Park Manor Bee Cave
Park Manor Bee Cave in Bee Cave, TX — inspection on July 21, 2024.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 7/19/2024 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance.
The Surveyor monitored the POR on 07/21/24 as followed:
Observations made on 07/21/24 from 11:30 AM - 11:52 PM revealed three residents' scheduled narcotics matched with the narcotic count sheet on the medication carts.
One of the medications was down to four days' worth left and had already been reordered. Resident #2's fentanyl patches (quantity of four) had been delivered on 07/19/24.
Observation of the patch on Resident #2's right shoulder revealed the patch with the date of 07/20/24 (which coincides with her MAR).
During interviews on 07/21/24 from 11:42 AM - 2:25 PM, one RN, three LVNs, and three MAs from different shifts all stated they had been in-serviced on reordering medications and pain management before working the floor.
All stated that any medication needed to be reordered when there was only seven days left of medication.
They then stated they would then follow-up with the pharmacy to get an ETA, and if not delivered during their shift, they would notify the NP and DON.
They all stated if another staff member informed them they reached out to the pharmacy for a refill, they would not just take their word but would call the pharmacy to verify themselves.
Each staff member stated if a resident was in pain, they would administered pain medication immediately.
They described several signs and symptoms of non-verbal pain such as facial grimacing, moaning, and agitation.
Each staff member stated it was unacceptable for a resident to go without a prescribed medication, especially if they were in pain.
Review of the facility's QAPI agenda, dated 07/19/24, reflected the MD, DON, ADM, LNFAML, DON, and RNCL were in attendance.
Review of an in-service entitled Process for Reordering Pain Medications and Signs and Symptoms of Pain in Residents, dated 07/19/24 and conducted by the LNFAML, reflected the ADM and DON were reeducated on the process.
Review of a Medication Audit of Narcotics, dated 07/20/24, reflected pain medications on all medication carts were audited and accounted for.
Review of an in-service entitled Process for Reordering Pain Medications and Signs and Symptoms of Pain in Residents, from 07/20/24 - 07/21/24, reflected all medication aides and nurses were educated on the process.
While the IJ was removed on 07/21/24 at 12:50 PM, the facility remained at a level of actual no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.
676373
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676373 B.
Wing 07/21/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Park Manor Bee Cave 14058 Bee Caves Parkway, Bldg B Bee Cave, TX 78738
Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 7/19/2024 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance.
676373
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676373 B.
Wing 07/21/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Park Manor Bee Cave 14058 Bee Caves Parkway, Bldg B Bee Cave, TX 78738