March 2025. The DON stated she recalled working with Resident#1 and that she was a bit difficult. The DON stated that Resident #2 often refused to take medication and go to dialysis. The DON stated Resident #2 was forgetful and had some memory loss. The DON stated that she was contacted on 06/21/2025 by LVN CC that Resident #2 was outside. The DON stated that when she arrived the facility Resident #2 was across the street at the apartments. The DON stated Resident #2 told the DON that she wanted to visit her daughter. The DON stated that she found Resident #2 before 1:00 PM and that it was sometime between 11:00 AM and 1:00 PM, but she was unsure exactly when it was. The DON stated that Resident #2 had no injuries when she was found. The DON stated that Resident #2 had no prior elopements and she was unsure why Resident #2's care plan had 06/06/2025 listed as an elopement. The DON stated that Resident #2 would sit outside. The DON stated that after 06/21/2025 Resident #2 was put on 1:1 supervision. The DON stated that prior to the 06/21/2025 elopement there were no interventions in place. The DON stated that the risk to an resident elopement was that with the traffic or people driving fast it was a hazard especially since Resident #2 cannot ambulate quickly in her wheelchair. The DON stated that it was not figured out how Resident #2 left the facility and she had gone outside before but not to leave. The DON stated that the building conducted a search when Resident #2 was reported missing and notified her and the ADM. The DON stated that some staff walked around the building and some staff got into their vehicles and drove around. The DON stated that Resident #2 had urinated and was sweaty, but had a bottle of water around her and was overall okay. The DON stated that the temperature the day of the elopement was hot and stated it was in the 90's for sure. The DON stated that she believed staff were in-serviced on elopement and reiterated the steps on what to do when an elopement happened. The DON stated that after a resident was found, a head-to-toe assessment was done, notified the NP/MD and let the resident's family know they had been found. The DON stated the facility may then look for a more secured environment for the facility. The DON stated that staff should document the elopement on an incident report and it was important so that follow up could have been done with the resident and ensure they were being monitored. The DON stated that there were certain criteria that would mean an elopement was reportable to HHSC. The DON stated that if the resident were confused, demented or wandered aimlessly and was exit seeking were all things that would make an elopement reportable to HHSC. The DON stated she considered this incident reportable, but did not think it was not reported and did not know why. During an interview on 10/21/2025 at 5:01 PM, the ADM stated that Resident #2 had declined dialysis for the last few days. The ADM stated that Resident #2 came downstairs and sat outside. The ADM stated on 06/21/2025 she received a call from the facility that staff could not find Resident #2. The ADM stated she interviewed the nurse and RN H and it was reported to her that a 676207 Page 2 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some different resident's family member reported that a resident was across the street and that the family member saw Resident #2 ask another family (not Resident #2's) to take her across the street and the unknown family member asked Resident #2 if she was allowed to go across the street to which Resident #2 replied yes. The ADM stated she did not know who either family member was, or what resident they were related to. The ADM stated that Resident #2 was found across the street at an apartment complex with this unknown individual. The ADM stated by the time she arrived at the facility Resident #2 had been found and she started in-service with staff on elopement. The ADM stated that Resident #2 was placed on 1:1 until she was discharged . The ADM stated that once a resident went out they cannot keep them at the facility as they did not have an wander guard system. The ADM stated that Resident #2 did not have any previous elopements. The ADM stated that staff reported Resident #2 had refused medication and looked for her for lunch and that was when staff noticed they could not find her. The ADM stated it was about 10-20 minutes that Resident #2 could not be found. The ADM stated that Resident #2 told the unknown individual she wanted a burger and wanted to go to the restaurant across the street The ADM stated that Resident #2 was confused and refusal of dialysis caused increased confusion which is why she tried to go across the street and leave. The ADM defined elopement as when a resident left a building that is confused or had no intent as to where they were going and stated that Resident #2 had intention to go to the restaurant, but was not able to cross the street. The ADM stated she was unsure why Resident #2 had an elopement date of 06/06/2025 for an elopement and that 06/21/2025 was the only time she was aware Resident #2 had an elopement. The ADM stated that Resident #2 was put on 1:1 supervision until a secured facility was found. The ADM stated elopements were reportable to HHSC if they met criteria but since the Resident had a family member with her it was not reportable because she had supervision. The ADM stated it would have been reported if there was a significant injury related to the elopement. The ADM stated it was not reported to HHSC because Resident #2 had someone with her. The ADM stated an investigation was done and that was how she found out a family member took her out and then an in-service was conducted. The ADM stated there were no statements because the unknown family members left. During a subsequent interview with the DON on 10/21/2025 at 5:15 PM, the DON stated that she found Resident #2 at the apartment complex and there were no other staff with the DON and Resident #2 was alone. During an interview on 10/21/2025 at 5:42 PM, RN H that it was reported by a family member of another resident stated there was a man taking Resident #2 across the street. RN H stated that she did not know the person who reported this to her and guessed it had to be the family member of a different resident. RN H stated that she and another staff went across the street to the apartment complex and Resident #2 was found at the complex. RN H stated prior to crossing the street she observed Resident #2 with a male crossing the street (not on a cross walk) and they were walking towards the apartment complex with the unknown male pushing Resident #2 in a wheelchair. RN H stated she asked the unknown male where he came from and that he stated he was going inside the facility and became agitated and stated Resident #2 told him she lived in the apartments and he believed her. RN N stated that when she went across the street to get Resident #2 it was the afternoon and it was not dark. RN H stated that Resident #2 did not go outside prior to the elopement and mostly spent time in her room. RN H stated that the LVN CC completed a head to toe assessment. RN H stated that Resident #2 had supervision because someone was with her and Resident #2 stated he was taking me to my apartment. RN H defined elopement as someone leaving home without any permission or anyone knowing about it or where that person was. RN H that she considered this an elopement whether Resident #2 was with someone or not because Resident #2 left without any permission and she was not in her right mind. RN H stated she did not know how long Resident #2 was 676207 Page 3 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some gone. During an interview on 10/22/2025 at 11:05 AM, ADM stated that there was no elopement reported to her on 06/05/2025 or 06/06/2025. The ADM stated had it been reported to her that Resident #2 tried to cross the street Resident #2 would have been put on 1:1 supervision and discharged much sooner. ADM stated that she would have expected any elopement to be reported to her or the DON. The ADM stated an investigation would have been conducted with interview from Resident #2 to try and figure out what caused the elopement. The ADM stated during investigation normally she talked to the resident staff, find out the last time the resident was seen and put the resident on 1:1 and get with family to start the discharge process. The ADM stated there were no incident reports for 06/05/2025, 06/06/2025 or 06/21/2025 elopements, or witness statements. Review of TULIP from June 2025 through 10/22/2025 reflected no reports for elopements. Review of in-service dated 06/27/2025 titled Elopement reflected in-service was completed with staff and reviewed the policy Elopement Response Protocol. Review of Adhoc QAPI Plan dated 07/01/2025 reflected the ADM was notified on 06/21/2025 at 12:30 PM the facility that a resident was missing. Review reflected there were no staff or witness statements included in the meeting notes. Review reflected inconsistencies among staff on Resident #2's 06/21/2025 elopement. Review reflected there was no investigation or information regarding a 06/05/2025 or 06/06/2025 elopement. Review of facility policy dated March 2012 titled Elopement Response Protocol reflected to Notify Department of Aging and Disability in accordance with guidelines for reportable incidents and based on elopement risk patient may be discharged . Head-to-toe nursing assessment must be completed upon return in addition the physician and responsible party must be notified and document. Review of facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating with revision date of September 2022 reflected if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Review also reflected:2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a. The state licensing/certification agency responsible for surveying/licensing the facility. 676207 Page 4 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings included:Review of Resident #1's face sheet dated 10/320/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage with loss of consciousness status unknown, sequela (bleeding on the brain's surface) where the patient lost consciousness, but the duration is unknown, and it's a sequela, meaning a condition resulting from a previous illness or injury), generalized idiopathic epilepsy and epileptic syndromes (a group of epilepsy syndromes characterized by seizures that originate in both hemispheres of the brain and affect the entire body), and other seizures (a type of seizure that is not a tonic-clonic (a type of generalized seizure that affects the entire brain) seizures).Review of Resident #1's quarterly MDS assessment, dated 07/31/25, reflected a BIMS score of 3, indicating severe cognitive impairment.Record review of Resident #1's care plan dated reflected the following focus areas:focus dated 08/01/25 potential for complications related to seizure disorder and anticonvulsant therapy (the use of medications to prevent or control seizures, also known as convulsions) with intervention dated 08/01/25 give medications per order and monitor labs-report focus dated 08/01/25 Resident #1 had a seizure disorder with intervention dated 08/01/25 give seizure medication as ordered by doctor. Further review revealed the residents medication refusals were not addressed. Review of Resident #1's orders reflected administration of Nicotine Patch 24-hour 7 MG/24 (concentration is equivalent to concentration is equivalent to 2.4% nicotine by volume) apply 1 patch transdermally (the administration through the skin) one time a day 7:00 am for smoking sensation and remove per schedule start date 04/26/25 discharge date [DATE]. Record review of Resident #1's eMAR for June 2025 reflected administration of Nicotine Patch 24-hour 7 MG/24 (concentration is equivalent to concentration is equivalent to 2.4% nicotine by volume) apply 1 patch transdermally (the administration through the skin) one time a day 7:00 am for smoking sensation and remove per schedule start date 04/26/25 discharge date [DATE]. LVN C entered eMAR Code #2 (resident refused) for the following dates: 06/03/25, 06/06/25, 06/09/25, 06/11/25, 06/12/25, 06/13/25, and 06/13/25.Review of Resident #1's orders reflected give 1 tablet MG Folic Acid (a vitamin of the B complex, found especially in leafy green vegetables, liver, and kidney) by month one time a day at 7:00 am for vitamin deficiency start date 05/01/25 and discharge date [DATE].Review of Resident #1's eMAR for May 2025 reflected administration of 1 tablet MG Folic Acid (a vitamin of the B complex, found especially in leafy green vegetables, liver, and kidney) by month one time a day at 7:00 am for vitamin deficiency start date 05/01/25 and discharge date [DATE]. MT B entered eMAR Code #2 (resident refused) for the following dates: 05/13/25, 05/20/25, 05/21/25, 05/23/25, 05/26/25, 05/27/25, 05/28/25, 05/29/25, 05/30/25.Review of Resident #1's eMAR for June 2025 reflected administration of 1 tablet MG Folic Acid (a vitamin of the B complex, found especially in leafy green vegetables, liver, and kidney) by month one time a day at 7:00 am for vitamin deficiency start date 05/01/25 and discharge date [DATE]. MT A entered eMAR Code #2 (resident refused) on 06/01/25 and MT B for the following dates: 06/02/25, 06/03/25, 06/04/25, 06/05/25, 06/06/25, 06/09/25, 06/10/25, 06/11/25, 06/12/25 06/13/25, and 06/16/25. Review of Resident #1's orders reflected 676207 Page 5 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some one 3 MG tablet Melatonin (a hormone naturally produced by the pineal gland in the brain that plays a crucial role in regulating the body's sleep-wake cycle, known as the circadian rhythm) by mouth at bedtime for sleep start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for June 2025 reflected one 3 MG tablet Melatonin (a hormone naturally produced by the pineal gland in the brain that plays a crucial role in regulating the body's sleep-wake cycle, known as the circadian rhythm) by mouth at bedtime for sleep start date 05/01/25 and discharge date [DATE]. MT A entered eMAR Code #2 (resident refused ) on 06/01/25. Review of Resident #1's orders reflected one 15 MG tablet of Mirtazapine (antidepressant used to treat major depressive disorder) by mouth at bedtime for depression start date 05/01/25 and discharge date [DATE].Review of Resident #1's eMAR for June 2025 one 15 MG tablet of Mirtazapine (antidepressant used to treat major depressive disorder) by mouth at bedtime for depression start date 05/01/25 and discharge date [DATE]. MT A entered Code #2 (resident refused) on 06/01/25. Review of Resident #1's orders reflected multiple vitamin tablet give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected multiple vitamin tablet give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE]. MT B entered eMAR Code #2 (resident refused) for the following dates: 5/13/25, 05/19/25, 05/20/25, 05/21/25, 05/23/25, 05/26/25, 05/27/25, 05/28/25, 05/29/25, and 05/30/25. Review of Resident #1's eMAR for June 2025 reflected multiple vitamin tablet give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE]. MT A entered eMAR Code #2 (resident refused) on 06/01/25 and MT B for the following dates: 06/02/25, 06/03/25, 06/04/25, 06/05/25, 06/06/25, 06/07/25, 06/08/25, 06/09/25, 06/10/25, 06/11/25, 06/12/25, 06/13/25, and 06/16/25.Review of Resident #1's orders reflected vitamin B1 (Essential for the proper functioning of the nervous, cardiovascular, and digestive systems) give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected vitamin B1 (Essential for the proper functioning of the nervous, cardiovascular, and digestive systems) give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE]. MT B entered eMAR Code #2 (resident refused) for the following dates: 05/13/25, 05/20/25, 05/21/25, 05/23/25, and 05/26/25, 05/27/25, 05/28/25, 05/29/25, and 05/30/25. Review of Resident #1's eMAR for June 2025 reflected vitamin B1 (Essential for the proper functioning of the nervous, cardiovascular, and digestive systems) give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE]. MT A entered eMAR Code #2 (resident refused) on 06/01/25 8:00 am and MT B for the following dates: 06/02/25, 06/03/25, 06/04/25, 06/25/25, 06/09/25, 06/10/25, 06/11/25, 06/12/25, 06/13/25 and 06/16/25.Review of Resident #1's orders reflected Docusate Sodium (a type of laxative known as a stool softener) oral tablet 100 MG give one tablet by mouth every 12 hours at 8:00 am and 7:00 pm for constipation start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected Docusate Sodium (a type of laxative known as a stool softener) oral tablet 100 MG give one tablet by mouth every 12 hours at 8:00 am for constipation start date 05/01/25 and discharge date [DATE]. MT B entered eMAR Code #2 (resident refused) for the following dates05/20/25, 05/21/25, 05/23/25, and 05/26/25, 05/27/25, 05/28/25, 05/29/25 and 05/30/25. Review of Resident #1's eMAR for June 2025 reflected Docusate Sodium (a type of laxative known as a stool softener) oral tablet 100 MG give one tablet by mouth every 12 hours at 8:00 am and 7:00 pm for constipation start date 05/01/25 and discharge date [DATE]. MT A entered eMAR Code #2 (resident refused) for 8:00 am and 7:00 pm on 06/01/25 and MT B for 8:00 am on the following dates: 06/02/25, 06/03/25, 06/04/25, 06/05/25, 06/06/25, 06/09/25, 06/10/25, 06/11/25, 06/12/25, 06/13/25 and 06/16/25.Review of 676207 Page 6 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #1's orders reflected Valproic ACD (anti-convulsant medication used to treat various types of seizures and other neurological conditions) capsule 250 mg give two capsules orally every 8 hours at 7:00 am, 3:00 pm, and 11:00 pm for seizure start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for June 2025 reflected Valproic ACD (anti-convulsant medication used to treat various types of seizures and other neurological conditions) capsule 250 mg give two capsules orally every 8 hours at 7:00 am for seizure start date 05/01/25 and discharge date [DATE]. MT A entered eMAR Code #2 (resident refused) entered on 06/01/25 and MT B for the following dates: 06/02/25, 06/03/25, 06/04/25, 06/05/25, 06/06/25, 06/09/25, 06/10/25, 06/11/25, 06/12/25, 06/13/25 and 06/16/25.Review of Resident #1's orders reflected levetiraceta Solution (medication used to control and prevent seizures associated with epilepsy) give 15 ml orally two times a day at 7:00 am and 7:00 pm for seizures start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected levetiraceta Solution (medication used to control and prevent seizures associated with epilepsy) give 15 ml orally two times a day at 7:00 am for seizures start date 05/01/25 and discharge date [DATE]. MT B entered eMAR Code #2 (resident refused) for the following dates: 05/13/25, 05/20/25, 05/21/25, and 05/23/25. Review of Resident #1's eMAR for June 2025 reflected levetiraceta Solution (medication used to control and prevent seizures associated with epilepsy) give 15 ml orally two times a day at 7:00 am and 7:00 pm for seizures start date 05/01/25 and discharge date [DATE]. MT A entered eMAR Code #2 (resident refused) at 7:00 am and 7:00 pm on 06/01/25 and MT B at 7:00 am for the following dates: 06/02/25, 06/03/25, 06/04/25, 06/05/25, 06/06/25, 06/09/25, 06/10/25, 06/11/25, 06/12/25, 06/13/25, and 06/16/25.Review of Resident #1's orders reflected Tylenol 8-hour oral tablet extended release 650 MG (Acetaminophen) give one table by mouth every 8 hours at 7:00 am, 3:00 pm, and 11:00 pm for pain level start date 05/20/25 and discharge date [DATE]. Review of Resident #1's eMAR for June 2025 reflected Tylenol 8-hour oral tablet extended release 650 MG (Acetaminophen) give one table by mouth every 8 hours at 7:00 am for pain level start date 05/20/25 and discharge date [DATE]. MA T entered eMAR Code #2 (resident refused) on 06/01/25 and MT B for the following dates: 06/02/25, 06/03/25, 06/05/25, 06/06/25 , 06/09/25, 06/10/25, 06/11/25, 06/12/25, 06/13/25 and 06/16/25.Review of Resident #1's orders reflected Metoprolol tar tablet (medication is used to treat high blood pressure, chest pain (angina), and to improve survival after a heart attack) give 0.5 tablet orally every 12 hours at 7:00 am and 7:00 pm related to essential (primary) hypertension (a condition where the force of blood against artery walls is consistently higher than normal, typically defined as 130/80 mmHg or higher) start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected Metoprolol tar tablet (medication is used to treat high blood pressure, chest pain (angina), and to improve survival after a heart attack) give 0.5 tablet orally every 12 hours at 7:00 am related to essential (primary) hypertension (a condition where the force of blood against artery walls is consistently higher than normal, typically defined as 130/80 mmHg or higher) start date 05/01/25 and discharge date [DATE]. MT B entered eMAR Code #2 (resident refused) for the following dates: 05/21/25, 05/26/25, 05/27/25, 05/28/25, 05/29/25, and 05/30/25. Review of Resident #1's eMAR for June 2025 reflected Metoprolol tar tablet (medication is used to treat high blood pressure, chest pain (angina), and to improve survival after a heart attack) give 0.5 tablet orally every 12 hours at 7:00 am and 7:00 pm related to essential (primary) hypertension (a condition where the force of blood against artery walls is consistently higher than normal, typically defined as 130/80 mmHg or higher) start date 05/01/25 and discharge date [DATE]. MT A entered eMAR Code #2 (resident refused) at 7:00 am and 7:00 pm on 06/01/25 and MT B for 7:00 am on the following dates: 06/02/25, 06/03/25, 06/04/25, 06/05/24, 06/06/25, 06/09/25, 06/10/25, 06/11/25, 06/12/25, 06/13/25, and 676207 Page 7 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 06/16/25.Interview on 10/20/25 at 8: 56 am with the ADON reflected if the number 2 was entered in a residents' eMAR it meant that the resident refused to take the medication. If a resident refused medication from the MT, the policy was for the MT to notify the nurse who would notify the RP and either the NP or MD. Interview on 10/20/25 at 9:22 pm with the NP via phone reflected Resident #1 refused to take his medications. She said he was very non-compliant about a lot of resident care; she gave the example of Resident #1 refusing to take his showers. She said Resident #1 would get angry with staff members and throw them out of his room. She said she cannot recall the number of times the facility called her and told her that Resident #1 refused to take his medications, but it was several times. Interview on 10/20/25 at 1:22 p.m., MT B reflected she had worked at the facility since 2011, worked with Resident #1 and Resident #1 did refuse to take his medications. She said when Resident #1 refused to take his medications, she would try 2 or 3 times to get him to take it and if he still refused, she would tell a nurse he refused. She said she was not sure if she had access to the care plans and it was the responsible of the nurse to document any medication refusals in resident progress notes. She said she discussed his medication refusals with the charge nurses but did not specifically remember who or when. Interview on 10/20/25 at 1:36 p.m., LVN C reflected she worked with Resident #1, and it was common knowledge he did not take his medication. She said she notified both the MD and the RP. She said she reported in staff morning meetings that Resident #1 did not take his medication. She said a care plan was the outline of the care a resident received when at the facility and a care plan included the expectations and goals that the facility had for residents. She said a possible negative effect of not care planning for resident medication refusals was that you would not know how to address the problem and the resident might not get medications the resident needs. Interview on 10/22/25 at 9:25 a.m., MT A via phone reflected she did not really remember Resident #1. She said it was the responsibility of a MT to notify the nurse if a resident refused medication. She said she would try three times to give a resident medication and after that, she would leave it up to the nurse to administer the medication to the resident.Interview on 10/22/25 at 3:40 p.m., the MDS Coordinator reflected a care plan encompassed what services were provided for a resident and was the A to Z, beginning to end, of resident information. He said he did the facility resident comprehensive care plans and sometimes he worked as a nurse on the floor. He said he relied on information received from the nurses who cared for the residents to add to a residents' care plan. He said if a resident refused medication, it should have been included in the resident's care plan. He said the possible negative effect of information not being included in a resident plan was that the information would not be disseminated to the front-line care givers and could affect residents care. Interview on 10/23/25 at 10:56 a.m., MT B reflected Resident #1 would say get out when she would try to give him his medications. She said she would go back two times and try to give him medications and some days he accepted it and some days he did not. She said every time he refused his medications she let someone know. She said she did not know the names of the nurses she told because there were quite a few nurses. Interview on 10/23/25 at 11:06 a.m., the MD reflected she was aware that Resident #1 refused his medications. Interview on 10/23/25 at 1:11 p.m., the ADON reflected a care plan was an individualized plan of care for that resident. She said a care plan started at resident admission and was added to as the facility learned about a resident. She said there was an opportunity to add to the care plan from the input from nurses and other people from the IDT Team (a patient, family members, and professionals from different fields to coordinate care). She said she knew that Resident #1 could be combative and resistant to care so maybe Resident #1 refused medications. She said it was important to identify which care a resident was resistant to and the approach to different refusals of 676207 Page 8 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some care would be different. She said refusals to take medication should be care planned because staff could know about the refusals and follow the interventions and goals for that resident outlined in the residents' care plan. She said a possible negative effect of not care planning for medication refusals was lack of care for that resident and lack of interventions. Interview on 10/24/25 at 9:04 a.m., the Administrator reflected a care plan should tell you everything you need to know about how to are for the resident. She said it was necessary because you need to know what might or might not work for that resident. She said medication refusals should be care planned because it was a behavior and any behavior should be care planned and the facility needs to have interventions to address issues. She said medication refusals could be life threatening. She said everyone was responsible for a care plan. She said the MDS Coordinator was responsible because they did the charts. She said the nurse management team were responsible for making sure resident information was properly documented and the Administrator was ultimately responsible for making sure things were done. She said a possible negative effect of not documenting was that you are not going to fix the problem and in an extreme situation the resident could die. Interview on 10/24/25 at 11:44 a.m., the DON reflected it was her expectation that nurses document changes of condition and resident medication refusal was a change of condition. She said a care plan was an overall summary of how a resident should be cared for and how and what the staff would do to provide care for that resident. She said medication refusals should be care planned. She said the MDS Coordinator was responsible for the resident care plan, but nurses added to the resident care plan. She said that CNAs and MTs do not have any responsibility for care plans. A possible negative effect of not documenting medication refusals in a care plan would be that there would be no documentation that the resident did not get the therapeutic benefits of the medication. A refusal of medication in the care plan would trigger everyone to know that they needed to intervene in a different way when a resident refused to take the medication. She said that medication refusals could have been discussed in the facility morning meetings and resident care plans could be updated. Record review of facility policy Care Plan, Comprehensive Person-Centered dated March 2022 reflected a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan reflects currently recognized standards of practice for problem areas and conditions. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. 676207 Page 9 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings included: Review of Resident #2's face sheet reflected a [AGE] year-old-female admitted on initially admitted on [DATE] and discharged on 07/06/2025 with diagnoses of end stage renal disease (final stage of chronic kidney disease when the kidneys have deteriorated and no longer perform their functions), unspecified dementia (condition where a person experiences cognitive decline), unspecified convulsions (seizures where the specific cause cannot be determined), altered mental status (a change in a person's level of consciousness, alertness, and cognitive function), repeated falls, dependence on renal dialysis (medical necessity for a person to use a machine to filter their blood because their kidneys failed to do so), muscle weakness, and difficulty walking. Review of Resident #2 quarterly MDS dated [DATE] reflected Resident #2 had not exhibited wandering behavior. Resident #2 had a BIMS of 12. Review reflected Resident used a wheelchair or scooter and was able to independently ambulate. Review of Resident #2 care plan dated 05/01/2025 with revision date of 07/07/2025 reflected Resident #2 had an ADL self-care performance deficit related to confusion, dementia impaired balance, and limited mobility. Further review reflected Resident #2 had a potential risk for elopement as evidenced by history of attempt to leave facility unattended. Review reflected Resident #2 was found in the front parking lot on 06/06/2025 and attempted to leave premises, trying to cross the street with revision date of 07/07/2025 with interventions to assess for alternative placement frequent monitoring, and provide 1:1 sitter at bedside. Review reflected Resident #2 has impaired cognitive function, difficulty making decisions, short term memory loss with revision date of 07/07/2025 with interventions to cue reorient and supervise as needed. Review of Resident #2's elopement risk assessment dated [DATE] reflected Resident #2 was at risk and was cognitively impaired, able to ambulate and has intentionally or unintentionally attempted to leave the community. Review of both EMR # 1 and EMR #2 reflected there were no elopement assessments completed prior to 06/21/2025. Review of nursing progress notes dated 06/05/2025 written by LVN BB reflected Resident #2 was noticed by staff wheeling herself outside the facility trying to cross the road. Resident was approached by staff and brought back to the facility. [Resident #2] said she was trying to get to her family. Resident was brought back to her room and monitored continuously till end of shift. Oncoming nurse notified of [Resident #2's] elopement behavior. Review of Resident #2's nursing progress notes dated 06/06/2025 written by LVN BB reflected Resident #2 was found wandering outside the street trying to cross the road. She was brought back into the building and helped to her room. Review of Resident #2's nursing progress note dated 06/21/2025 at 12:34 PM written by LVN CC reflected Resident #2 was last seen at about 10:58 [am] when she refused to get her blood sugar checked, at about 11:18 [am], RN H came state someone saw a woman across the street with her head tied, message related to supervisor by the receptionist. The description looks like resident. RN H and other staff members also searched neighborhood, resident could not be seen at this time. [LVN CC] and another nurse crossed the street walked through the apartment complex resident was not seen. [LVN CC] notified 676207 Page 10 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 911, on call MD. DON aware. Review of Resident #2's nursing progress note by LVN CC dated 06/21/2025 at 1:40 PM, reflected head to toe assessment was done with no physical injury noted. Observation on 10/22/2025 at 8:30 AM reflected a four lane street in front of the facility with a sign posted the speed limit was 50 mph. During an interview on 10/22/2025 at 6:14 PM, LVN CC stated she worked on 06/21/2025 and was the nurse for Resident #2. She stated Resident #2 refused to go to dialysis and that she called and reported this to the doctor. LVN CC stated that Resident #2 was upstairs initially and LVN CC went to check on Resident #2 after her dialysis refusal and Resident #2 was not in her room. LVN CC stated that the receptionist stated sent someone upstairs to tell the nurse that Resident #2 was seen downstairs and that the receptionist was not used to Resident #2 being downstairs. LVN CC stated that she went downstairs and someone told her that someone was seen crossing the street. LVN CC stated she walked to the apartments across the street and asked around if anyone had seen the resident and after searching and not findings Resident #2 they returned to the facility. LVN CC stated she then returned to the facility and called the DON and that it had been at least 40 minutes. LVN CC stated she also called 911 and at this time other CNAs were still searching for Resident #2 and found her at the apartments across the street. LVN CC stated it was several CNAs that returned with Resident #2. LVN CC stated Resident #2 appeared the same and had no changes. LVN CC stated that the street in front of the facility was like a freeway and it was dangerous and could not believe Resident #2 went that far. LVN CC stated she did not recall the time of day and thought it was mid-morning or early afternoon. LVN CC stated she assessed Resident #2 for injuries and none were found. LVN CC stated she was not sure who told the receptionist Resident #2 had left the facility and that person had already left the facility. During an interview on 10/21/2025 at 5:42 PM, RN H stated it was reported by a family member of another resident that there was a man taking Resident #2 across the street. RN H stated she did not know the person who reported this to her and guessed it had to be the family member of a different resident. RN H stated she and another staff member went across the street to the apartment complex and Resident #2 was found at the complex. RN H stated prior to crossing the street she observed Resident #2 with an unknown male crossing the street (not on a cross walk) and they were walking towards the apartment complex with the unknown male pushing Resident #2 in a wheelchair. RN H stated she asked the unknown male after Resident #2 was found where he came from and he stated he was going inside the facility and became agitated and stated Resident #2 told him she lived in the apartments and he believed her. RN H stated when she went across the street to get Resident #2 it was the afternoon and it was not dark. RN H stated Resident #2 did not go outside prior to the elopement and mostly spent time in her room. RN H stated LVN CC completed a head to toe assessment. RN H stated Resident #2 had supervision because someone was with her and Resident #2 stated he was taking me to my apartment. RN H defined elopement as someone leaving home without any permission or anyone knowing about it or where that person was. RN H stated she considered this an elopement whether Resident #2 was with someone or not because Resident #2 left without any permission and she was not in her right mind. RN H stated she did not know how long Resident #2 was gone. During an interview on 10/21/2025 at 1:16 PM, RN AA stated that she has worked at the facility for 2 and a half years and used to work double weekend shift, but recently switched to 6:00 am - 2:00 pm. RN AA stated that she used to work with Resident #2 and that she was told that Resident #2 exited the facility and was found outside and she believed it was sometime before July 2025, but unsure exactly when. RN AA stated she worked the day Resident #2 eloped, but was not Resident #2's nurse that day. RN AA stated that Resident #2 was found by multiple staff at the apartments across the street. RN AA stated that all staff looked everywhere for Resident #2. RN AA stated the protocol for elopement was to 676207 Page 11 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few assess the resident and take their vitals. RN AA stated that Resident mostly sat in her room, but was able to ambulate in her wheelchair. RN AA stated that the day of the elopement Resident #2 stated she was looking for her mom. RN AA stated that she was unsure how the resident got across the s treet and it was a very busy street in front of the facility. RN AA stated that staff reported the elopement to the DON and the ADM. RN AA stated prior to that incident, she was unsure if Resident #2 had any other elopements. During an interview on 10/21/2025 at 1:58 PM, FM stated that the facility notified him that Resident #2 would be discharged as she had walked off the property and she was transferred to a different facility that was secured. FM stated that Resident #2 was confused due to her dementia. During an interview on 10/21/2025 at 3:08 PM, the DON stated that she worked as the DON of the facility since March 2025. The DON stated she recalled working with Resident#2 and that she was a bit difficult. The DON stated Resident #2 often refused to take medication and go to dialysis. The DON stated Resident #2 was forgetful and had some memory loss. The DON stated she was contacted on 06/21/2025 by LVN CC that Resident #2 was outside. The DON stated when she arrived the facility Resident #2 was across the street at the apartments. The DON stated Resident #2 told the DON that she wanted to visit her family member. The DON stated she found Resident #2 before 1:00 PM and that it was sometime between 11:00 AM and 1:00 PM, but she was unsure exactly when it was. The DON stated Resident #2 had no injuries when she was found. The DON stated Resident #2 had no prior elopements and she was unsure why Resident #2's care plan had 06/06/2025 listed as an elopement. The DON stated Resident #2 would sit outside. The DON stated after 06/21/2025 Resident #2 was put on 1:1 supervision. The DON stated prior to the 06/21/2025 elopement there were no interventions in place. The DON stated the risk to an resident elopement was that with the traffic or people driving fast it was a hazard especially since Resident #2 cannot ambulate quickly in her wheelchair. The DON stated it was not figured out how Resident #2 left the facility and she had gone outside before but not to leave. The DON stated the building conducted a search when Resident #2 was reported missing and notified her and the ADM. The DON stated some staff walked around the building and some staff got into their vehicles and drove around. The DON stated Resident #2 had urinated and was sweaty, but had a bottle of water around her and was overall okay. The DON stated the temperature the day of the elopement was hot and stated it was in the 90's for sure. The DON stated she believed staff were in-serviced on elopement and reiterated the steps on what to do when an elopement happened. The DON stated after a resident was found, a head-to-toe assessment was done, notified the NP/MD and let the resident's family know they had been found. The DON stated the facility may then look for a more secured environment for the facility. The DON stated staff should document the elopement on an incident report and it was important so that follow up could have been done with the resident and ensure they were being monitored. The DON stated there were certain criteria that would mean an elopement was reportable to HHSC. The DON stated if the resident were confused, demented or wandered aimlessly and was exit seeking were all things that would make an elopement reportable to HHSC. The DON stated she considered this incident reportable, but did not think it was not reported and did not know why. During an interview on 10/21/2025 at 4:35 PM, Receptionist EE stated she was familiar with Resident #2 and Resident #2 used to attend some activities and she never saw her go sit outside. Receptionist EE stated Resident #2 tried to leave the building and Receptionist EE asked Resident #2 to go back upstairs, but she could not recall when this was. Receptionist EE stated she had not been informed of any residents who were unable to leave the building or that should not go outside unattended. Receptionist EE stated the road in front of the building was busy and she would not personally cross it and would suggest that residents not cross it and it was very dangerous. Receptionist EE stated that Resident #2 was in 676207 Page 12 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few a wheelchair and moved at a slow pace. During an interview on 10/21/2025 at 5:01 PM, the ADM stated that Resident #2 had declined dialysis for the last few days. The ADM stated that Resident #2 came downstairs and sat outside. The ADM stated on 06/21/2025 she received a call from the facility that staff could not find Resident #2. The ADM stated she interviewed the nurse and RN H and it was reported to her that a different resident's family member reported that a resident was across the street and that the family member saw Resident #2 ask another family (not Resident #2's) to take her across the street and the unknown family member asked Resident #2 if she was allowed to go across the street to which Resident #2 replied yes. The ADM stated she did not know who either family member was, or what resident they were related to. The ADM stated Resident #2 was found across the street at an apartment complex with this unknown individual. The ADM stated by the time she arrived at the facility Resident #2 had been found and she started in-service with staff on elopement. The ADM stated Resident #2 was placed on 1:1 until she was discharged . The ADM stated once a resident went out they cannot keep them at the facility as they did not have an wander guard system. The ADM stated Resident #2 did not have any previous elopements. The ADM stated staff reported Resident #2 had refused medication and looked for her for lunch and that was when staff noticed they could not find her. The ADM stated it was about 10-20 minutes that Resident #2 could not be found. The ADM stated that Resident #2 told the unknown individual she wanted a burger and wanted to go to the restaurant across the street. The ADM stated Resident #2 was confused and refusal of dialysis caused increased confusion which was why she tried to go across the street and leave. The ADM defined elopement as when a resident left a building that was confused or had no intent as to where they were going and stated that Resident #2 had intention to go to the restaurant, but was not able to cross the street. The ADM stated she was unsure why Resident #2 had an elopement date of 06/06/2025 and 06/21/2025 was the only time she was aware Resident #2 had an elopement. The ADM stated Resident #2 was put on 1:1 supervision until a secured facility was found. The ADM stated elopements were reportable to HHSC if they met criteria but since the Resident had a family member with her it was not reportable because she had supervision. The ADM stated it would have been reported if there was a significant injury related to the elopement. The ADM stated it was not reported to HHSC because Resident #2 had someone with her. The ADM stated an investigation was done and that was how she found out a family member took her out and then an in-service was conducted. The ADM stated there were no statements because the unknown family members left. During a subsequent interview with the DON on 10/21/2025 at 5:15 PM, the DON stated that she found Resident #2 at the apartment complex and there were no other staff with the DON and Resident #2 was alone.During an interview on 10/22/2025 at 11:05 AM, ADM stated that there was no elopement reported to her on 06/05/2025 or 06/06/2025. The ADM stated had it been reported to her that Resident #2 tried to cross the street Resident #2 would have been put on 1:1 supervision and discharged much sooner. ADM stated she would have expected any elopement to be reported to her or the DON. The ADM stated an investigation would have been conducted with interview from Resident #2 to try and figure out what caused the elopement. The ADM stated during investigation normally she talked to the resident staff, find out the last time the resident was seen and put the resident on 1:1 and get with family to start the discharge process. The ADM stated there were no incident reports for 06/05/2025, 06/06/2025 or 06/21/2025 elopements. During an interview on 10/21/2025 at 2:52 PM, with MT I stated that she did not usually work weeks and recalled working with Resident #2 and stated that Resident #2 was confused. MT I stated that Resident #2 sometimes tried to elope. MT I stated he heard about when Resident #2 was found across the street at an apartment complex.During an interview on 10/21/2025 at 2:58 PM LVN FF stated she worked with Resident #2. LVN FF stated Resident #2 was 676207 Page 13 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few confused quite a bit and she tried to leave the facility a couple of times. LVN FF stated she was not working when Resident #2 eloped from the facility and had only heard the staff looked for Resident #2 at she was not on the premises. LVN FF stated she knew someone brought Resident #2 inside the facility one time because she tried to go across the street. LVN FF stated the only interventions she recalled for Resident #2 was to keep an eye on her. LVN FF stated if a resident was missing the first thing to do was search everywhere and if the resident cannot be found to notify the DON and have all staff start to look for the resident. During an interview on 10/22/2025 at 12:42 PM MD G stated he recalled Resident #2 and she used to refuse dialysis. MD G stated that he did not recall her cognition level, but did believe she had a cognitive decline because she did not always understand the importance of going to dialysis. MD G stated if Resident #2 eloped from the facility and had been without dialysis there was a risk to develop uremia and cause confusion, but he was unsure if that is what Resident #2 experienced. Review of facility policy dated March 2012 titled Elopement Response Protocol reflected to Notify Department of Aging and Disability in accordance with guidelines for reportable incidents and based on elopement risk patient may be discharged . Head-to-toe nursing assessment must be completed upon return in addition the physician and responsible party must be notified and document. The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 06/05/2025 and ended on 07/06/2025. The facility had corrected the noncompliance before the survey began. The facility took the following actions to correct the non-compliance:-Review of in-service dated 06/21/2025 titled elopements reflected in-service was completed with staff with no additional information included.-Review of in-service dated 06/27/2025 titled Elopement reflected in-service was completed with staff and reviewed the policy Elopement Response Protocol. -Review of Adhoc QAPI Plan dated 07/01/2025 reflected the ADM was notified on 06/21/2025 at 12:30 PM the facility that a resident was missing. Interview with charge nurse found resident refused medications an dialysis and was missing for approximately 20 minutes. Interview with weekend supervisor indicated patient asked another family member to take her across the street because she wanted to go get food. Family member took resident to the restaurant and then she wanted to go to the other side of the parking lot. RN H went across the street to get the resident and she was at the apartments. In-service on elopement was conducted and facility updated 100 % of elopement risk assessments. Review reflected there were no staff or witness statements included in the meeting notes. Review reflected inconsistencies among staff on Resident #2's 06/21/2025 elopement. Review reflected there was no investigation or information regarding a 06/05/2025 or 06/06/2025 elopement.-Review of Resident #2's monitoring sheet dated 06/21/2025 reflected Resident #2 was on 1:1 supervision -Review of Resident #2's monitoring sheets dated 06/28/2025 through 07/06/2025 reflected Resident #2 was on 1:1 supervision throughout each shift.-Review of facility elopement risk assessments dated 07/01/2025 reflected no residents were at risk for elopement. 676207 Page 14 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0693 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. While the IJ was removed on [DATE] at 2:20 PM, the facility remained out of compliance at a scope of isolate and severity level of actual harm because all staff had not been trained on safe positioning for residents receiving enteral feeding, aspiration precautions and timely interventions.This failure could place residents at risk of tube malfunction, aspiration, and death.Findings include:Review of Resident #4's face sheet, dated [DATE], reflected an [AGE] year-old female admitted to the facility on [DATE] and discharged [DATE]. Her diagnoses included gastroesophageal reflux disease (a chronic condition where stomach acid flows back into the throat), gastrostomy status (an surgical external opening into the stomach for nutritional support), hemiplegia affecting right dominant side (paralysis to the right dominant side of the body), chronic obstructive pulmonary disease (chronic lung disease that limits airflow and causes ongoing respiratory symptoms), cerebral infarction (a blood clot that impairs blood flow through the artery in the brain), and dysphagia (difficulty swallowing). Review of Resident #4's significant change of status MDS, dated [DATE], reflected a BIMS score of 00 which indicated severe cognitive impairment. Review of Resident #4 care plan report, effective date [DATE], reflected Problems: [Resident #4] is at risk for impaired nutritional status and complications due to enteral [the delivery of nutrients directly into the stomach] feeding. with Interventions: Elevate HOB at least 30 degrees during and 1 hour after feeing. Monitor for s/s of Aspiration.Review of Resident #4's medication administration record, dated 02/2025, reflected Fibersource HN 0.05 gram-1.2 kcal/mL liquid for tube feed (65 cc/hr x 22) liquid enteral tube by shift starting [DATE] and signed off on [DATE] days by LVN A with 520.00 indicating the total milliliters Resident #4 was administered that shift. Review of Resident #4's treatment administration record, dated 02/2025, reflected G-tube - check for residual three times daily starting [DATE] with notes Check GT for residual. If more than 60 cc's hold feedings for 2 hours and recheck. Notify MD if residual remains above 60 cc's after holding for 2 hours. Also reflected was, G-tube - Elevate HOB () by shift starting [DATE]. Neither order reflected a signature on [DATE]. Review of Resident #4's nurses note, dated [DATE] at 11:23 PM, and written by LVN D reflected During routine rounds, the patient was observed with decreased respirations and a weak pulse. A reassessment was conducted, and vital signs were unobtainable. The patient was unresponsive with no signs of respiration or circulation. The attending hospice provider, Director of Nursing (DON), and family were notified of the patient's passing. The family was provided with emotional support and education on next steps per hospice protocol. The physician was notified, and the time of death was confirmed. Post-mortem care was provided according to hospice guidelines. The funeral home was contacted per the family's request. No signs of distress noted. Funeral home arrived around 2:30 pm and provided with required documentation.Observation of video footage without audio provided by Resident #4's FM D, dated [DATE], revealed the following with timestamps in military time as provided:12:20:40-12:20:49 - CNA E lowered the HOB to lay Resident #4 flat. The video stopped as CNA E was removing the top sheet from 676207 Page 15 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0693 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #4. The feeding pump on the left side of the screen appeared to have the screen lit up, indicating it was on. 12:21:23 - Video resumed and Resident #4 was sitting with the head of her bed elevated approximately 45 degrees. CNA E then left the room. Resident #4 did not appear in any distress at that time.12:22:52-12:23:04 - CNA E returned to room, followed by LVN D. Resident #4 started at that time with a moderate amount of white fluid coming from her mouth and down the right side of her chin. LVN D was looking at Resident #4 then walked into the bathroom.12:23:18 - CNA was observed using a cloth to clean the white liquid off Resident #4's chin. LVN D was observed returning to the room as she was putting on gloves and the video stopped briefly.12:23:46-12:26:10 - The video resumed and LVN D was looking behind the nightstand next to the bed with an oral suction device in her hand. She appeared to locate the power cord to the suction machine and plugged it in. LVN D then appeared to be looking around the room and in drawers for something. LVN D appeared to not be able to find what she was looking for and left the room. CNA E remained in the room.12:30:44 - LVN D returned to the room with what appeared to be a suction catheter in her hand.12:30:47-12:30:55 - LVN D stood at the foot of Resident #4's bed waiting for CNA E to put on gloves and move out of the way. LVN D then set the suction catheter on the nightstand and entered the bathroom. 12:31:13 - LVN D exited the bathroom while putting on gloves. She then picks up the oral suction device (that was already in the room) and disconnected it from the suction tubing. She then appeared to be looking at the oral suction device and then touched the suction tubing near the suction machine/canister. The front panel for the feeding pump remained lit up indicating it was turned on. The video stopped.12:31:35 - The video resumed with LVN D standing at Resident #4's left side with oral suction device, connected to the suction tubing, in LVN D's right hand.12:32:16-12:32:32 - LVN D inserted oral suctioning device into Resident #4's mouth and moved it all around in her mouth then removed it from Resident #4's mouth.12:33:14-12:33:34 - LVN D put tip of oral suction device in water to clear the line. She then disconnected the oral suction device and connected the suction catheter. LVN D then placed the suction catheter in Resident #4's mouth. The video then stopped. 12:34:16 - The video resumed with LVN D laying the suction catheter on the nightstand. LVN D is then observed bending over and turning the dial on the oxygen concentrator that was delivering oxygen to Resident #4 through her nasal cannula.12:34:18-12:34:49 - LVN D is observed placing her hand on Resident #4's arm and shaking, then she moved her hand to Resident #4's chest. LVN D's hand then returned to Resident #4's arm to rub her arm forcefully. The feeding pump's screen remained on at this time.12:34:51-12:34:59 - LVN D placed her open left hand on Resident #4's left wrist, it appeared she was checking for a pulse. LVN D then removed her hand from Resident #4's wrist, took off gloves, and left the room. CNA E remained in room with Resident #4. 12:36:23-12:37:07 - LVN D appeared to attempt to get a response from Resident #4 by touching her arm. 12:37:07 - LVN D took her cell phone out of her pocket and called someone. 12:37:32 LVN D left the room while talking on her cell phone. Feeding pump light remained on. 12:38:03-12:38:30 LVN D returned to Resident #4's room and touched resident on the arm again to check for a response. She then turned to leave the room but stopped and turned around. She appeared to be talking to CNA E (no audio was provided with video) and lifted her right hand to point at the feeding pump. CNA E started touching the feeding pump, she then bent over to look at the pump closer and appeared to press something on the feeding pump. CNA E then stood back up and looked at LVN D and started talking while shaking her head left and right. LVN D then left the room, while CNA E continued to look at the feeding pump. 12:39:11 CNA E left the room.12:43:50 - LVN D and CNA E were observed entering the room. LVN D walked directly to the oxygen concentrator and appeared to press something on the machine. LVN D then used her hand to hold Resident #4's wrist. She appeared to have been checking for a 676207 Page 16 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0693 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few pulse. After releasing Resident #4's wrist, LVN D appeared to be talking to CNA E and pointed at feeding pump. LVN D then removed Resident #4's nasal cannula from her nose. She then walked around the bed to the feeding pump (the light on the screen of the feeding pump remained on) and appeared to be pressing something on the machine.12:44:47 - The light on the feeding pump screen turned off after LVN D was done touching it. She then disconnected Resident #4's PEG tube from feeding pump tubing. LVN D and CNA E then appeared to start post-mortem care (the care provided to a person after they die). 12:46:47 LVN D left the room followed shortly after by CNA E.12:47:20 - CNA E entered the room and continued post-mortem care for Resident #4. 12:49:30 - Ex-DON entered Resident #4's room and entered the bathroom. She returned to the room shortly afterward. CNA E then exited the room. Ex-DON then approached Resident #4 and adjusted Resident #4's clothes, she then held Resident #4's wrist to possibly assess for a pulse. Ex-DON then appeared to touch the top of Resident #4's foot. 12:52:45 - CNA E returned to the room with linen. Ex-DON and CNA E continued providing post-mortem care to Resident #4, which included Ex-DON cleaning her eyes. 12:53:44 - LVN D returned to the room and appeared to have a conversation with Ex-DON. After the conversation, Ex-DON exits the room and LVN D and CNA E resume post-mortem care until the end of the video. During a phone interview on [DATE] at 12:22 PM, FM D stated she was concerned about the care provided to Resident #4 on the day she died. She discussed the video from [DATE] that was submitted and stated she would attempt to resend with audio available. FM D stated she met with the ex-DON on [DATE] and showed her the video, but the ex-DON was no longer working at the facility, in fact, she quit that day. She stated the ex-DON told her several things in the video should have been done differently and was apologetic. She stated she could not remember the names of the staff members in the video that provided care to Resident #4. FM D stated Resident #4 was choking in the video and died shortly afterward. She stated she just wished staff would have moved faster to suction Resident #4 that day so that Resident #4 did not have to suffer before she died. During an interview on [DATE] at 09:19 AM, LVN D stated she was taking care of Resident #4 on the day she died. She stated that Resident #4 had been declining for an unknown amount of time. She stated the CNA (she could not remember who the CNA was that day) had provided care to Resident #4 and then reported to LVN D that Resident #4 needed to be suctioned. She stated the suction tubing in the room was not the correct one or was not functioning (she couldn't quite remember), so she had to leave the room to go get the correct materials to suction Resident #4. LVN D assessed Resident #4, she had some, but not a lot, clear secretions. LVN D denied Resident #4 showing any signs of distress or aspiration prior to her death. LVN D then stated, I don't remember the exact situation going on, I just remember caring for the patient. She then stated she just provided the general care for Resident #4 that day. LVN D stated, Honestly, I don't remember that far back, and I don't want to say something that isn't true.During an interview on [DATE] at 10:40 AM, the video without audio of Resident #4 was viewed with LVN D. LVN D stated she had not seen the video previously. She stated she still could not remember the name of the CNA working that day, even after seeing her on video. LVN D stated that the CNA should notify the nurse to turn off a feeding pump prior to providing care that required the head of the bed to be lowered. She stated that residents should not be laid flat if they are connected to a feeding pump and receiving formula through a PEG tube. She stated if they were laid flat while receiving a continuous feeding through a PEG tube, then the resident could aspirate (the stomach contents could go up the throat and into their airway). LVN D stated she was unaware that Resident #4's head of the bed was lowered to lay her flat by the CNA that day. She stated, It was not out of the ordinary for [Resident #4] to be suctioned. There was nothing alarming when I assessed her. LVN D was asked about the secretions coming from Resident #4's mouth in the 676207 Page 17 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0693 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few video. She stated Resident #4 was drooling. She then stated, I don't remember her having a colored secretion, it was a clear secretion. LVN D stated after watching the video she had to go downstairs to obtain the materials needed to suction Resident #4. After viewing the video where she suctioned Resident #4, LVN D stated she didn't remember if the oral suctioning device was able to suction the secretions. She then stated, At this point, I feel uncomfortable with guessing what happened based on the video because I cannot hear what is being said. I feel like she was in her normal state. There was not a large amount of secretions. I was just doing my normal patient care for her. LVN D stated she remembered calling Ex-DON because she was in the building to let her know. She stated Ex-DON did not work at the facility anymore. When LVN D was asked about specifics of the video she kept repeating, I feel uncomfortable saying because I can't hear what is being said. She acknowledged checking for a radial pulse for Resident #4 while waiting for Ex-DON to enter the room during the video. LVN D remained resistant to answering questions during the interview. She was asked Should anything have been done differently? after watching the video. She responded, Honestly I couldn't hear what was going on, but I did my best to care for her as a patient. During an interview on [DATE] at 11:38 AM, the DON stated she started at the facility on [DATE]. She stated CNAs are required to notify the nurse to pause a feeding pump if they needed to provide care for the resident that required lowering the head of the bed to less than 30 degrees. She stated it was not within the CNA scope of practice to alter the feeding pump by pausing it, turning it on, and/or turning it off, even if the nurse is in the room and tells them to do it. The video of Resident #4, dated [DATE], was viewed with the DON. She stated she had no knowledge of the incident or the video prior to the interview. She stated the CNA in the video no longer worked in the facility and that she could not remember her name. The DON stated the feeding pump appeared to be on and running in the beginning of the video when CNA E entered the room. She stated the video showed CNA E laying Resident #4 completely flat and the pump appeared to still be running. She stated by laying Resident #4 in that position, it could cause aspiration, cause the formula to go back up into the esophagus[throat] and down into the lungs and aspirate The DON watched CNA E and LVN D(whom she identified by name) enter the room and liquid start coming from Resident #4's mouth and stated, looks like something is coming out of her mouth It looks like formula, white and opaque. The DON stated she would expect LVN D to move with a sense of urgency to turn off the feeding pump and set the resident all the way up. She stated the video showed it took LVN D almost 10 minutes to suction Resident #4 after she first showed signs of aspiration and even then, the pump continued to appear to be running. The DON watched the remainder of the video and stated, that was disheartening. She stated the staff did not appear to have a sense of urgency, the pump was not turned off until after the resident appeared without life, the resident was not properly assessed with vitals and lung sounds upon signs of aspiration, and post-mortem care was started prior to the RN pronouncing death in the video. She stated she thought the outcome of Resident #4 might have changed if CNA E had the nurse pause the feeding pump prior to lowering the head of the bed. The DON stated, If the nurse would have suctioned her and raised the head higher and stopped the feeding, it could have possibly changed the outcome. We don't know how much formula had already gone into the lungs. We could have done an x-ray to see if she needed some type of treatment. She stated the video never showed a RN pronouncement of death because that required a stethoscope to listen for lung and heart sounds and no stethoscope was witnessed in the video. She stated LVN D should have removed any medical treatments, including taking the nasal cannula off Resident #4, until after the death was pronounced by a RN. She stated she expected LVN D to assess Resident #4 and document what was witnessed, including the color and amount of fluids that came out of Resident #4's mouth, her 676207 Page 18 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0693 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few assessment of lung sounds, interventions performed like: suctioning, what position Resident #4 was placed in and when the feeding pump was turned off, and also notification of proper personnel. After reviewing the nurses' note that documented the event, the DON stated, that's not how it went down. She didn't take a pulse ox, she didn't listen to the lungs. The note doesn't reflect the initial encounter with fluid coming from her mouth. She then stated she expected more from staff. The DON stated she would provide a staffing sheet for [DATE] and the employee files for the staff involved in the video.During an interview on [DATE] at 04:15 PM, the DON stated LVN D was scheduled to work 2pm-10pm that evening and would be working the remainder of her shift. During an observation on [DATE] at 04:17 PM, LVN D was witnessed standing at a medication cart on the 200-hall. During an interview on [DATE] at 04:44 PM, CNA F stated she was trained by the ADON to press the pause button on feeding pumps prior to lowering the head of the bed to prevent the resident from aspirating and to restart the pump once the head of the bed was raised back up. Attempted phone interview with MD G x 3 on [DATE] at 11:28 AM, 12:40 PM, and 05:43 PM without success.During an interview on [DATE] at 07:24 PM, the ADM stated the DON told her she had watched a video that was disheartening earlier that day but did not get any further details about the video. She stated she felt she had a good relationship with Resident #4's family. She stated she never discussed a video related to Resident #4 with Ex-DON. The ADM stated Ex-DON quit while the ADM was out of town. She stated prior to that she had discussed Ex-DON moving to the weekend nurse manager position in March. The video from [DATE] provided by FM D was viewed with the ADM. The ADM stated she did not know who the CNA in the video was. The ADM started shaking her head left and right. When asked why, she stated because she is lowering the head of the bed without having the nurse shut the pump off.Ok so she is spitting up.looks like formula to me. The ADM was able to identify LVN D and Ex-DON in the video. After the video, the ADM was asked what she observed wrong in the video and if protocol was followed. The ADM stated, Everything on it.the CNA lowered the head of the bed, the nurse did not turn off the pump.when she was throwing up she was not placed on her side while they were working to get the suction machine to work.the nurse did not do an assessment.she did not listen to lung sounds.I am in shock.No, protocol was not followed.I am so confused right now. The ADM stated she was not surprised to learn Resident #4 had died because she had been declining for some time. The ADM denied receiving the video in an email. She stated if she had seen the video before she would have fired the CNA, the LVN and reported it to regulatory services. The ADM stated the DON should have notified her about what was observed in the video and LVN D should have been removed from her shift immediately. The ADM stated she would notify the DON to escort LVN D out of the building immediately. Review of facility policy titled Nursing Policy & Procedure Enteral-Section 4, dated 06/2006 and last updated 03/2019, reflected Administration of Formula via Feeding Tube Gravity, Bolus, Pump.Procedures.Elevate head of bed at 30 to 45 degree angle or above during the feeding and for at least one hour after the feeding. Potential Complications of Tube Feedings.Responsibility.Licensed Nurse.Purpose.Prevention and possible solutions to complications in the tube fed Patient.Problem.Mechanical: Aspiration Pneumonia.Prevention/Possible Solution.Observe for signs and symptoms of aspiration (wheezes, rales, cough, apnea[temporary pause in breathing], hypotension[low blood pressure]).Elevate HOB 30 to 45 degrees during feeding and 30-60 minutes after feeding.Endotracheal[into the trachea/breathing tubes that connect mouth and nose to lungs] suctioning to stimulate cough when aspiration witnessed.Observation on [DATE] at 08:21 PM, the ADM escorted LVN D out of the building.During an interview on [DATE] at 08:53 AM, the ADM identified CNA E as the CNA in the video. She stated the DON told her who the CNA was in the video. She stated CNA E was working last night and once she realized it, she sent CNA E home immediately. She stated she also 676207 Page 19 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0693 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few suspended the DON because she did not remove LVN D and CNA E from providing care to the residents of the facility immediately after observing the video. The ADM provided the staffing sheet for [DATE].Review of facility Daily Sign in Sheet, dated Friday February 21, 2025, reflected LVN D and CNA E were assigned to Resident #4's room on that day.This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The ADM was notified on [DATE] at 10:39 AM and a template was given. During an interview on [DATE] at 04:22 PM, MD G stated he was the primary physician for Resident #4. He stated he did not remember any specific information about Resident #4 though. He stated if a resident were receiving continuous feeding by a feeding pump through a PEG tube, then the head of the bed should be raised greater than 30 degrees to prevent aspiration. He stated a resident could aspirate at any time, but the chances of the resident aspirating if the head of the bed is lowered when they are receiving formula through a PEG tube greatly increases. The following Plan of Removal submitted by the facility was accepted on [DATE] at 12:26 PM: Immediate JeopardyPlan of Removal[DATE]F693 Tube Feeding Management Immediate Action:Impact Statement:The facility failed to ensure residents who are fed by enteral means receive the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. The facility failed to ensure Resident #4 was not laid in a flat position while her feeding tube was actively flowing by CNA E.The facility failed to ensure LVN D provided timely nursing care/ interventions in response to Resident #4's possible aspiration on [DATE]. Please accept this as a Plan of Removal for the alleged Immediate Jeopardy related to failure to ensure that ensure residents who are fed by enteral means receive the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.Systematic Approach:Immediate Action Resident #4 is no longer in facility. The Executive Director suspended LVN D, CNA E, and Director of Nursing as soon as Executive Director received notification from state surveyors at approximately 8:00pm on [DATE]. Depending on conclusion of ongoing investigation, if warranted and staff are to return, they will be provided with training prior to providing direct care to residents. The Executive Director initiated a formal investigation and initial report submitted to HHSC on [DATE]. The Executive Director notified the facility Medical Director of the Immediate Jeopardy on [DATE]. An emergency QAPI meeting was held on [DATE]. [DATE] The Regional Director of Regulatory Compliance, Regional Director of Clinical Services and Nurse Managers audited all current resident (a total of eight residents), with feeding tubes to ensure proper positioning during feedings (head of bed elevated to 30-45 degrees), medical orders reviewed to ensure Head Of Bed is elevated order is in place, and competency validation for current CNAs and licensed nurses. Competencies included safe positioning for nurses and CNAs, and oral suctioning for nurses. No additional residents were found to be at risk. Audits completed on [DATE]. Competencies to be completed on [DATE]. Executive Director, Regional Director of Regulatory Compliance, Nurse Managers will in-service all CNAs and Licensed Nurses in Safe positioning for residents receiving enteral feeding, aspiration precautions and timely interventions. Training for all newly hired staff will be completed prior to being assigned to the floor beginning [DATE]. Training for all PRN staff or staff who have not worked since 8/2025 will be completed prior to working beginning [DATE] and will continue until all PRN nursing staff have received training. Any PRN staff who has not worked in 60 days will be removed from the PRN program. Each employee will complete a post-test after their education to ensure staff are able to identify any residents at risk of aspiration. If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. 676207 Page 20 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0693 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Education will be completed by [DATE]. Assessment [DATE] The Regional Director of Regulatory Compliance, Regional Director of Clinical Services and Nurse Managers audited all current residents with feeding tubes (a total of eight residents), to ensure proper positioning during feedings (head of bed elevated to 30-45 degrees), medical orders reviewed to ensure Head Of Bed is elevated, and competency validation for current CNAs and licensed nurses. Competencies included safe positioning for nurses and CNAs, and oral suctioning for nurses. No additional residents were found to be at risk. Audits completed on [DATE]. Competencies to be completed on [DATE]. Who will be responsible: The Regional Director of Regulatory Compliance/ Unit ManagersWho Will monitor: Executive Director/Regional Director of Clinical conduct two daily random observations of licensed nurses performing tube feedings for 30 days, ensuring proper positioning and suctioning technique as applicable. The Nurse Managers and/ or Designee will conduct two daily observations of CNAs providing care to a resident who receives tube feeding to ensure proper positioning, and ensuring CNAs are not turning off feeding pump, but instead communicating with nurse. Staff who fail to demonstrate competency will receive immediate retraining. Depending on conclusion of current investigation, if warranted and LVN A and CNA B are to return, they will be provided with training prior to providing direct care to residents After the 30 days, random observations will continue to be completed to include 10% of residents who receive enteral feedings per week for eight weeks. Staff who fail to demonstrate competency will receive immediate retraining. Nurse Managers and/or designee will audit new admissions with enteral feedings to ensure orders to maintain Head of Bed elevated are in place. Policy and Procedures Policy and procedures were reviewed by [NAME] President of Operations, Regional Director of Regulatory and Compliance, Regional Director of Clinical Services, Executive Director, and Director of Nursing. Policies include Administration of Formula Via Feeding Tube Gravity, Bolus, Pump. No policies needed any revisions. Monitoring of the POR on [DATE]-[DATE] included the following:Review of Resident #4's electronic health record reflected she was discharged from the facility on [DATE] at 01:45 PM to deceased .During interviews on [DATE] from 12:16 PM-06:30 PM and [DATE] from 09:10 AM - 01:30 PM, nine CNAs, six LVNs, and three RNs from different shifts all stated they were in-serviced before their shifts on safe positioning for residents receiving enteral feeding, aspiration precautions, and timely interventions, including competency training on suctioning for all licensed nurses. All were able to explain the correct positioning for residents receiving enteral feeding, who was allowed to start/stop/adjust/silence the feeding pump, signs and symptoms of aspiration, and what to do if they observe a resident aspirating. Review of LVN D's employment file, on [DATE], revealed she was suspended on [DATE] and involuntarily terminated on [DATE] for misconduct. Review of CNA E's employment file, on [DATE], revealed she was suspended on [DATE] and involuntarily terminated on [DATE] for misconduct.Review of the DON's employment file, on [DATE], revealed she was suspended on [DATE] and involuntarily terminated on [DATE] for unprofessional behavior.Review of facility-reported incident reflected, a formal complaint to regulatory authorities with intake number 1045259 was initiated and submitted on [DATE] at 10:23 PM.Review of the facility's AD HOC QAPI Plan, dated [DATE], reflected the medical director, the ADON, the ADM, and other facility and corporate staff were in attendance. Review of statement written by the ADM reflected: Medical Director.was notified of immediate jeopardy on [DATE] at approximately 9:00 PM. Review of electronic health records for eight of eight residents who received enteral nutrition revealed medical orders to ensure the head of the bed was elevated were in place.Observations on [DATE] at 11:50 AM and 4:45 PM revealed eight of eight residents that received enteral nutrition with the head of their bed elevated greater than 30 degrees. Observations on [DATE] at 09:30 AM 676207 Page 21 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0693 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and 01:00 PM revealed eight of eight residents that received enteral nutrition with the head of their bed elevated greater than 30 degrees.Review of facility audit, dated [DATE], reflected orders for and observation of head of bed elevated for eight of eight residents that received enteral nutrition was completed by the RDRC.Review of facility audit, dated [DATE]-[DATE], reflected daily audits were conducted for observations of enteral feeding for of eight of eight residents that received enteral nutrition by either the ADM or the RDRC.Review of 20 post-tests and 20 skills check-off sheets, dated [DATE], reflected licensed nurses demonstrated proper skills and demonstrated knowledge on performing respiratory assessments, suctioning and respiratory care. Review of 107 post-tests, dated [DATE]-[DATE], reflected staff demonstrated knowledge of competency for enteral feeding. Review of in-service spread sheet reflected 98 of 103 staff had completed in-services as of [DATE]. During an interview on [DATE] at 1:30 PM, the ADM stated more than 90% of their staff had been in-serviced on safe positioning for residents receiving enteral feeding, aspiration precautions and timely intervention. She stated that no one would work until they were in-serviced. The ADM was notified the IJ was removed on [DATE] at 2:20 PM. However, the facility remained out of compliance at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.During an interview, after exit, on [DATE] at 05:04 PM, Ex-DON stated she previously worked at the facility, but quit on the last week in February 2025. She ac 676207 Page 22 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Review of Resident #3 face sheet reflected a [AGE] year-old-male admitted on [DATE] at 7:00 PM and discharged on 03/15/2025 at 12:15 PM. Diagnoses included hypertensive heart disease (condition where prolonged high blood pressure damages the heart muscle), chronic kidney disease (condition where the kidneys gradually lose their ability to filter waste from the blood), malignant neoplasm of thyroid gland (cancer that develops in the thyroid gland). Review of admission MDS dated [DATE] reflected Resident #3 Section O titled Special Treatments, Procedures and Programs reflected tracheostomy care was not selected. Review of baseline care plan dated 03/15/2025 by ADON reflected Resident #3 was alert / cognitively intact. Review of care plan dated 03/15/2025 reflected Resident #3 was on enhanced barrier precautions with feeding tubes selected for the reason and tracheostomy was not selected. Review of admission/ re-admission charge nurse report form dated 03/14/2025 by RN ZZ reflected Resident #2 had a thyroidectomy, shortness of breath, neck swelling, and a peg tube. Review reflected Resident #3 was alert and oriented x3 (person, time, place, situation). There was no information that Resident #3 had a tracheostomy. Review of nursing admission assessment with admission date of 03/14/2025 reflected no tracheostomy was present for Resident #3. Review of Resident #3 hospital discharge instructions dated 03/14/2025 reflected Resident #3 required a portable trach suctioning, had a shiley (size 6) and a cuffless trach (reusable inner cannulas). Review reflected does patient have a tracheostomy?: Yes. Review of physician orders and treatments dated 03/15/2025 reflected there were no orders for tracheostomy care or suctioning. Review of the MAR/ TAR for Resident #3 dated 03/15/2025 reflected there were no treatments provided for tracheostomy care. Review of nursing progress notes dated 03/15/2025 by LVN O at 1:19 PM Resident #3's family member stated that Resident #3 complained of back pain and requested to be sent to the hospital. LVN O scheduled transportation with vital signs within normal limits. Interview was attempted with Resident #3 on 10/20/2025 at 3:14 PM , however, the number provided for Resident #3 was out of service. An email was sent at 3:17 PM on 10/20/2025 with no response. During an interview on 10/21/2025 at 10:51 AM, LVN O stated he has worked at the facility since December 2024. He stated that if residents were admitted with a tracheostomy, there was a suctioning machine set up in the residents room and the nurse had to make sure the resident had tracheostomy care per doctor's orders. LVN O stated this included PRN suctioning orders as well. LVN O stated it was hard to say often residents needed to be suctioned because secretions are different for every resident. LVN O stated that usually tracheostomy care was done in the morning between 4:00 am and 6:00 am. LVN O stated he worked overnight and he usually provided tracheostomy care in the morning which included to change the dressing of the tracheostomy. LVN O stated that if a resident was a new admission then orders were received from the hospital and then verified by the on-call doctor. LVN O stated that after admission the on-call provider would be notified that a resident admitted with a tracheostomy and the provider would give orders for care to be put into the system. LVN O stated he did not recall Resident #3 and whether or not the resident had a tracheostomy. During an interview on 10/22/2025 at 12:42 PM, MD G stated if a resident admitted to the facility with a tracheostomy then there is an order set for tracheostomy care that staff can put into the system and it was expected that Residents Affected - Few 676207 Page 23 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few they do so and verify orders with the provider. During an interview on 10/22/2022 at 3:24 PM, RN ZZ stated she did not recall Resident #3 or if he had a tracheostomy. RN ZZ stated that sometimes nurses will take report for other nurses and taking report did not always mean they completed the admission for the resident. RN ZZ stated there was a respiratory therapist that provide care a few times a week and that charge nurses also provided tracheostomy care. RN ZZ stated that usually tracheostomy care was done every shift and at least assessed. RN ZZ stated that if dressing was soiled it will get changed and it was also changed when tracheostomy care is provided. RN ZZ stated that there are also orders put into place as to when to provide tracheostomy care. RN ZZ stated for new admissions, the doctor usually put the orders for tracheostomy care. RN ZZ stated that there were also standing orders for tracheostomy care that the DON will put in. RN ZZ stated that usually suctioning was completed every four hours and as needed. During an interview and observation on 10/22/2025 at 3:48 PM, ADON stated she did not recall Resident #3 at all and that her name was on the assessment because she may have helped out the charge nurse. ADON reviewed Resident #3's discharge information and stated that based on the hospital discharge paperwork it looked like Resident #3 had a tracheostomy. ADON stated that charge nurses completed tracheostomy care and there was a respiratory therapist that came out a few times a week and would provide tracheostomy care as well and change out supplies and assess residents. ADON stated orders for tracheostomy care were provided by doctors and there were standing orders in place for resident who admitted with a tracheostomy that the nurse could put in. ADON stated there were also orders from discharge records from the hospital. ADON stated orders should be put in the same day the resident admitted to the facility. ADON stated it was important for orders to be put in so nurses know to provide tracheostomy care. ADON stated tracheostomy care was performed each shift and suctioning was provided according to how much secretion the resident had. ADON stated a potential risk for a resident not receiving tracheostomy care was risk of aspiration or shortness of breath. ADON stated usually she checked admission orders when she arrived the next morning, but she was not at the facility on weekends and the RN H would check the admissions on the weekends. An attempted telephone interview was conducted on 10/23/2025 at 11:39 AM and 1:03 PM with the DON a voicemail was left but the call was not returned. During an interview on 10/23/2025 at 12:02 PM, LVN Y stated that if a resident admitted with a tracheostomy the nurse was supposed to place all tracheostomy orders into the computer and that included the suctioning orders and tracheostomy care. LVN Y stated that tracheostomy care was provided each shift and suctioning was done as needed and when the care was performed. LVN Y stated that the doctor providers the orders and they are put into the system. LVN Y stated that there are existing orders that can be put in place for new admissions with tracheostomy. LVN Y stated that discharge orders were received and report is received form the hospital to ensure that information is received on whether or not the resident has a tracheostomy to ensure everything is put into place. During an interview on 10/23/2025 at 3:49 PM, the ADM stated there are standing orders that can be put into place for residents who admit with tracheostomies. The ADM stated there are batch orders that can be put in and reviewed with everything the residents needs for tracheostomy care. The ADM stated new admission orders are reviewed daily during the IDT which included significant changes and admissions. The ADM stated a resident should have had tracheostomy care the day of admission and the nurse should have verified those orders. The ADM stated if the hospital did not provide orders, staff can reach out to the hospital and once the orders were verified they can be put in. The ADM stated there was no time limit as to when orders could be verified with the doctor. The ADM stated a potential risk to a resident not having tracheostomy care orders could be respiratory distress or death. Review of in-services for February 2025 through October 2025 676207 Page 24 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0695 Level of Harm - Minimal harm or potential for actual harm reflected there were no in-services conducted on tracheostomy care. Review of in-service dated 04/18/2025 titled admission Assessments was completed with nursing staff and reflected nurses are to complete admission assessment within 24 hours. Review of policy titled Tracheostomy Care with revision date of August 2013 reflected procedure included to check the physician order. Residents Affected - Few 676207 Page 25 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. While the IJ was removed on [DATE] at 2:20 PM, the facility remained out of compliance at a scope of isolate and severity level of actual harm because all staff had not been trained on safe positioning for residents receiving enteral feeding, aspiration precautions and timely interventions.These failures could place residents at risk for being provided care by staff who do not have the skills and competencies necessary for providing care and services. Findings included:Review of Resident #4's face sheet, dated [DATE], reflected an [AGE] year-old female admitted to the facility on [DATE] and discharged [DATE]. Her diagnoses included gastroesophageal reflux disease (a chronic condition where stomach acid flows back into the throat), gastrostomy status (an surgical external opening into the stomach for nutritional support), hemiplegia affecting right dominant side (paralysis to the right dominant side of the body), chronic obstructive pulmonary disease (chronic lung disease that limits airflow and causes ongoing respiratory symptoms), cerebral infarction (a blood clot that impairs blood flow through the artery in the brain), and dysphagia (difficulty swallowing). Review of Resident #4's significant change of status MDS, dated [DATE], reflected a BIMS score of 00 which indicated severe cognitive impairment.Review of Resident #4 care plan report, effective date [DATE], reflected Problems: [Resident #4] is at risk for impaired nutritional status and complications due to enteral [the delivery of nutrients directly into the stomach] feeding. with Interventions: Elevate HOB at least 30 degrees during and 1 hour after feeing. Monitor for s/s of Aspiration.Review of Resident #4's medication administration record, dated 02/2025, reflected Fibersource HN 0.05 gram-1.2 kcal/mL liquid for tube feed (65 cc/hr x 22) liquid enteral tube by shift starting [DATE] and signed off on [DATE] days by LVN A with 520.00 indicating the total milliliters Resident #4 was administered that shift. Review of Resident #4's treatment administration record, dated 02/2025, reflected G-tube - check for residual three times daily starting [DATE] with notes Check GT for residual. If more than 60 cc's hold feedings for 2 hours and recheck. Notify MD if residual remains above 60 cc's after holding for 2 hours. Also reflected was, G-tube - Elevate HOB () by shift starting [DATE]. Neither order reflected a signature on [DATE]. Review of Resident #4's nurses note, dated [DATE] at 11:23 PM, and written by LVN D reflected During routine rounds, the patient was observed with decreased respirations and a weak pulse. A reassessment was conducted, and vital signs were unobtainable. The patient was unresponsive with no signs of respiration or circulation. The attending hospice provider, Director of Nursing (DON), and family were notified of the patient's passing. The family was provided with emotional support and education on next steps per hospice protocol. The physician was notified, and the time of death was confirmed. Post-mortem care was provided according to hospice guidelines. The funeral home was contacted per the family's request. No signs of distress noted. Funeral home arrived around 2:30 pm and provided with required documentation.Observation of video footage without audio provided by Resident #4's FM D, dated [DATE], revealed the following 676207 Page 26 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few with timestamps in military time as provided:12:20:40-12:20:49 - CNA E lowered the HOB to lay Resident #4 flat. The video stopped as CNA E was removing the top sheet from Resident #4. The feeding pump on the left side of the screen appeared to have the screen lit up, indicating it was on. 12:21:23 - Video resumed and Resident #4 was sitting with the head of her bed elevated approximately 45 degrees. CNA E then left the room. Resident #4 did not appear in any distress at that time.12:22:52-12:23:04 - CNA E returned to room, followed by LVN D. Resident #4 started at that time with a moderate amount of white fluid coming from her mouth and down the right side of her chin. LVN D was looking at Resident #4 then walked into the bathroom.12:23:18 - CNA was observed using a cloth to clean the white liquid off Resident #4's chin. LVN D was observed returning to the room as she was putting on gloves and the video stopped briefly.12:23:46-12:26:10 - The video resumed and LVN D was looking behind the nightstand next to the bed with an oral suction device in her hand. She appeared to locate the power cord to the suction machine and plugged it in. LVN D then appeared to be looking around the room and in drawers for something. LVN D appeared to not be able to find what she was looking for and left the room. CNA E remained in the room.12:30:44 - LVN D returned to the room with what appeared to be a suction catheter in her hand.12:30:47-12:30:55 - LVN D stood at the foot of Resident #4's bed waiting for CNA E to put on gloves and move out of the way. LVN D then set the suction catheter on the nightstand and entered the bathroom. 12:31:13 - LVN D exited the bathroom while putting on gloves. She then picks up the oral suction device (that was already in the room) and disconnected it from the suction tubing. She then appeared to be looking at the oral suction device and then touched the suction tubing near the suction machine/canister. The front panel for the feeding pump remained lit up indicating it was turned on. The video stopped.12:31:35 - The video resumed with LVN D standing at Resident #4's left side with oral suction device, connected to the suction tubing, in LVN D's right hand.12:32:16-12:32:32 - LVN D inserted oral suctioning device into Resident #4's mouth and moved it all around in her mouth then removed it from Resident #4's mouth.12:33:14-12:33:34 - LVN D put tip of oral suction device in water to clear the line. She then disconnected the oral suction device and connected the suction catheter. LVN D then placed the suction catheter in Resident #4's mouth. The video then stopped. 12:34:16 - The video resumed with LVN D laying the suction catheter on the nightstand. LVN D is then observed bending over and turning the dial on the oxygen concentrator that was delivering oxygen to Resident #4 through her nasal cannula.12:34:18-12:34:49 - LVN D is observed placing her hand on Resident #4's arm and shaking, then she moved her hand to Resident #4's chest. LVN D's hand then returned to Resident #4's arm to rub her arm forcefully. The feeding pump's screen remained on at this time.12:34:51-12:34:59 - LVN D placed her open left hand on Resident #4's left wrist, it appeared she was checking for a pulse. LVN D then removed her hand from Resident #4's wrist, took off gloves, and left the room. CNA E remained in room with Resident #4. 12:36:23-12:37:07 - LVN D appeared to attempt to get a response from Resident #4 by touching her arm. 12:37:07 - LVN D took her cell phone out of her pocket and called someone. 12:37:32 LVN D left the room while talking on her cell phone. Feeding pump light remained on. 12:38:03-12:38:30 LVN D returned to Resident #4's room and touched resident on the arm again to check for a response. She then turned to leave the room but stopped and turned around. She appeared to be talking to CNA E (no audio was provided with video) and lifted her right hand to point at the feeding pump. CNA E started touching the feeding pump, she then bent over to look at the pump closer and appeared to press something on the feeding pump. CNA E then stood back up and looked at LVN D and started talking while shaking her head left and right. LVN D then left the room, while CNA E continued to look at the feeding pump. 12:39:11 CNA E left the room.12:43:50 - LVN D and CNA E were observed entering the room. LVN D walked 676207 Page 27 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few directly to the oxygen concentrator and appeared to press something on the machine. LVN D then used her hand to hold Resident #4's wrist. She appeared to have been checking for a pulse. After releasing Resident #4's wrist, LVN D appeared to be talking to CNA E and pointed at feeding pump. LVN D then removed Resident #4's nasal cannula from her nose. She then walked around the bed to the feeding pump (the light on the screen of the feeding pump remained on) and appeared to be pressing something on the machine.12:44:47 - The light on the feeding pump screen turned off after LVN D was done touching it. She then disconnected Resident #4's PEG tube from feeding pump tubing. LVN D and CNA E then appeared to start post-mortem care (the care provided to a person after they die). 12:46:47 - LVN D left the room followed shortly after by CNA E.12:47:20 - CNA E entered the room and continued post-mortem care for Resident #4. 12:49:30 - Ex-DON entered Resident #4's room and entered the bathroom. She returned to the room shortly afterward. CNA E then exited the room. Ex-DON then approached Resident #4 and adjusted Resident #4's clothes, she then held Resident #4's wrist to possibly assess for a pulse. Ex-DON then appeared to touch the top of Resident #4's foot. 12:52:45 - CNA E returned to the room with linen. Ex-DON and CNA E continued providing post-mortem care to Resident #4, which included Ex-DON cleaning her eyes. 12:53:44 - LVN D returned to the room and appeared to have a conversation with Ex-DON. After the conversation, Ex-DON exits the room and LVN D and CNA E resume post-mortem care until the end of the video. --During a phone interview on [DATE] at 12:22 PM, FM D stated she was concerned about the care provided to Resident #4 on the day she died. She discussed the video from [DATE] that was submitted and stated she would attempt to resend with audio available. FM D stated she met with the ex-DON on [DATE] and showed her the video, but the ex-DON was no longer working at the facility, in fact, she quit that day. She stated the ex-DON told her several things in the video should have been done differently and was apologetic. She stated she could not remember the names of the staff members in the video that provided care to Resident #4. FM D stated Resident #4 was choking in the video and died shortly afterward. She stated she just wished staff would have moved faster to suction Resident #4 that day so that Resident #4 did not have to suffer before she died. During an interview on [DATE] at 09:19 AM, LVN D stated she was taking care of Resident #4 on the day she died. She stated that Resident #4 had been declining for an unknown amount of time. She stated the CNA (she could not remember who the CNA was that day) had provided care to Resident #4 and then reported to LVN D that Resident #4 needed to be suctioned. She stated the suction tubing in the room was not the correct one or was not functioning (she couldn't quite remember), so she had to leave the room to go get the correct materials to suction Resident #4. LVN D assessed Resident #4, she had some, but not a lot, clear secretions. LVN D denied Resident #4 showing any signs of distress or aspiration prior to her death. LVN D then stated, I don't remember the exact situation going on, I just remember caring for the patient. She then stated she just provided the general care for Resident #4 that day. LVN D stated, Honestly, I don't remember that far back, and I don't want to say something that isn't true.During an interview on [DATE] at 10:40 AM, the video without audio of Resident #4 was viewed with LVN D. She stated she had not seen the video before. She stated she still could not remember the name of the CNA working that day, even after seeing her on video. LVN D stated that the CNA should notify the nurse to turn off a feeding pump prior to providing care that required the head of the bed to be lowered. She stated that residents should not be laid flat if they are connected to a feeding pump and receiving formula through a PEG tube. She stated if they were laid flat while receiving a continuous feeding through a PEG tube, then the resident could aspirate (the stomach contents could go up the throat and into their airway). LVN D stated she was unaware that Resident #4's head of the bed was lowered to lay her flat by the CNA that day. She stated, It was not out of 676207 Page 28 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the ordinary for [Resident #4] to be suctioned. There was nothing alarming when I assessed her. LVN D was asked about the secretions coming from Resident #4's mouth in the video. She stated Resident #4 was drooling. She then stated, I don't remember her having a colored secretion, it was a clear secretion. LVN D stated after watching the video she had to go downstairs to obtain the materials needed to suction Resident #4. After viewing the video where she suctioned Resident #4, LVN D stated she didn't remember if the oral suctioning device was able to suction the secretions. She then stated, At this point, I feel uncomfortable with guessing what happened based on the video because I cannot hear what is being said. I feel like she was in her normal state. There was not a large amount of secretions. I was just doing my normal patient care for her. LVN D stated she remembered calling Ex-DON because she was in the building to let her know. She stated Ex-DON did not work at the facility anymore. When LVN D was asked about specifics of the video she kept repeating, I feel uncomfortable saying because I can't hear what is being said. She acknowledged checking for a radial pulse for Resident #4 while waiting for Ex-DON to enter the room during the video. LVN D remained resistant to answering questions during the interview. She was asked Should anything have been done differently? after watching the video. She responded, Honestly I couldn't hear what was going on, but I did my best to care for her as a patient.During an interview on [DATE] at 11:38 AM, the DON stated she started at the facility on [DATE]. She stated CNAs are required to notify the nurse to pause a feeding pump if they needed to provide care for the resident that required lowering the head of the bed to less than 30 degrees. She stated it was not within the CNA scope of practice to alter the feeding pump by pausing it, turning it on, and/or turning it off, even if the nurse is in the room and tells them to do it. The video of Resident #4, dated [DATE], was viewed with the DON. She stated the CNA in the video no longer worked in the facility and that she could not remember her name. The DON stated the feeding pump appeared to be on and running in the beginning of the video when CNA E entered the room. She stated the video showed CNA E laying Resident #4 completely flat and the pump appeared to still be running. She stated by laying Resident #4 in that position, it could cause aspiration, cause the formula to go back up into the esophagus[throat] and down into the lungs and aspirate The DON watched CNA E and LVN D (whom she identified by name) enter the room and liquid start coming from Resident #4's mouth and stated, looks like something is coming out of her mouth It looks like formula, white and opaque. The DON stated she would expect LVN D to move with a sense of urgency to turn off the feeding pump and set the resident all the way up. She stated the video showed it took LVN D almost 10 minutes to suction Resident #4 after she first showed signs of aspiration and even then, the pump continued to appear to be running. The DON watched the remainder of the video and stated, that was disheartening. She stated the staff did not appear to have a sense of urgency, the pump was not turned off until after the resident appeared without life, the resident was not properly assessed with vitals and lung sounds upon signs of aspiration, and post-mortem care was started prior to the RN pronouncing death in the video. She stated she thought the outcome of Resident #4 might have changed if CNA E had the nurse pause the feeding pump prior to lowering the head of the bed. The DON stated, If the nurse would have suctioned her and raised the head higher and stopped the feeding, it could have possibly changed the outcome. We don't know how much formula had already gone into the lungs. We could have done an x-ray to see if she needed some type of treatment. She stated the video never showed a RN pronouncement of death because that required a stethoscope to listen for lung and heart sounds and no stethoscope was witnessed in the video. She stated LVN D should have removed any medical treatments, including taking the nasal cannula off Resident #4, until after the death was pronounced by a RN. She stated she expected LVN D to assess Resident #4 and document what was witnessed, 676207 Page 29 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few including the color and amount of fluids that came out of Resident #4's mouth, her assessment of lung sounds, interventions performed like: suctioning, what position Resident #4 was placed in and when the feeding pump was turned off, and also notification of proper personnel. After reviewing the nurses' note that documented the event, the DON stated, that's not how it went down. She didn't take a pulse ox, she didn't listen to the lungs. The note doesn't reflect the initial encounter with fluid coming from her mouth. She then stated she expected more from staff. The DON stated she would provide a staffing sheet for [DATE] and the employee files for the staff involved in the video.During an interview on [DATE] at 04:15 PM, the DON stated LVN D was scheduled to work 2pm-10pm that evening and would be working the remainder of her shift. During an observation on [DATE] at 04:17 PM, LVN D was witnessed standing at a medication cart on the 200-hall.During an interview on [DATE] at 04:40 PM, CNA R stated she had worked at the facility for about a week and had not received training on how to care for residents who were receiving enteral feedings. She stated if a resident had a feeding tube connected to a pump, then she could still lay the resident back flat and just needed to be aware of the feeding tube to not dislodge it. She didn't know if a resident could choke if they were laid flat. She stated she thought they could only choke if they were chewing on something. During an interview on [DATE] at 04:44 PM, CNA F stated she was trained by the ADON to press the pause button on feeding pumps prior to lowering the head of the bed to prevent the resident from aspirating and to restart the pump once the head of the bed was raised back up. During an interview on [DATE] at 04:46 PM, MT L stated a resident who received enteral nutrition through a feeding tube needed to have the pump paused prior to laying them down to provide peri-care. She stated she just paused the feeding pump and restarted it after providing care to the resident. She stated she did not have to notify the nurse to pause or restart the pump. During an interview on [DATE] at 04:57 PM, RN ZZ stated a resident who received enteral nutrition through a feeding tube needed to have the nurse stop and restart the pump before and after providing peri-care. She stated the nurse needed to be the one to stop and restart the pump because the nurse needed to assess the resident each time the pump is stopped and started. Attempted phone interview with MD G x 3 on [DATE] at 11:28 AM, 12:40 PM, and 05:43 PM without success.During an interview on [DATE] at 07:24 PM, the ADM stated the DON told her she had watched a video that was disheartening earlier that day but did not get any further details about the video. She stated she felt she had a good relationship with Resident #4's family. She stated she never discussed a video related to Resident #4 with Ex-DON. The ADM stated Ex-DON quit while the ADM was out of town. She stated prior to that she had discussed Ex-DON moving to the weekend nurse manager position in March. The video from [DATE] provided by FM D was viewed with the ADM. The ADM stated she did not know who the CNA in the video was. The ADM started shaking her head left and right. When asked why, she stated because she is lowering the head of the bed without having the nurse shut the pump off.Ok so she is spitting up.looks like formula to me. The ADM was able to identify LVN D and Ex-DON in the video. After the video, the ADM was asked what she observed wrong in the video and if protocol was followed. The ADM stated, Everything on it.the CNA lowered the head of the bed, the nurse did not turn off the pump.when she was throwing up she was not placed on her side while they were working to get the suction machine to work.the nurse did not do an assessment.she did not listen to lung sounds.I am in shock.No, protocol was not followed.I am so confused right now. The ADM stated she was not surprised to learn Resident #4 had died because she had been declining for some time. The ADM denied receiving the video in an email. She stated if she had seen the video before she would have fired the CNA, the LVN and reported it to regulatory services. The ADM stated the DON should have notified her about what was observed in the video and LVN D should have been removed from her shift 676207 Page 30 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few immediately. The ADM stated she would notify the DON to escort LVN D out of the building immediately. Review of facility policy titled Nursing Policy & Procedure Enteral-Section 4, dated 06/2006 and last updated 03/2019, reflected Administration of Formula via Feeding Tube Gravity, Bolus, Pump.Procedures.Elevate head of bed at 30 to 45 degree angle or above during the feeding and for at least one hour after the feeding. Potential Complications of Tube Feedings.Responsibility.Licensed Nurse.Purpose.Prevention and possible solutions to complications in the tube fed Patient.Problem.Mechanical: Aspiration Pneumonia.Prevention/Possible Solution.Observe for signs and symptoms of aspiration (wheezes, rales, cough, apnea[temporary pause in breathing], hypotension[low blood pressure]).Elevate HOB 30 to 45 degrees during feeding and 30-60 minutes after feeding.Endotracheal[into the trachea/breathing tubes that connect mouth and nose to lungs] suctioning to stimulate cough when aspiration witnessed.This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The ADM was notified on [DATE] at 08:04 PM and a template was given.Observation on [DATE] at 08:21 PM, the ADM escorted LVN D out of the building.During an interview on [DATE] at 08:53 AM, the ADM identified CNA E as the CNA in the video. She stated the DON told her who the CNA was in the video. She stated CNA E was working last night and once she realized it, she sent CNA E home immediately. She stated she also suspended the DON because she did not remove LVN D and CNA E from providing care to the residents of the facility immediately after observing the video. The ADM provided the staffing sheet for [DATE].Review of facility Daily Sign in Sheet, dated Friday February 21, 2025, reflected LVN D and CNA E were assigned to Resident #4's room on that day. During an interview on [DATE] at 04:22 PM, MD G stated he was the primary physician for Resident #4. He stated he did not remember any specific information about Resident #4 though. He stated if a resident were receiving continuous feeding by a feeding pump through a PEG tube, then the head of the bed should be raised greater than 30 degrees to prevent aspiration. He stated a resident could aspirate at any time, but the chances of the resident aspirating if the head of the bed is lowered when they are receiving formula through a PEG tube greatly increases. The following Plan of Removal submitted by the facility was accepted on [DATE] at 12:26 PM: Immediate JeopardyPlan of Removal[DATE]F726 Competent Nursing Staff Immediate Action:Impact Statement:The facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques and ensure that all licensed nurses have the specific competencies and skill sets to care for residents necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. The facility failed to ensure Resident #1 was not laid in a flat position while her feeding tube was actively flowing by CNA E.The facility failed to ensure LVN D provided timely nursing care/ interventions in response to Resident #4's possible aspiration on [DATE]. Please accept this as a Plan of Removal for the alleged Immediate Jeopardy related to failure to ensure that nurse aides are able to demonstrate competency in skills and techniques and ensure that all licensed nurses have the specific competencies and skill sets to care for residents necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.Systematic Approach:Immediate Action Resident #4 is no longer in facility. The Executive Director suspended LVN D, CNA E, and Director of Nursing as soon as Executive Director received notification from state surveyors at approximately 8:00pm on [DATE]. Depending on conclusion of ongoing investigation, if warranted and staff are to return, they will be provided with training prior to providing direct care to residents. The Executive Director initiated a formal investigation and initial report submitted to HHSC on [DATE]. The Executive Director notified the facility Medical Director of the Immediate Jeopardy on [DATE]. An emergency QAPI meeting was held on [DATE]. [DATE] The Regional Director of Regulatory Compliance, Regional Director of Clinical Services and Nurse Managers audited all current 676207 Page 31 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident (a total of eight residents), with feeding tubes to ensure proper positioning during feedings (head of bed elevated to 30-45 degrees), medical orders reviewed to ensure Head Of Bed is elevated order is in place, and competency validation for current CNAs and licensed nurses. Competencies included safe positioning for nurses and CNAs, and oral suctioning for nurses. No additional residents were found to be at risk. Audits completed on [DATE]. Competencies to be completed on [DATE]. Executive Director, Regional Director of Regulatory Compliance, Nurse Managers will in-service all CNAs and Licensed Nurses in Safe positioning for residents receiving enteral feeding, aspiration precautions and timely interventions. Training for all newly hired staff will be completed prior to being assigned to the floor beginning [DATE]. Training for all PRN staff or staff who have not worked since 8/2025 will be completed prior to working beginning [DATE] and will continue until all PRN nursing staff have received training. Any PRN staff who has not worked in 60 days will be removed from the PRN program. Each employee will complete a post-test after their education to ensure staff are able to identify any residents at risk of aspiration. If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. Education will be completed by [DATE]. ? ? Assessment [DATE] The Regional Director of Regulatory Compliance, Regional Director of Clinical Services and Nurse Managers audited all current residents with feeding tubes (a total of eight residents), to ensure proper positioning during feedings (head of bed elevated to 30-45 degrees), medical orders reviewed to ensure Head Of Bed is elevated, and competency validation for current CNAs and licensed nurses. Competencies included safe positioning for nurses and CNAs, and oral suctioning for nurses. No additional residents were found to be at risk. Audits completed on [DATE]. Competencies to be completed on [DATE] ? Who will be responsible: The Regional Director of Regulatory Compliance/ Unit Managers? Who Will monitor: Executive Director/Regional Director Designee will conduct two daily random observations of licensed nurses performing tube feedings for 30 days, ensuring proper positioning and suctioning technique as applicable. The Nurse Managers and/ or Designee will conduct two daily observations of CNAs providing care to a resident who receives tube feeding to ensure proper positioning, and ensuring CNAs are not turning off feeding pump, but instead communicating with nurse. Staff who fail to demonstrate competency will receive immediate retraining. Depending on conclusion of current investigation, if warranted and LVN D and CNA E are to return, they will be provided with training prior to providing direct care to residents After the 30 days, random observations will continue to be completed to include 10% of residents who receive enteral feedings per week for eight weeks. Staff who fail to demonstrate competency will receive immediate retraining. Nurse Managers and/or designee will audit new admissions with enteral feedings to ensure orders to maintain Head of Bed elevated are in place.? Policy and Procedures Policy and procedures were reviewed by [NAME] President of Operations, Regional Director of Regulatory and Compliance, Regional Director of Clinical Services, Executive Director, and Director of Nursing. Policies include Administration of Formula Via Feeding Tube Gravity, Bolus, Pump. No policies needed any revisions. Monitoring of the POR on [DATE]-[DATE] included the following:Review of Resident #4's electronic health record reflected she was discharged from the facility on [DATE] at 01:45 PM to deceased .During interviews on [DATE] from 12:16 PM-06:30 PM and [DATE] from 09:10 AM - 01:30 PM, nine CNAs, six LVNs, and three RNs from different shifts all stated they were in-serviced before their shifts on safe positioning for residents receiving enteral feeding, aspiration precautions, and timely interventions, including competency training on suctioning for all licensed nurses. All were able to explain the correct positioning for residents receiving enteral feeding, who was allowed to 676207 Page 32 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few start/stop/adjust/silence the feeding pump, signs and symptoms of aspiration, and what to do if they observe a resident aspirating. Review of LVN D's employment file, on [DATE], revealed she was suspended on [DATE] and involuntarily terminated on [DATE] for misconduct. Review of CNA E's employment file, on [DATE], revealed she was suspended on [DATE] and involuntarily terminated on [DATE] for misconduct.Review of the DON's employment file, on [DATE], revealed she was suspended on [DATE] and involuntarily terminated on [DATE] for unprofessional behavior.Review of facility-reported incident reflected, a formal complaint to regulatory authorities with intake number 1045259 was initiated and submitted on [DATE] at 10:23 PM.Review of the facility's AD HOC QAPI Plan, dated [DATE], reflected the medical director, the ADON, the ADM, and other facility and corporate staff were in attendance. Review of statement written by the ADM reflected: Medical Director.was notified of immediate jeopardy on [DATE] at approximately 9:00 PM. Review of electronic health records for eight of eight residents who received enteral nutrition revealed medical orders to ensure the head of the bed was elevated were in place.Observations on [DATE] between 11:50 AM and 4:45 PM revealed eight of eight residents that received enteral nutrition with the head of their bed elevated greater than 30 degrees. Observations on [DATE] between 09:30 AM and 01:00 PM revealed eight of eight residents that received enteral nutrition with the head of their bed elevated greater than 30 degrees.Review of facility au 676207 Page 33 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 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: Nicotine Patch 05/01/25, 05/02/15, 05/05/25, 05/09/25, 05/15/25, 05/16/25, and 05/27/25 Folic Acid Tablet 05/01/25, 05/02/15, 05/05/25, 05/09/25, 05/15/25, 05/16/25, and 05/27/25 and 06/27/25 and 06/28/25 multiple vitamin tablet 5/01/25, 05/09/25, and 05/15/25 vitamin B1 05/01/25, 05/09/25, and 05/15/25 Docusate Sodium 05/01/25, 05/09/25, and 05/15/25 levetiracetam Solution 05/01/25, 05/09/25, and 05/15/25 Tylenol 05/01/25, 05/09/25, 05/13/25, and 05/15/25 Enteral Feed 05/01/25, 05/02/25, 05/14/25, 05/30/25, 06/06/25 and 06/12/25 This failure could place residents at risk of experiencing worsening of their condition, increased risk of falls, pain, and injury. Findings included:Review of Resident #1's face sheet dated 10/320/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage with loss of consciousness status unknown, sequela (bleeding on the brain's surface) where the patient lost consciousness, but the duration is unknown, and it's a sequela, meaning a condition resulting from a previous illness or injury), generalized idiopathic epilepsy and epileptic syndromes (a group of epilepsy syndromes characterized by seizures that originate in both hemispheres of the brain and affect the entire body), and other seizures (a type of seizure that is not a tonic-clonic (a type of generalized seizure that affects the entire brain) seizures).Review of Resident #1's quarterly MDS assessment, dated 07/31/25, reflected a BIMS score of 3, indicating severe cognitive impairment.Record review of Resident #1's care plan reflected focus dated 08/01/25 potential for complications related to seizure disorder and anticonvulsant therapy (the use of medications to prevent or control seizures, also known as convulsions) with intervention dated 08/01/25 give medications per order and monitor labs-report focus dated 08/01/25 Resident #1 had a seizure disorder with intervention dated 08/01/25 give seizure medication as ordered by doctor. Record review of Resident #1's order dated 02/11/25 reflected may give medication by mouth or via G-Tube (a feeding tube inserted through a surgical opening in the abdomen directly into the stomach to deliver nutrition, fluids, and medication). Record review of Resident #1's orders reflected Nicotine Patch 24-hour 7 MG/24 (concentration is equivalent to concentration is equivalent to 2.4% nicotine by volume) apply 1 patch transdermally (the administration through the skin) one time a day at 7:00 am for smoking sensation and remove per schedule start date 04/26/25 discharge date [DATE]. Record review of Resident #1's eMAR for May 2025 for administration of Nicotine Patch 24-hour 7 MG/24 (concentration is equivalent to concentration is equivalent to 2.4% nicotine by volume) apply 1 patch transdermally (the administration through the skin) one time a day at 7:00 am for smoking sensation reflected blank spaces for the following dates: 05/01/25, 05/02/15, 05/05/25, 05/09/25, 05/15/25, 05/16/25, and 05/27/25. Review of Resident #1's orders reflected give Folic Acid Tablet (prevents and treats low levels of folate (vitamin B9) in your body) 1 MG via G-Tube one time a day for vitamin deficiency start date 06/27/25 discharge date [DATE]. Review of Resident #1's eMAR for May of 2025 for Folic Acid Tablet (prevents and treats low levels of folate (vitamin B9) in your body) 1 MG tablet one time a day at 7:00 am via G-Tube for vitamin deficiency start date 06/27/25 discharge date [DATE] blank spaces for the following dates: 05/01/25, 05/09/25, 05/15/25. Review of Resident #1's eMAR for June of 2025 for Folic Acid Tablet (prevents and treats low levels of folate (vitamin B9) in your body) 1 MG tablet one time a day at 7:00 am via G-Tube for vitamin deficiency start 676207 Page 34 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some date 06/27/25 discharge date [DATE] blank spaces for 06/27/25 and 06/28/25. Review of Resident #1's orders reflected multiple vitamin tablet give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May reflected multiple vitamin tablet give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE] blank spaces for 05/01/25, 05/09/25, and 05/15/25.Review of Resident #1's orders reflected vitamin B1 (Essential for the proper functioning of the nervous, cardiovascular, and digestive systems) give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE].Review of Resident #1's eMAR for May 2025 reflected vitamin B1 (Essential for the proper functioning of the nervous, cardiovascular, and digestive systems) give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE] blank spaces for the following dates: 05/01/25, 05/09/25, and 05/15/25.Review of Resident #1's orders reflected Docusate Sodium (a type of laxative known as a stool softener) oral tablet 100 MG give one tablet by mouth every 12 hours at 8:00 am and 8:00 pm for constipation start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected Docusate Sodium (a type of laxative known as a stool softener) oral tablet 100 MG give one tablet by mouth every 12 hours at 8:00 am and 8:00 pm for constipation start date 05/01/25 and discharge date [DATE] blank spaces for the following dates and times 8:00 am 05/01/25, 8:00 am 05/09/25, and 8:00 am 05/15/25. Review of Resident #1's orders reflected levetiracetam Solution (medication used to control and prevent seizures associated with epilepsy) give 15 ml orally two times a day at 7:00 am and 7:00 pm for seizures start date 05/01/25 and discharge date [DATE]. Review of Resident #1's orders reflected levetiracetam Solution (medication used to control and prevent seizures associated with epilepsy) give 15 ml orally two times a day at 7:00 am and 7:00 pm for seizures start date 05/01/25 and discharge date [DATE] blank spaces for 7:00 am 05/01/25, 05/09/25, and 05/15/25,Review of Resident #1's orders reflected Tylenol 8-hour oral tablet extended release 650 MG (Acetaminophen) give one table by mouth every 8 hours at 7:00 am, 3:00 pm, and 11:00 pm for pain level start date 05/01/25 and discharge date [DATE].Review of Resident #1's orders reflected Tylenol 8-hour oral tablet extended release 650 MG (Acetaminophen) give one table by mouth every 8 hours at 7:00 am, 3:00 pm, and 11:00 pm for pain level start date 05/01/25 and discharge date [DATE] blank spaces for 7:00 am 05/01/25, 7:00 am 05/09/25, 11:00 pm 05/13/25, 7:00 am 05/15/25. Review of Resident #1's orders reflected enteral feed (the delivery of a special liquid nutrition formula directly into the digestive system through a tube to provide the nutrients and calories a person cannot get by eating or drinking) every shift lsosource 1.5 at 50 ml/hour (provides a continuous feeding rate with 75 calories per hour) via (by means of) feeding tube with auto flushes (enabled nurses to administer flush solution at regular intervals during continuous tube feeding, decreasing the risk of a clog and possibly sparing the patient the distress of tube replacement) at 30 ml every 4 hours. May remove for care and services start date 05/01/25 discharge date [DATE]. Review of Resident #1's eMAR for May of 2025 for enteral feed (the delivery of a special liquid nutrition formula directly into the digestive system through a tube to provide the nutrients and calories a person cannot get by eating or drinking) every shift Isosource ( a calorically dense complete nutrition formula ) 1.5 at 50 ml/hour (provides a continuous feeding rate with 75 calories per hour) via (by means of) feeding tube with autoflushes (enabled nurses to administer flush solution at regular intervals during continuous tube feeding, decreasing the risk of a clog and possibly sparing the patient the distress of tube replacement) at 30 ml every 4 hours. May remove for care and services start date 05/01/25 discharge date [DATE] reflected blank spaces for Day 05/01/25, Day and Night 05/02/25, Night 05/14/25, and Day 05/30/25.Review of Resident #1's eMAR for June of 676207 Page 35 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2025 for enteral feed (the delivery of a special liquid nutrition formula directly into the digestive system through a tube to provide the nutrients and calories a person cannot get by eating or drinking) every shift Isosource ( a calorically dense complete nutrition formula ) 1.5 at 50 ml/hour (provides a continuous feeding rate with 75 calories per hour) via (by means of) feeding tube with autoflushes (enabled nurses to administer flush solution at regular intervals during continuous tube feeding, decreasing the risk of a clog and possibly sparing the patient the distress of tube replacement) at 30 ml every 4 hours. May remove for care and services start date 05/01/25 discharge date [DATE] reflected blank spaces for 06/06/25 night and 06/12/25 night.Interview on 10/20/25 at 12:14 pm with LVN J a Charge Nurse reflected if there was blank entry in the eMAR for a medication administration, the medication was not administered and it was a medication error and horrible resident quality of care and [NAME] tottered close to abuse and neglect. She said the charge nurses and DON were accountable to make sure medication was properly documented. Interview on 10/20/25 at 12:52 pm with LVN K reflected blanks in a residents' eMAR showed that the resident did not get a medication and it was bad because medication levels could be affected. She said it was not good quality of care and could risk residents' health all the way around for there to be blanks in the eMAR indicating no medication was administered. She said it was the responsibility of the charge nurse and the nurse administering the medication to make sure medication administration was documented. Interview on 10/20/25 at 1:36 pm with LVN C reflected if there were blank spaces in a resident eMAR, medication administration was not documented and therefore, medication administration did not take place. She said the negative effect of not documenting in the eMAR and therefore resident not receiving medication was that it did not attempting to resolve the problem the MD prescribed the medication to resolve. She said if the resident was not receiving the medication the disease process would probably worsen. It was not good quality of care not to document in the eMAR and the lack of medication administration could risk residents' health all the way around. She said documentation was the responsibility of the charge nurse and the nurse administering the medication. Interview on 10/23/25 at 10:27 am with LVN FF reflected if there were holes in the Emar, medication was not administered and it was a medication error. She said a possible negative effect of not documenting in the eMAR was that the resident did not get their medications or a resident could receive a double dose of medication and the resident would not receive the benefit of taking the medication. Interview on 10/23/25 at 1:11 pm with the ADON reflected it was important to document, and it was important to document communication in the eMAR from shift to shift. She said documentation was important to the resident for ongoing patient care. She said if you did not document that a resident received the medication the next shift will just assume he received the medication. Interview on 10/24/25 at 9:04 with the Administrator reflected the nurse management team were responsible to make sure that resident information was properly documented and the Administrator was ultimately responsible for making sure things were done. A possible negative effect of not documenting was that you were not going to fix the problem and a resident could die. She revealed that the holes in the resident eMAR were not proper documentation. She said if there was a blank the medication was not given. If it was not documented, it was not done. She said if residents did not get their medications, residents did not get the benefit of the medicationInterview on 10/24/25 at 11:44 am with the DON reflected if you did not document it stated you did not care for your resident and presented an overall statement of the care and treatment received. She said if it was not documented it was not done. She said it was the responsibility of the nurse managers to make sure staff were documenting properly. Record review of facility Medication Administration policy dated December 2012 reflected medications shall be administered in a safe and timely manner, and as 676207 Page 36 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some prescribed, only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Medications must be administered in accordance with the orders, including any required time frame. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. The date and time the medication was administered;b. The dosage;c. The route of administration;d. The injection site (if applicable);e. Any complaints or symptoms for which the drug was administered;f. Any results achieved and when those results were observed; andg. The signature and title of the person administering the drug. Review of facility Refusal of Treatment policy dated May 2013 reflected Our facility shall honor a resident's request not to receive medical treatment as prescribed by his or her physician, as well as care routines outlined on the resident's assessment and plan of care. The resident is not forced to accept any medical treatment and may refuse specific treatment even though it is prescribed by a physician. Treatment is defined as care provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms. If a resident refuses treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will interview the resident to determine what and why the resident is refusing in order to try to address the resident's concerns and explain the consequences. The Care Plan Team will assess the resident's needs and offer the resident alternative treatments, if available and pertinent, while continuing to provide other services outlined in the care plan. If the resident's refusal brings about a significant change, a reassessment will be made and such information will be incorporated into the resident's care plan. Should the resident refuse to accept treatment, detailed information relating to the refusal must be entered into the resident's medical record.Documentation pertaining to a resident's refusal of treatment shall include at least the following:The date and time the staff tried to give a medication or treatment was attempted;The medication or treatment refused;The resident's response and reason(s) for refusal;The name of the person attempting to administer the treatment;That the resident was informed (to the extent of their ability to understand) of the purpose of the treatment and the consequences of not receiving the medication/or treatment;The resident's condition and any adverse effects due to such refusal;The date and time the physician was notified as well as the physician's response;All other pertinent observations; andThe signature and title of the person recording the data.The Attending Physician must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the refusal. For example, a resident's refusal to take a diuretic while experiencing acute congestive heart failure should be reported immediately, while a refusal to take a blood pressure medication while the blood pressure is well controlled can be reported within 24 hours. 676207 Page 37 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings included:Review of Resident #1's orders reflected administration of Nicotine Patch 24-hour 7 MG/24 (concentration is equivalent to concentration is equivalent to 2.4% nicotine by volume) apply 1 patch transdermally (the administration through the skin) one time a day 7:00 am for smoking sensation and remove per schedule start date 04/26/25 discharge date [DATE] Record review of Resident #1's eMAR for June 2025 reflected administration of Nicotine Patch 24-hour 7 MG/24 (concentration is equivalent to concentration is equivalent to 2.4% nicotine by volume) apply 1 patch transdermally (the administration through the skin) one time a day 7:00 am for smoking sensation and remove per schedule start date 04/26/25 discharge date [DATE] reflected eMAR Code #2 (resident refused) entered by LVN C for 06/03/25, 06/06/25, 06/09/25, 06/11/25, 06/12/25, 06/13/25, and 06/13/25.Review of Resident #1's orders reflected give 1 tablet MG Folic Acid (a vitamin of the B complex, found especially in leafy green vegetables, liver, and kidney) by month one time a day at 7:00 am for vitamin deficiency start date 05/01/25 and discharge date [DATE].Review of Resident #1's eMAR for May 2025 reflected administration of 1 tablet MG Folic Acid (a vitamin of the B complex, found especially in leafy green vegetables, liver, and kidney) by month one time a day at 7:00 am for vitamin deficiency start date 05/01/25 and discharge date [DATE] reflected eMAR Code #2 (resident refused ) entered by MT B for 05/13/25, 05/20/25, 05/21/25, 05/23/25, 05/26/25 through 05/30/25.Record review of Resident #1's progress notes for May 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of 1 tablet MG Folic Acid (a vitamin of the B complex, found especially in leafy green vegetables, liver, and kidney) by month one time a day at 7:00 am for vitamin deficiency start date 05/01/25 and discharge date [DATE] for dates 05/13/25, 05/20/25, 05/21/25, 05/23/25, 05/26/25 through 05/30/25. Review of Resident #1's progress notes for June 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of administration of 1 tablet MG Folic Acid (a vitamin of the B complex, found especially in leafy green vegetables, liver, and kidney) by month one time a day at 7:00 am for vitamin deficiency start date 05/01/25 and discharge date [DATE] for 06/01/25, 06/02/25 through 06/06/25, 06/09/25 through 06/13/25, and 06/16/25Review of Resident #1's orders reflected multiple vitamin tablet give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected multiple vitamin tablet give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE] reflected eMAR Code #2 (resident refused) entered by MT B for 5/13/25, 05/19/25 through 05/21/25, 05/23/25, 05/26/25 through 05/30/25. Record review of Resident #1's progress notes for May 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of multiple vitamin tablet give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE] for 5/13/25, 05/19/25 through 05/21/25, 05/23/25, 05/26/25 through 05/30/25.Review of Resident #1's orders reflected vitamin B1 (Essential for the proper functioning of the nervous, cardiovascular, and digestive systems) give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 676207 Page 38 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reflected vitamin B1 (Essential for the proper functioning of the nervous, cardiovascular, and digestive systems) give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE] reflected eMAR Code #2 (resident refused) entered by MT B for 05/13/25, 05/20/25, 05/21/25, 05/23/25, and 05/26/25 through 05/30/25.Record review of Resident #1's progress notes for May 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of vitamin B1 (Essential for the proper functioning of the nervous, cardiovascular, and digestive systems) give 1 tablet by mouth one time a day at 7:00 am for supplement start date 05/01/25 and discharge date [DATE] for 5/13/25, 05/19/25 through 05/21/25, 05/23/25, 05/26/25 through 05/30/25.Review of Resident #1's orders reflected Docusate Sodium (a type of laxative known as a stool softener) oral tablet 100 MG give one tablet by mouth every 12 hours at 8:00 am and 7:00 pm for constipation start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected Docusate Sodium (a type of laxative known as a stool softener) oral tablet 100 MG give one tablet by mouth every 12 hours at 8:00 am and 7:00 pm for constipation start date 05/01/25 and discharge date [DATE] reflected eMAR Code #2 (resident refused) entered by MT B for 8:00 am 05/20/25, 8:00 am 05/21/25, 8:00 am 05/23/25, and 8:00 am 05/26/25 through 05/30/25. Record review of Resident #1's progress notes for May 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of Docusate Sodium (a type of laxative known as a stool softener) oral tablet 100 MG give one tablet by mouth every 12 hours at 8:00 am and 7:00 pm for constipation start date 05/01/25 and discharge date [DATE] for 8:00 am 05/20/25, 8:00 am 05/21/25, 8:00 am 05/23/25, and 8:00 am 05/26/25 through 05/30/25. Review of Resident #1's progress notes for June 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of Docusate Sodium (a type of laxative known as a stool softener) oral tablet 100 MG give one tablet by mouth every 12 hours at 8:00 am and 7:00 pm for constipation start date 05/01/25 and discharge date [DATE] for 8:00 am 06/02/25 through 06/06/25, 8:00 am 06/09/25 through 06/13/25 and 8:00 am 06/16/25.Review of Resident #1's orders reflected levetiracetam Solution (medication used to control and prevent seizures associated with epilepsy) give 15 ml orally two times a day at 7:00 am and 7:00 pm for seizures start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected levetiracetam Solution (medication used to control and prevent seizures associated with epilepsy) give 15 ml orally two times a day at 7:00 am and 7:00 pm for seizures start date 05/01/25 and discharge date [DATE] reflected eMAR Code #2 (resident refused) entered by MT B for 7:00 am 05/13/25, 7:00 am 05/20/25, 7:00 am 05/21/25, and 7:00 am 05/23/25.Record review of Resident #1's progress notes for May 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of levetiracetam Solution (medication used to control and prevent seizures associated with epilepsy) give 15 ml orally two times a day at 7:00 am and 7:00 pm for seizures start date 05/01/25 and discharge date [DATE] for 7:00 am 05/13/25, 7:00 am 05/20/25, 7:00 am 05/21/25, and 7:00 am 05/23/25.Review of Resident #1's progress notes for June 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration levetiracetam Solution (medication used to control and prevent seizures associated with epilepsy) give 15 ml orally two times a day at 7:00 am and 7:00 pm for seizures start date 05/01/25 and discharge date [DATE] for 7:00 am and 7:00 pm 06/01/25 and MT B for 7:00 am 06/02/25 through 06/06/25, 7:00 am 06/09/25 through 06/13/25, and 7:00 am 06/16/25.Review of Resident #1 orders reflected Metoprolol tar tablet (medication is used to treat high blood pressure, chest pain (angina) and to improve survival after a heart attack) give 0.5 tablet orally every 12 hours at 7:00 am and 7:00 pm related to essential (primary) hypertension (a condition where the force of blood against artery walls is consistently higher than normal, typically 676207 Page 39 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some defined as 130/80 mmHg or higher) start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for May 2025 reflected Metoprolol tar tablet (medication is used to treat high blood pressure, chest pain (angina), and to improve survival after a heart attack) give 0.5 tablet orally every 12 hours at 7:00 am and 7:00 pm related to essential (primary) hypertension (a condition where the force of blood against artery walls is consistently higher than normal, typically defined as 130/80 mmHg or higher) start date 05/01/25 and discharge date [DATE] reflected eMAR Code #2 (resident refused) entered by MT B for 7:00 am 05/21/25, 7:00 am 05/26/25 through 05/30/25.Record review of Resident #1's progress notes for May 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of Metoprolol tar tablet (medication is used to treat high blood pressure, chest pain (angina), and to improve survival after a heart attack) give 0.5 tablet orally every 12 hours at 7:00 am and 7:00 pm related to essential (primary) hypertension (a condition where the force of blood against artery walls is consistently higher than normal, typically defined as 130/80 mmHg or higher) start date 05/01/25 and discharge date [DATE] for 05/26/25 through 05/30/25.Review of Resident #1's orders reflected one 3 MG tablet Melatonin (a hormone naturally produced by the pineal gland in the brain that plays a crucial role in regulating the body's sleep-wake cycle, known as the circadian rhythm) by mouth at bedtime for sleep start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for June 2025 reflected one 3 MG tablet Melatonin (a hormone naturally produced by the pineal gland in the brain that plays a crucial role in regulating the body's sleep-wake cycle, known as the circadian rhythm) by mouth at bedtime for sleep start date 05/01/25 and discharge date [DATE] reflected eMAR Code #2 (resident refused ) entered by MT A for 06/01/25. Record review of Resident #1's progress notes for June 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of Melatonin (a hormone naturally produced by the pineal gland in the brain that plays a crucial role in regulating the body's sleep-wake cycle, known as the circadian rhythm) by mouth at bedtime for sleep start date 05/01/25 and discharge date [DATE] for 06/01/25.Review of Resident #1's orders reflected one 15 MG tablet of Mirtazapine (antidepressant used to treat major depressive disorder) by mouth at bedtime for depression start date 05/01/25 and discharge date [DATE].Review of Resident #1's eMAR for June 2025 one 15 MG tablet of Mirtazapine (antidepressant used to treat major depressive disorder) by mouth at bedtime for depression start date 05/01/25 and discharge date [DATE] reflected eMAR Code #2 (resident refused) entered by MT A for 06/01/25.Record review of Resident #1's progress notes for June 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of Mirtazapine (antidepressant used to treat major depressive disorder) by mouth at bedtime for depression start date 05/01/25 and discharge date [DATE] for 06/01/25.Review of Resident #1's orders reflected Valproic ACD (anti-convulsant medication used to treat various types of seizures and other neurological conditions) capsule 250 mg give two capsules orally every 8 hours at 7:00 am, 3:00 pm, and 11:00 pm for seizure start date 05/01/25 and discharge date [DATE]. Review of Resident #1's eMAR for June 2025 reflected Valproic ACD (anti-convulsant medication used to treat various types of seizures and other neurological conditions) capsule 250 mg give two capsules orally every 8 hours at 7:00 am, 3:00 pm, and 11:00 pm for seizure start date 05/01/25 and discharge date [DATE] eMAR Code #2 (resident refused) entered by MT A for 7:00 am 06/01/25 and MT B for 7:00 am 06/02/25 through 06/06/25, 7:00 am 06/09/25 through 06/13/25 and 7:00 am 06/16/25.Record review of Resident #1's progress notes for June 2025 reflected no notification to the MD, NP, or RP indicating that Resident #1 refused administration of Valproic ACD (anti-convulsant medication used to treat various types of seizures and other neurological conditions) capsule 250 mg give two capsules orally every 8 hours at 7:00 am, 3:00 pm, and 11:00 pm for 676207 Page 40 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some seizure start date 05/01/25 and discharge date [DATE] for 7:00 am 06/01/25 and MT B for 7:00 am 06/02/25 through 06/06/25, 7:00 am 06/09/25 through 06/13/25 and 7:00 am 06/16/25.Interview on 10/21/25 at 12:14 pm with LVN J reflected when a resident refused a medication you had to enter a progress note and input why the resident refused the medication and call the NP or MD and RP. Nurses were required to in the resident's progress notes what the NP or MD stated about the medication refusal. She said it was a problem if there was no documentation of the medication refusal in progress notes because there was no plan of action going forward or information if there was an adverse reaction. She said the nurse the communication was broken it was a gap in resident care. She said if you did not put a note in the progress notes, you probably did not notify the NP or MD. She said medication refusal could impede a resident's overall health status. Interview on 10/20/25 at 12:52 pm with LVN K reflected she worked with Resident #1 and administered him medication. If a resident refused medications the nurse was expected to notify the NP or MD and RP and document the refusal and the notifications in the residents EMR. The negative effect of not documenting that a resident did not receive medication and not attempting to resolve the problem was that the MD did not have an opportunity to address the problem. To not document when a resident refused medication was not good quality of care and could risk a resident's health. Documenting was the responsibility of the charge nurse and the nurse administering the medication. Interview on 10/20/25 at 1:36 pm with LVN C reflected it was common knowledge that Resident #1 refused his medication, and she notified the doctor and the RP and said, Lord I hope I did when asked if she documented the refusal and the notification in the progress notes. She said if Resident #1 did not have enough of his seizure medications, he could have had a seizure, and the doctor should have been notified and it should have been in the progress notes. She said if something was not documented, it was not done and if you did not document it did not take place. She said it was the responsibility of the charge nurse to make sure documentation was taken care.Interview on 10/23/25 at 1:11 pm with the ADON reflected if a resident refused mediation the refusal should be documented in the resident's progress notes and the notification to the MD and family of the refusal should be documented and the progress notes. She said it should be documented every time a resident refused medication. She said documenting was important to residents for the residents' ongoing patient care. Interview on 10/21/24 at 4:27 pm with the MD G reflected he knew that Resident #1 refused his medications, and it was his understanding that nursing staff would have to notify the RP. He said there was no notification that Resident #1's refusal of his seizure medication was that extensive. He said missing the doses could have caused a seizure, but they were monitoring his levels of seizure medications, and the labs did not indicate his levels were abnormal. Interview on 10/24/25 at 9:04 am with the Administer reflected the management and nursing team are responsible for making sure things are properly documented. Nurses should notify the MD, family when a resident refuses medication and this communication should be documented in the residents' progress notes. A possible negative effect of not documenting was that you were not going to fix the problem and a resident could die with the case of this, because Resident #1 refused his seizure medication, he could have had a seizure.Interview on 10/24/25 at 11:44 am with the DON reflected that it was her expectation that nurses documented in the progress notes for a change of condition and said a resident's refusal to take medication was a change of condition. She said medication refusal should be documented and notification of the refusal to the MD, family, and supervisor should be documented. She said that every time a resident refused medication it should be documented. She said the possible negative effect of not documenting medication refusals would be MDs would not be able to have the information to try a different route or different treatment. She said documentation was very important and was the 676207 Page 41 of 42 676207 10/24/2025 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0842 Level of Harm - Minimal harm or potential for actual harm verification of how you cared for the resident. She said if you did not document, it stated you did not care for your resident. She said you could not confirm that the MD or RP were contacted if it was not documented. She said if it was not documented it was not done. She said it was the responsibility of the nurse managers to make sure staff were documenting properly. The facility was unable to provide a policy on documentation. Residents Affected - Some 676207 Page 42 of 42