Park Manor Bee Cave

F 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

she be sent out again to the hospital. The DON stated that when she spoke with Resident #1's family they referenced [DATE REDACTED] and that Resident #1 was up in the chair all day. The DON stated that it was reported to her about Resident #1 being in the chair mid-morning on [DATE REDACTED]. During an interview on [DATE REDACTED] at 5:15 PM, the ADM stated that there were hour checks for Resident #1 because her family had concerns about frequency of checks and wanted continuous care and more one-on-one level. The ADM stated that from his understanding and based on the logs she was checked on hourly. The ADM stated that staff were expected to see if the resident or family needed anything and if Resident #1's brief was dry. The ADM stated that when he tried to speak with Resident #1 she could not respond verbally. The ADM stated on [DATE REDACTED] therapy put Resident #1 in her wheelchair and she had not been put in a chair before. The ADM stated that staff reported she was more responsive and able to use her call light after she was up. The ADM stated that when he reviewed the hourly check he believed there was a gap on that particular day. The ADM stated that

he did not know how long Resident #1 was in her chair that day and stated he knew she was in chair a good part of the day and did not think she was in the chair for nine hours. The ADM stated that Resident #1 used a mechanical lift to transfer and would have expected staff to have transfer her from her wheelchair to provide care as they could not do if she was in her chair. The ADM stated the risk of Resident #1 being in her chair for an extended time was skin breakdown, pressure, ulcers, pain and being uncomfortable in general. The ADM stated that he did not think Resident #1 was able to make her needs known. Review of facility policy dated 02/2025 titled Resident Rights reflected residents had the right to be treated with consideration, respect, and full recognition of his or her dignity and individuality. Review of facility in-services for last sixty days [DATE REDACTED], [DATE REDACTED] and [DATE REDACTED] reflected no in-services were conducted on rounding or check and change rounding for Resident #1.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

had a decreased immune system. The ADON stated that the areas for sterile supplies should be sterilized

before the supplies were laid out and that nothing else should be on the same area that is not being used for that care. During an interview on 09/10/2025 at 4:35 PM, the NP stated that the yankauer should be tested prior to use and staff can hear it was working by turning it on. The NP stated staff could use water to clear the link of the yankauer and it was okay to use water and not saline since staff were not doing anything with the patient and just to clear the tube. The NP stated that when staff did deeper suctioning sterile gloves were used, but not when providing routine tracheostomy care and stated its an open hole so its not really sterile. The NP stated she used to have to have sterile gloves to clean the inner cannula, but

she was not sure what the protocol was anymore. The NP stated that she expected staff to use hand sanitizer any time they walked into a resident's room and prior to donning gloves and after doffing gloves.

The NP stated that gloves from a hallway or touching the environment was not generally a good thing and that staff really should not put on gloves until they were ready to perform care. During an interview on 09/10/2025 at 4:51 PM, the DON stated she expected staff to perform hand hygiene before and after patient care, before entering a room, when hands were soiled or dirty and in between glove changes. The DON stated she expected staff to use sterile gloves for tracheostomy care and foley changes. The DON stated she expected staff to test the yankauer prior to starting tracheostomy care and it could be tested by touching the tip of the yankauer to the staff's gloved thumb. The DON stated she personally would not test

the yankauer in an open container of water and staff should have opened a new sterile water container. The DON stated that prior to set up, the area that items were paced on should have been sanitized and a sterile field should not have been taken out of the staff's line of vision. The DON stated staff should not have touched the nurse's cart or light switch without performing hand hygiene prior to providing resident care and changing gloves. The DON stated hand hygiene was important to not introduce infection to the resident.

The DON stated that oxygen was monitored during tracheostomy care, before and after. The DON stated that she expected staff to preoxygenate before suctioning to ensure they have the appropriate amount of oxygen and she would not expect staff to lower the oxygen flow and would increase it during tracheostomy care. During an interview on 09/10/2025 at 5:15 PM, the ADM stated he expected staff to perform hand hygiene before they interact with residents, especially if they were on enhanced barrier precautions, handling meals, before and after perineal care and before and after putting on gloves. The ADM stated that

he knew a tracheostomy was having a hole in the throat and from what he has learned they required regular suctioning, but he would defer to the DON. Review of facility in-services for last sixty days July 2025, August 2025 and September 2025 reflected no in-services were conducted on tracheostomy care.

Review of facility policy with subject Tracheostomy, Care and Cleaning of with revision date of 05/2007 reflected This is a STERILE procedure. Further review reflected staff should wash hands prior to beginning

the procedure, open plastic bag and cuff and place within reach so you do no to reach across the sterile field to discard items. Review of undated skills check off titled Tracheal Suctioning reflected perform hand hygiene and follow any necessary infection control guidelines, prepare suction equipment, turn on suction machine, open the suction catheter and sterile basin and fill with sterile normal saline. Review also reflected to preoxygenate the individual to maximize oxygen saturation in preparation for suctioning. Further

review reflected remove gloves and perform hand hygiene.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

tracheostomy care, before and after. The DON stated that she expected staff to preoxygenate before suctioning to ensure they have the appropriate amount of oxygen and she would not expect staff to lower

the oxygen flow and would increase it during tracheostomy care. During an interview on 09/10/2025 at 5:15 PM, the ADM stated he expected staff to perform hand hygiene before they interact with residents, especially if they are on enhanced barrier precautions, handling meals, before and after perineal care and

before and after putting on gloves. The ADM stated that he knew a tracheostomy was having a hole in the throat and from what he has learned they required regular suctioning, but he would defer to the DON.

Review of facility in-services for last sixty days July 2025, August 2025 and September 2025 reflected no in-services were conducted on tracheostomy care. Review of facility policy titled Infection Prevention and Control Program with revision date of 10/2022 reflected facility staff will conduct themselves and provide care in a way that minimizes the spread of infection and staff will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Review of facility policy titled Hand Hygiene with revision date of 04/2025 reflected hand hygiene is a general term that applies to hand washing antiseptic hand wash and alcohol-based hand rub. Review reflected to use alcohol-based hand rub

before and after direct contact with residents, before performing any non-surgical invasive procedures,

before donning sterile close, before handing clean or soiled dressings, after handling used dressings, and

after removing gloves.

Event ID:

Facility ID:

If continuation sheet