🔎 Kirkwood Manor
Inspection Results
Inspection Overview
Kirkwood Manor has been cited for a total of 62 deficiencies since we began saving each survey.
In Texas, the average facility has **34.42 deficiencies** in our database. This profile shows the longer-term view.
Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.
Understanding Deficiency Severity (A-L Scale)
The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**
| Severity (Harm) | Scope (Widespread?) | Code Range |
|---|---|---|
| No Actual Harm | Isolated to Pattern | A - C |
| No Actual Harm | Widespread | D - F |
| **Actual Harm** | Isolated | G |
| **Actual Harm** | Pattern | H |
| **Actual Harm** | Widespread | I |
| **Immediate Jeopardy** | Isolated | J |
| **Immediate Jeopardy** | Pattern | K |
| **Immediate Jeopardy** | Widespread | L |
Detailed Deficiency List (Most Recent First)
Scope/Severity: E
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.
Scope/Severity: D
PASARR screening for Mental disorders or Intellectual Disabilities
Scope/Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Scope/Severity: D
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: D
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.
Scope/Severity: D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Scope/Severity: E
Provide and implement an infection prevention and control program.
Scope/Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: K
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: E
Ensure that residents are free from significant medication errors.
Scope/Severity: E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity: D
Reasonably accommodate the needs and preferences of each resident.
Scope/Severity: E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Scope/Severity: D
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.
Scope/Severity: D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Scope/Severity: D
Ensure each resident receives an accurate assessment.
Scope/Severity: E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Provide enough food/fluids to maintain a resident's health.
Scope/Severity: D
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Scope/Severity: D
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.
Scope/Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: D
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.
Scope/Severity: D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity: E
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Scope/Severity: E
Provide training in compliance and ethics.
Scope/Severity: D
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.
Scope/Severity: D
Ensure that residents are fully informed and understand their health status, care and treatments.
Scope/Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Scope/Severity: D
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.
Scope/Severity: D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Scope/Severity: D
Ensure each resident receives an accurate assessment.
Scope/Severity: D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Scope/Severity: E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: D
Ensure the activities program is directed by a qualified professional.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: E
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: D
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.
Scope/Severity: E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity: D
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.
Scope/Severity: E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Scope/Severity: D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: E
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Scope/Severity: E
Provide and implement an infection prevention and control program.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Scope/Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Scope/Severity: E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity: E
Provide and implement an infection prevention and control program.
Explore More Resources for Kirkwood Manor
Or return to the main profile page for
Kirkwood Manor
Search by key terms like services or cities you are interested in (New Braunfels medicaid, dialysis, price etc) below:
All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**