Park Manor Bee Cave

In the surveyor’s words

From the most serious findings on record at Park Manor Bee Cave, in the surveyor’s own words.

• Immediate jeopardy, patternF697Jul 21, 2024

  Based on observation, interview, and record review, the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice for two (Resident #1 and Resident #2) of four residents reviewed for pain. The facility failed to provide effective pain management for Residents #1 and #2 as they went multiple days without their pain medication leaving them in excruciating pain. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/19/24 at 3:00 PM. […]

• Immediate jeopardy, patternF755Jul 21, 2024

  Based on observation, interview, and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for two (Resident #1 and Resident #2) of four residents reviewed for pharmaceutical services. The facility failed to ensure Residents #1 and #2's pain medication was ordered in a timely manner. On several occasions they went without their pain medication subsequently leaving them in excruciating pain. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/19/24 at 3:00 PM. […]

• Actual harm, patternF695May 28, 2025

  Based on interview and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for one (Resident #1) of three residents reviewed for respiratory care. The facility failed to ensure nurses were documenting the oxygen flow rate or response to oxygen therapy for Resident #1. The facility failed to have an ongoing system of monitoring Resident #1 as her oxygen saturations dropped below 92% on several occasions, she could no longer participate in therapy, her CO2 lab value was 40 (normal range was 23-31), and she continued to be short of breath days prior to hospitalization on 04/12/25 where she was diagnosed with acute and chronic hypoxic (low levels of oxygen in your body tissues)… […]

• Actual harm, patternF755Nov 16, 2023

  Based on interview, observation, and record review, the facility failed to provide accurate and timely pharmaceutical services to meet the needs of each resident, in that: Three residents (Resident #1, Resident #2, Resident #3) out of six reviewed had not consistently received medications ordered to meet their needs. The facility failed to acquire and administer prescribed drugs as ordered; Resident #1 had not received all doses of his Triamcinolone Cream as ordered, Resident #2 had not received all doses of her sleep-aide medication (Temazepam) and pain medication (Norco) as ordered, and Resident #3 had not received all doses of her pain medication (Morphine Sulfate) as ordered. […]

• Actual harm, patternF690Oct 11, 2023

  Based on interview and record review the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #1) of three residents reviewed for indwelling urinary catheters, in that: The facility failed to change Resident #1's foley catheter bag or collect a specimen from him for urinalysis according to physician orders. This failure could place residents with indwelling urinary catheters at risk of sepsis, renal failure, urinary tract infections, and pain. […]