Cycle 1
Health 2025-02-18 · Fire 2025-02-18
19 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Pearland, TX
The Colonnades at Reflection Bay
2-star overall rating with 1-star inspections with Special Focus status with $115,667 in total fines with 19 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
12001 Shadow Creek Parkway, Pearland, TX
(713) 434-3800
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
149
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cantex Continuing Care
Operator or chain grouping
Approved since
1984-01-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
38 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.48
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.35
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.06
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.39
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,014
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.75
Composite VBP score used to determine payment impact.
Payment multiplier
0.9909
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.20
Baseline 20.21% · Performance 19.95% · Measure score 3.20 · Achievement 3.20 · Improvement 0.3
Healthcare-associated infections
4.14
Baseline 5.92% · Performance 6.60% · Measure score 4.14 · Achievement 4.14 · Improvement 0
Total nurse turnover
6.61
Baseline 100.00% · Performance 46.56% · Measure score 6.61 · Achievement 4.19 · Improvement 6.61
Adjusted total nurse staffing
1.15
Baseline 3.39 hours · Performance 3.40 hours · Measure score 1.15 · Achievement 1.15 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.4% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 146 · Observed rate 11.64% · Lower 95% interval 7.51% |
| Discharge to community | 62.31% |
50.57%
11.7 pts better
|
Better than the National Rate · Eligible stays 153 · Observed rate 45.75% · Lower 95% interval 51.34% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 151 · Denominator 151 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 151 |
| Discharge self-care score | 60.47% |
53.69%
6.8 pts better
|
Numerator 52 · Denominator 86 |
| Discharge mobility score | 55.81% |
50.94%
4.9 pts better
|
Numerator 48 · Denominator 86 |
| Pressure ulcers or injuries, new or worsened | 0.66% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 151 · Adjusted rate 0.57% |
| Healthcare-associated infections requiring hospitalization | 6.6% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 99 · Observed rate 8.08% · Lower 95% interval 4.17% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 177 |
| Staff flu vaccination coverage | 14.4% |
42%
27.6 pts worse
|
Numerator 37 · Denominator 257 |
| Discharge function score | 62.79% |
56.45%
6.3 pts better
|
Numerator 54 · Denominator 86 |
| Transfer of health information to provider | 96.7% |
95.95%
0.8 pts better
|
Numerator 88 · Denominator 91 |
| Transfer of health information to patient | 96.77% |
96.28%
0.5 pts better
|
Numerator 30 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 30.99% |
25.2%
5.8 pts better
|
Numerator 22 · Denominator 71 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
97.1%
2.7 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.1% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.3%
0.4 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.7% · Q3 2.7% · Q4 2.8% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
3.3%
2 pts worse
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 4.3% · Q3 6.4% · Q4 5.2% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.9% |
18.9%
8 pts better
|
19.6%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 11.5% · Q3 9.9% · Q4 9.2% · 4Q avg 10.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.5% |
10.8%
7.3 pts better
|
16.7%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 1.4% · Q3 1.2% · Q4 3.6% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.9% |
15.4%
1.5 pts worse
|
16.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 27.3% · Q3 3.6% · Q4 11.6% · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.7% |
16.1%
0.4 pts better
|
14.9%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 20.3% · Q3 11.5% · Q4 10.6% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.5%
0.3 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.8% |
15.0%
10.2 pts better
|
19.8%
15 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.6% · Q3 1.1% · Q4 3.2% · 4Q avg 4.8% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
4.2%
1 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 3.1% · Q3 6.4% · Q4 7.2% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
89.7%
9.7 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 98.9% · Q3 99.5% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
12.0%
5.3 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 8.0% · Expected 13.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.1% |
1.5%
1.4 pts better
|
1.6%
1.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.5% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.9% |
88.0%
10.9 pts better
|
79.7%
19.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
25.9%
1.6 pts better
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 30.1% · Expected 29.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-08 · Fire 2023-12-08
12 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-09-30 · Fire 2022-09-30
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-02-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-02-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-14
F · Potential for more than minimal harm
2023-12-08
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-12-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-12-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-15
E · Potential for more than minimal harm
2022-09-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-11-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Not marked corrected
D · Potential for more than minimal harm
2025-11-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
D · Potential for more than minimal harm
2025-11-20
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Not marked corrected
J · Immediate jeopardy
2025-10-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-19
J · Immediate jeopardy
2025-10-24
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2026-01-13
J · Immediate jeopardy
2025-10-24
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2026-01-13
E · Potential for more than minimal harm
2025-10-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-01-13
E · Potential for more than minimal harm
2025-10-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-01-13
E · Potential for more than minimal harm
2025-10-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-13
E · Potential for more than minimal harm
2025-10-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-10-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-01-13
K · Immediate jeopardy
2025-06-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-06-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-06-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-04-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-20
K · Immediate jeopardy
2025-02-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-14
E · Potential for more than minimal harm
2025-02-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-14
E · Potential for more than minimal harm
2025-02-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-02-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-14
D · Potential for more than minimal harm
2024-12-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-12-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-26
D · Potential for more than minimal harm
2024-12-04
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-12-26
D · Potential for more than minimal harm
2024-12-04
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-12-26
E · Potential for more than minimal harm
2024-10-04
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-04
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-07-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-31
D · Potential for more than minimal harm
2024-07-30
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-08-31
D · Potential for more than minimal harm
2024-07-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-31
F · Potential for more than minimal harm
2024-05-31
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-06-20
G · Actual harm
2023-12-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-10-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-10-24
E · Potential for more than minimal harm
2023-10-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-10-13
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-10-24
G · Actual harm
2023-10-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-05-16
G · Actual harm
2023-10-06
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-05-16
F · Potential for more than minimal harm
2022-09-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-11
E · Potential for more than minimal harm
2022-09-30
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-09-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-09-30
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-09-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-09-30
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-11-11
C · Minimal harm
2022-09-30
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-11-11
Penalties and ownership
What sits behind the stars
$68,150
2025-06-06
Fine
Fine · fine $68,150
Fine
$29,782
2025-02-18
Fine
Fine · fine $29,782
Fine
$9,525
2023-12-08
Fine
Fine · fine $9,525
Fine
$8,210
2023-10-06
Fine
Fine · fine $8,210
Fine
Ownership
Sweeny Hospital District
5% Or Greater Direct Ownership Interest · Organization
Colonnades Health Care Center Ltd Co
Operational/Managerial Control · Organization
Paggeot, Frances
Operational/Managerial Control · Individual
Park, Kelly
Corporate Officer · Individual
Rajan, Kavitha
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Terra Bella Health and Wellness Suites
Houston, TX
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $168,542 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Tuscany Village
Pearland, TX
4-star overall rating with 4-star inspections with $14,069 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Avir at Orem
Houston, TX
4-star overall rating with 4-star inspections with $34,418 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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