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
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.48
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.72
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,075
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9907
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.71
Baseline 21.91% · Performance 18.39% · Measure score 6.71 · Achievement 6.56 · Improvement 6.71
Healthcare-associated infections
3.99
Baseline 8.73% · Performance 7.06% · Measure score 3.99 · Achievement 2.61 · Improvement 3.99
Total nurse turnover
2.39
Baseline 47.69% · Performance 53.92% · Measure score 2.39 · Achievement 2.39 · Improvement 0
Adjusted total nurse staffing
1.91
Baseline 2.56 hours · Performance 3.34 hours · Measure score 1.91 · Achievement 0.91 · Improvement 1.91
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.54% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 116 · Observed rate 11.21% · Lower 95% interval 7.69% |
| Discharge to community | 54.32% |
50.57%
3.8 pts better
|
No Different than the National Rate · Eligible stays 85 · Observed rate 50.59% · Lower 95% interval 45.2% |
| Medicare spending per beneficiary | 1.31 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 92.66% |
95.27%
2.6 pts worse
|
Numerator 101 · Denominator 109 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 109 |
| Discharge self-care score | 52.33% |
53.69%
1.4 pts worse
|
Numerator 45 · Denominator 86 |
| Discharge mobility score | 44.19% |
50.94%
6.8 pts worse
|
Numerator 38 · Denominator 86 |
| Pressure ulcers or injuries, new or worsened | 1.83% |
2.29%
0.5 pts better
|
Numerator 2 · Denominator 109 · Adjusted rate 1.79% |
| Healthcare-associated infections requiring hospitalization | 7.06% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 6.25% · Lower 95% interval 3.8% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 188 |
| Staff flu vaccination coverage | 40.74% |
42%
1.3 pts worse
|
Numerator 99 · Denominator 243 |
| Discharge function score | 53.49% |
56.45%
3 pts worse
|
Numerator 46 · Denominator 86 |
| Transfer of health information to provider | 85.71% |
95.95%
10.2 pts worse
|
Numerator 18 · Denominator 21 |
| Transfer of health information to patient | 97.73% |
96.28%
1.5 pts better
|
Numerator 43 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 6.25% |
25.2%
18.9 pts worse
|
Numerator 3 · Denominator 48 |
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 · Adjusted 2.0 · Observed 1.6 · Expected 1.5 · Used in QM five-star |
| 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 · Adjusted 1.4 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 100.0% |
| 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 · Q1 3.4% · Q2 2.5% · Q3 4.2% · Q4 4.2% · 4Q avg 3.6% · Used in QM five-star |
| 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 · Q1 6.5% · Q2 5.8% · Q3 7.6% · Q4 7.1% · 4Q avg 6.7% |
| 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 · Q1 0.9% · Q2 1.8% · Q3 4.5% · Q4 2.8% · 4Q avg 2.5% |
| 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 · Q1 17.0% · Q2 14.2% · Q3 11.4% · Q4 10.9% · 4Q avg 13.4% |
| 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 · Q1 5.7% · Q2 6.0% · Q3 5.5% · Q4 4.8% · 4Q avg 5.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.8% · Q3 0.8% · Q4 0.8% · 4Q avg 0.6% |
| 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 · Q1 39.3% · Q2 7.1% · Q3 47.0% · Q4 37.4% · 4Q avg 34.8% · Used in QM five-star |
| 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 · Q1 34.4% · Q2 26.4% · Q3 43.2% · Q4 37.0% · 4Q avg 35.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 22.1% · Q2 23.2% · Q3 25.9% · Q4 18.3% · 4Q avg 22.4% |
| 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 · Q1 4.0% · Q2 3.5% · Q3 4.7% · Q4 1.3% · 4Q avg 3.4% · Used in QM five-star |
| 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 · Q1 97.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| 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 · Adjusted 16.1% · Observed 18.3% · Expected 12.7% · Used in QM five-star |
| 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 · Q1 4.8% · Q2 6.4% · Q3 4.4% · Q4 0.0% · 4Q avg 3.9% · Used in QM five-star |
| 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 · 4Q avg 97.2% |
| 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 · Adjusted 21.2% · Observed 20.7% · Expected 23.3% · Used in QM five-star |
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
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#3
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