Park Manor Bee Cave
Park Manor Bee Cave in Bee Cave, TX — inspection on September 10, 2025.
Found 3 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
During an interview on [DATE] at 4:51 PM, the DON stated that Resident #1 was dependent on the mechanical lift for transfers.
The DON stated that typically when a resident was in a wheelchair it was for a max of two hours unless therapy has cleared the resident for [NAME] time or they have wound care.
The DON stated that she expected Resident #1 to be transferred with the mechanical lift to bed for any type of care they might have needed.
The DON stated that residents who were dependent on mechanical lift for transfers were at higher risk for skin breakdown and if they were not used to being up.
The DON stated that the resident could also be at a risk if they were incontinent and if they urinated the entire time they were up in the chair.
The DON stated that it did not meet her expectation that resident be up in a wheelchair for nine hours.
The DON stated it was ultimately the responsibility of the charge nurse to ensure the resident was transferred up to the wheelchair or laid down.
The DON stated the house checks came about because on [DATE] the family was concerned regarding perineal care. Resident #1 was assessed by wound care and had slight excoriation (irritation) on her perineal area and frequent rounding was implemented.
The DON stated that it was designed for the nurse or CNA to check and/or change Resident #1 and to see if she needed anything or was okay.
The DON stated that staff checked off if they performed care listed for Resident #1.
The DON stated that she interviewed staff and staff sated that they went in and did checks and changes with Resident #1 on [DATE].
The DON stated that some staff said they forgot to check it off, but she could only speak to what the staff told her.
The DON stated no change of condition was reported to her prior to Resident #1 going out to the hospital and it was by family request that she went to the hospital on [DATE].
The DON stated Resident #1 returned within 4 hours and family refused any care and requested she be sent out again to the hospital.
The DON stated that when she spoke with Resident #1's family they referenced [DATE] 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].
During an interview on [DATE] 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] 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], [DATE] and [DATE] reflected no in-services were conducted on rounding or check and change rounding for Resident #1.
676373 09/10/2025
Park Manor Bee Cave 14058 Bee Caves Parkway, Bldg B Bee Cave, TX 78738
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.
676373 09/10/2025
Park Manor Bee Cave 14058 Bee Caves Parkway, Bldg B Bee Cave, TX 78738
dressings, and after removing gloves.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.