D66

KIRKWOOD MANOR

Grade D 66/100 composite score

For profit - Corporation

CMS Star Ratings

Overall
2/5
Health Insp.
2/5
Quality
3/5
Staffing
3/5
RN Staffing
Not rated

Certified Beds

162

Ownership

For profit - Corporation

Total Fines

$29,026

Last Survey

N/A

2590 LOOP 337 N, NEW BRAUNFELS, TX 78130
8306200509

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.50h
LPN
0.94h
CNA
2.28h
Total
3.72h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

UVALDE COUNTY HOSPITAL AUTHORITY

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Nov 2019

100%

LAKE ISLAND HEALTHCARE, INC.

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Nov 2019

MARTIN, KYLE

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Nov 2019

YU, HAORAN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Nov 2019

APOLINAR, ADAM

IndividualCORPORATE OFFICERSince Jul 2022

BURNAM, SOON

IndividualCORPORATE OFFICERSince Dec 2021

KEETCH, CHAD

IndividualCORPORATE OFFICERSince Mar 2011

Penalties & Fines (1)

$29,026total fines
DateTypeDescriptionAmount
Mar 24, 2024Fine$29,026

Health Inspection Deficiencies (49)

June 4, 2025Health2 deficiencies
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Jun 5, 2025
0761DMinimal harm, Isolated

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

Corrected Jun 5, 2025
February 21, 2025Health10 deficiencies
0584EMinimal harm, Pattern

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

Corrected Mar 21, 2025
0645DMinimal harm, Isolated

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

Corrected Mar 21, 2025
0657DMinimal harm, Isolated

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

Corrected Feb 24, 2025
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Feb 27, 2025
0690DMinimal harm, Isolated

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

Corrected Mar 21, 2025
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Feb 22, 2025
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Feb 28, 2025
0761DMinimal harm, Isolated

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

Corrected Feb 28, 2025
0813DMinimal harm, Isolated

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Nutrition and Dietary Deficiencies

Corrected Mar 21, 2025
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Mar 21, 2025
January 10, 2025Health1 deficiency
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Jun 25, 2024
March 24, 2024Health3 deficiencies1 severe
0760EMinimal harm, Pattern

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Mar 25, 2024
0684KImmediate jeopardy, Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Mar 25, 2024
0842EMinimal harm, Pattern

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

Corrected Mar 25, 2024
January 26, 2024Health18 deficiencies
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Jan 31, 2024
0565EMinimal harm, Pattern

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Corrected Feb 29, 2024
0578DMinimal harm, Isolated

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

Corrected Feb 9, 2024
0636DMinimal harm, Isolated

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

Corrected Feb 16, 2024
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Feb 14, 2024
0656EMinimal harm, Pattern

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

Corrected Feb 29, 2024
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Feb 9, 2024
0692DMinimal harm, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Jan 31, 2024
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Feb 29, 2024
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Feb 16, 2024
0756EMinimal harm, Pattern

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

Corrected Feb 29, 2024
0758DMinimal harm, Isolated

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

Corrected Feb 16, 2024
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Feb 29, 2024
0840DMinimal harm, Isolated

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

Corrected Feb 2, 2024
0842DMinimal harm, Isolated

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

Corrected Feb 29, 2024
0944EMinimal harm, Pattern

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Administration Deficiencies

Corrected Mar 8, 2024
0946EMinimal harm, Pattern

Provide training in compliance and ethics.

Administration Deficiencies

Corrected Mar 8, 2024
0584DMinimal harm, Isolated

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

Corrected Feb 2, 2024
November 30, 2023Health2 deficiencies
0552DMinimal harm, Isolated

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Corrected Dec 22, 2023
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Dec 22, 2023
November 9, 2022Health13 deficiencies
0578DMinimal harm, Isolated

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

Corrected Nov 10, 2022
0640DMinimal harm, Isolated

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 10, 2022
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 10, 2022
0655DMinimal harm, Isolated

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

Corrected Nov 10, 2022
0656EMinimal harm, Pattern

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

Corrected Nov 10, 2022
0657DMinimal harm, Isolated

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

Corrected Nov 10, 2022
0680DMinimal harm, Isolated

Ensure the activities program is directed by a qualified professional.

Quality of Life and Care Deficiencies

Corrected Nov 30, 2022
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Nov 10, 2022
0689EMinimal harm, Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Nov 10, 2022
0695EMinimal harm, Pattern

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Nov 11, 2022
0700DMinimal harm, Isolated

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

Corrected Nov 11, 2022
0842EMinimal harm, Pattern

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

Corrected Nov 11, 2022
0909DMinimal harm, Isolated

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

Corrected Nov 10, 2022

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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.