Safety Report: The Colonnades At Reflection Bay
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
5Immediate jeopardy citations (severity J–L)
3Actual harm citations (severity G–I)
12Requirements cited on more than one inspection
J
Government finding: 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.
Nursing and Physician Services Deficiencies · Tag F726
J
Government finding: 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.
Quality of Life and Care Deficiencies · Tag F693
J
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
K
Government finding: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Tag F686
K
Government finding: Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · Tag F760
G
Government finding: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F684
G
Government finding: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F607
G
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600
Citations by topic
3Abuse, neglect & exploitation
4Infection control
6Medications & pharmacy
3Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
More citations in the most recent cycle (17) than in the cycle before (15).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (F690) | 4 | May 1, 2026; June 6, 2025; October 4, 2024; July 30, 2024 |
| Provide and implement an infection prevention and control program. (F880) | 4 | February 18, 2025; October 4, 2024; July 30, 2024; October 13, 2023 |
| 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. (F761) | 3 | May 1, 2026; November 20, 2025; October 13, 2023 |
| Provide safe and appropriate respiratory care for a resident when needed. (F695) | 3 | May 1, 2026; October 24, 2025; February 18, 2025 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 3 | November 20, 2025; October 24, 2025; July 30, 2024 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F550) | 2 | May 1, 2026; October 13, 2023 |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F755) | 2 | November 20, 2025; October 24, 2025 |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F842) | 2 | October 24, 2025; February 18, 2025 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F656) | 2 | October 24, 2025; April 21, 2025 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. (F677) | 2 | June 6, 2025; October 4, 2024 |
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 2 | December 31, 2024; December 8, 2023 |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. (F925) | 2 | December 4, 2024; May 31, 2024 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| October 24, 2025 | Fine | $17,659 |
| October 24, 2025 | Fine | $10,548 |
| June 6, 2025 | Fine | $44,960 |
| February 18, 2025 | Fine | $29,782 |
| December 8, 2023 | Fine | $9,525 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
May 1, 2026 — 6 citations
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected May 28, 2026
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected May 28, 2026
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · corrected May 28, 2026
D
PASARR screening for Mental disorders or Intellectual Disabilities
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F645 · corrected May 28, 2026
D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F627 · corrected May 28, 2026
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected May 28, 2026
November 20, 2025 — 3 citations · complaint investigation
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · complaint · corrected November 21, 2025
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · complaint · corrected November 21, 2025
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected November 21, 2025
October 24, 2025 — 8 citations (includes serious) · complaint investigation
J
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.
Immediate jeopardy to resident health or safety · Isolated · Nursing and Physician Services Deficiencies · F726 · complaint · corrected November 20, 2025
J
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.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F693 · complaint · corrected November 20, 2025
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected October 19, 2025
E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F842 · complaint · corrected November 20, 2025
E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F755 · complaint · corrected November 20, 2025
E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected November 20, 2025
E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected November 20, 2025
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · complaint · corrected November 20, 2025
June 6, 2025 — 3 citations (includes serious) · complaint investigation
K
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Immediate jeopardy to resident health or safety · Pattern · Quality of Life and Care Deficiencies · F686 · complaint · corrected June 30, 2025
E
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F677 · complaint · corrected June 30, 2025
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · complaint · corrected June 30, 2025
April 21, 2025 — 1 citation · complaint investigation
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected May 20, 2025
February 18, 2025 — 4 citations (includes serious)
K
Ensure that residents are free from significant medication errors.
Immediate jeopardy to resident health or safety · Pattern · Pharmacy Service Deficiencies · F760 · complaint · corrected March 14, 2025
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected March 14, 2025
E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F842 · corrected March 14, 2025
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · complaint · corrected March 14, 2025
December 31, 2024 — 1 citation · complaint investigation
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected January 24, 2025
December 4, 2024 — 3 citations · complaint investigation
D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
No actual harm, but potential for more than minimal harm · Isolated · Environmental Deficiencies · F925 · complaint · corrected December 26, 2024
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F584 · complaint · corrected December 26, 2024
D
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F558 · complaint · corrected December 26, 2024
October 4, 2024 — 3 citations · complaint investigation
E
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F677 · complaint · corrected October 25, 2024
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · complaint · corrected October 25, 2024
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · complaint · corrected October 25, 2024
July 30, 2024 — 3 citations · complaint investigation
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · complaint · corrected August 31, 2024
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · complaint · corrected August 31, 2024
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected August 31, 2024
May 31, 2024 — 1 citation · complaint investigation
F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
No actual harm, but potential for more than minimal harm · Widespread · Environmental Deficiencies · F925 · complaint · corrected June 20, 2024
December 8, 2023 — 1 citation (includes serious)
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F684 · corrected December 15, 2023
October 13, 2023 — 3 citations · complaint investigation
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · complaint · corrected October 24, 2023
E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F550 · complaint · corrected October 24, 2023
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · complaint · corrected October 24, 2023
October 6, 2023 — 2 citations (includes serious) · complaint investigation
G
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · complaint · corrected May 16, 2023
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected May 16, 2023
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare