KIRKWOOD MANOR
Grade D — 66/100 composite score
CMS Star Ratings
Certified Beds
162
Ownership
For profit - Corporation
Total Fines
$29,026
Last Survey
N/A
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Staffing Hours & Turnover
Hours per Resident per Day (PBJ)
Turnover Rates
Ownership
UVALDE COUNTY HOSPITAL AUTHORITY
100%
LAKE ISLAND HEALTHCARE, INC.
MARTIN, KYLE
YU, HAORAN
APOLINAR, ADAM
BURNAM, SOON
KEETCH, CHAD
Penalties & Fines (1)
| Date | Type | Description | Amount |
|---|---|---|---|
| Mar 24, 2024 | Fine | — | $29,026 |
Health Inspection Deficiencies (49)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pharmacy Service Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pharmacy Service Deficiencies
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Nutrition and Dietary Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Resident Rights Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Pharmacy Service Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Administration Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Administration Deficiencies
Provide training in compliance and ethics.
Administration Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Resident Rights Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies
Ensure the activities program is directed by a qualified professional.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Quality of Life and Care Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Environmental Deficiencies
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Frequently Asked Questions
What is the CareGrader rating for KIRKWOOD MANOR?
KIRKWOOD MANOR in NEW BRAUNFELS, Texas has a CareGrader grade of D (Below Average), with a composite score of 66.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.
What is the CMS star rating for KIRKWOOD MANOR?
KIRKWOOD MANOR has an overall CMS star rating of 2 out of 5, a health inspection rating of 2/5, and a staffing rating of 3/5. CareGrader combines this with additional data to calculate an A-F grade.
How many health deficiencies does KIRKWOOD MANOR have?
KIRKWOOD MANOR has 49 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.
Has KIRKWOOD MANOR been fined?
Yes. KIRKWOOD MANOR has $29,026 in total fines from CMS enforcement actions across 1 penalty.
How many beds does KIRKWOOD MANOR have?
KIRKWOOD MANOR has 162 certified beds with approximately 122 current residents (75% occupancy). The facility is located at 2590 LOOP 337 N, NEW BRAUNFELS, Texas 78130. It is a for profit - corporation facility.
Data Disclaimer
Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.