Park Manor Bee Cave: Tracheostomy Care Failures - TX]
That finding sits at the center of a September 2025 complaint inspection at Park Manor Bee Cave, a nursing facility at 14058 Bee Caves Parkway. Inspectors documented a cascade of infection control failures during tracheostomy care on a resident whose weakened immune system made each lapse more consequential than it might have been for someone healthier.
The problems began before the procedure did. The surface where sterile supplies were laid out had not been sanitized first. The Assistant Director of Nursing told inspectors that the area should have been sterilized before anything was placed on it, and that nothing unrelated to the procedure should share that space. Neither condition was met.
Then came the suction equipment. Staff tested the yankauer, a suction device used to clear airways, by dipping it into an open container of water rather than opening a new sterile water container. The Director of Nursing told inspectors she personally would not test the device that way. The facility's own undated skills checklist specified sterile normal saline for the suction basin, not tap water in a shared container.
Mid-procedure, the staff member touched the nurse's cart. Then the light switch. No hand hygiene. No glove change. The DON told inspectors that staff should not have touched either surface without first performing hand hygiene and changing gloves, because doing so risked introducing infection to a resident who was already immunocompromised.
The oxygen question added another layer. During tracheostomy care, the resident's oxygen flow was lowered. The DON said she would not expect staff to lower oxygen during the procedure and would instead increase it, consistent with the facility's own policy and skills checklist, which called for preoxygenating the resident before suctioning to maximize oxygen saturation.
The facility's tracheostomy policy, last revised in May 2007, opens with four words in capital letters: THIS IS A STERILE PROCEDURE. The policy instructs staff to wash hands before beginning and to position a discard bag within reach so they never have to reach across the sterile field. The skills checklist echoes that, requiring hand hygiene at the start and again at the end, with sterile technique throughout.
What the nurse practitioner told inspectors complicated the picture further. The NP said sterile gloves were used for deeper suctioning but not for routine tracheostomy care, because, as she put it, "it's an open hole so it's not really sterile." She also said she used to be required to use sterile gloves when cleaning the inner cannula but was no longer sure what the protocol required. The DON, by contrast, said she expected sterile gloves for tracheostomy care. The two clinicians, both in leadership roles, described different standards for the same procedure on the same patient population.
The NP also told inspectors she expected staff to use hand sanitizer every time they entered a resident's room, before putting on gloves, and after removing them, and that staff should not put gloves on until they were ready to perform care. That standard, she said, was not what inspectors had observed.
The facility conducted no in-services on tracheostomy care in the sixty days before the inspection. Records reviewed by inspectors covering July, August, and September 2025 showed none had been scheduled or completed.
The administrator told inspectors he understood a tracheostomy involved a hole in the throat and required regular suctioning, but deferred to the DON on clinical specifics. He said he expected hand hygiene before any resident interaction, particularly for residents on enhanced barrier precautions.
The resident at the center of the inspection had a compromised immune system. Their name does not appear in the public record. What does appear is the sequence: an unsanitized surface, non-sterile water used to test suction equipment, a light switch touched mid-procedure with soiled gloves, oxygen reduced during a procedure that the facility's own policy said required it to be increased, and no training conducted on any of it in two months.
The facility's tracheostomy policy has not been revised since 2007.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Manor Bee Cave from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 29, 2026 · Our methodology
Park Manor Bee Cave in Bee Cave, TX was cited for violations during a health inspection on September 10, 2025.
That finding sits at the center of a September 2025 complaint inspection at Park Manor Bee Cave, a nursing facility at 14058 Bee Caves Parkway.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.