Cycle 1
Health 2025-02-21 · Fire 2025-02-21
12 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
New Braunfels, TX
Kirkwood Manor
2-star overall rating with 2-star inspections with $29,026 in total fines with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
2590 Loop 337 N, New Braunfels, TX
(830) 620-0509
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
162
Certified beds
Average residents
123
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1988-02-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing
LPN hours / resident day
0.88
Licensed practical nurse staffing
Aide hours / resident day
2.13
Nurse aide staffing
Weekend hours
3.04
Weekend nurse staffing
RN turnover
56%
Annual RN turnover
Total nurse turnover
49%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.3%
0.3 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 6.7% |
2.7%
4 pts worse
|
11.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.5% |
3.3%
0.8 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.4% |
18.9%
5.5 pts better
|
19.6%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 5.5% |
10.8%
5.3 pts better
|
16.7%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.6% |
0.0%
0.6 pts worse
|
0.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 34.8% |
15.4%
19.4 pts worse
|
16.3%
18.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 35.2% |
16.1%
19.1 pts worse
|
14.9%
20.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.5%
0.3 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.4% |
15.0%
7.4 pts worse
|
19.8%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
4.2%
0.8 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
89.7%
9.6 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
12.0%
4.1 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.9% |
1.5%
2.4 pts worse
|
1.6%
2.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.2% |
88.0%
9.2 pts better
|
79.7%
17.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.2% |
25.9%
4.7 pts better
|
23.9%
2.7 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-26 · Fire 2024-01-26
22 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-11-09 · Fire 2022-11-09
15 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-20
E · Potential for more than minimal harm
2025-02-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-02-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-13
E · Potential for more than minimal harm
2025-02-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-02-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-24
F · Potential for more than minimal harm
2024-01-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-29
F · Potential for more than minimal harm
2024-01-26
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-03-01
F · Potential for more than minimal harm
2024-01-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-02
D · Potential for more than minimal harm
2024-01-26
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-02-06
D · Potential for more than minimal harm
2024-01-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-01
F · Potential for more than minimal harm
2022-11-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-29
E · Potential for more than minimal harm
2022-11-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-04
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-06-04
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-06-05
E · Potential for more than minimal harm
2025-02-21
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-02-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-21
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-02-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-02-21
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-22
D · Potential for more than minimal harm
2025-02-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-21
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-21
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-01-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-25
K · Immediate jeopardy
2024-03-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-25
E · Potential for more than minimal harm
2024-03-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-25
E · Potential for more than minimal harm
2024-03-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-25
F · Potential for more than minimal harm
2024-01-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-01-26
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-01-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-01-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-02-16
E · Potential for more than minimal harm
2024-01-26
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-01-26
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-01-26
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-31
D · Potential for more than minimal harm
2024-01-26
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-01-26
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-02-02
D · Potential for more than minimal harm
2024-01-26
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-01-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-31
D · Potential for more than minimal harm
2024-01-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-26
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-26
F840 · Administration Deficiencies
Health
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.
Corrected 2024-02-02
D · Potential for more than minimal harm
2024-01-26
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-02-29
D · Potential for more than minimal harm
2023-11-30
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-30
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-12-22
E · Potential for more than minimal harm
2022-11-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-11-10
E · Potential for more than minimal harm
2022-11-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-11-10
E · Potential for more than minimal harm
2022-11-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-11
E · Potential for more than minimal harm
2022-11-09
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-11-09
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2022-11-10
D · Potential for more than minimal harm
2022-11-09
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-11-10
D · Potential for more than minimal harm
2022-11-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-11-10
D · Potential for more than minimal harm
2022-11-09
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-11-10
D · Potential for more than minimal harm
2022-11-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-11-10
D · Potential for more than minimal harm
2022-11-09
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2022-11-30
D · Potential for more than minimal harm
2022-11-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-10
D · Potential for more than minimal harm
2022-11-09
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-11-09
F909 · Environmental Deficiencies
Health
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.
Corrected 2022-11-10
Penalties and ownership
What sits behind the stars
$29,026
2024-03-24
Fine
Fine · fine $29,026
Fine
Ownership
Uvalde County Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Apolinar, Adam
Corporate Officer · Individual
Burnam, Soon
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Lake Island Healthcare, Inc.
Operational/Managerial Control · Organization
Martin, Kyle
Operational/Managerial Control · Individual
Yu, Haoran
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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3-star overall rating with 3-star inspections with $22,205 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Sundance Inn Health Center
New Braunfels, TX
3-star overall rating with 2-star inspections with abuse icon flag with $6,364 in total fines with 15 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Avir at New Braunfels
New Braunfels, TX
1-star overall rating with 1-star inspections with $374,761 in total fines with 24 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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