KIRKWOOD MANOR
Open-data reference.
KIRKWOOD MANOR is a for profit - corporation facility in NEW BRAUNFELS, TX with 162 certified beds and a 2-star overall CMS rating. The facility has 49 deficiency records on file. Total penalties: $29K.
2590 LOOP 337 N, NEW BRAUNFELS, TX 78130
Phone: 8306200509
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 455732
- Ownership
- For profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 162
- Residents
- 123
- In Hospital
- No
- County
- Comal
- Last Inspection
- Feb 21, 2025
Staffing Data
- RN Hours
- 0.47 (nat'l avg: 0.68)
- LPN Hours
- 0.88
- CNA Hours
- 2.13
- Total Nursing Hours
- 3.48 (nat'l avg: 3.89)
- PT Hours
- 0.18
- Nursing Turnover
- 48.6%
- RN Turnover
- 55.6%
What the CMS Record Reveals About KIRKWOOD MANOR
KIRKWOOD MANOR operates 162 certified beds in NEW BRAUNFELS, TX with approximately 123 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (3★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 49 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $29K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.48 total nursing hours per resident day (national average 3.89), with RN coverage at 0.47 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, KIRKWOOD MANOR falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 48.6%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (49 most recent)
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.
Category: Pharmacy Service Deficiencies
Corrected: Jun 5, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Jun 5, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Mar 21, 2025
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Category: Nutrition and Dietary Deficiencies
Corrected: Mar 21, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: Feb 28, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Feb 28, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 22, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 21, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 27, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 24, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 21, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Mar 21, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Jun 25, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 25, 2024
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Mar 25, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 25, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Feb 2, 2024
Provide training in compliance and ethics.
Category: Administration Deficiencies
Corrected: Mar 8, 2024
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Category: Administration Deficiencies
Corrected: Mar 8, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 29, 2024
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.
Category: Administration Deficiencies
Corrected: Feb 2, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 29, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Feb 16, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Feb 29, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Feb 16, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 29, 2024
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 31, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 9, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 29, 2024
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 14, 2024
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 16, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Feb 9, 2024
Honor the resident's right to organize and participate in resident/family groups in the facility.
Category: Resident Rights Deficiencies
Corrected: Feb 29, 2024
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Jan 31, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 22, 2023
Ensure that residents are fully informed and understand their health status, care and treatments.
Category: Resident Rights Deficiencies
Corrected: Dec 22, 2023
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.
Category: Environmental Deficiencies
Corrected: Nov 10, 2022
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 11, 2022
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.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 11, 2022
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 11, 2022
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 10, 2022
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 10, 2022
Ensure the activities program is directed by a qualified professional.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 30, 2022
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 10, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 10, 2022
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 10, 2022
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 10, 2022
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 10, 2022
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.
Category: Resident Rights Deficiencies
Corrected: Nov 10, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 35.2% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 2.5% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.2% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 6.7% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.6% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 3.6% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 99.3% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 3.9% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 34.8% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 13.4% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 97.2% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 3.4% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 22.4% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 5.5% | Yes |
Penalty History 1 penalties totaling $29K
| Date | Type | Amount |
|---|---|---|
| Mar 24, 2024 | Fine | $29K |
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Frequently Asked Questions
What is the overall CMS rating for KIRKWOOD MANOR?
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How many beds does KIRKWOOD MANOR have?
Does KIRKWOOD MANOR have any deficiencies on record?
Has KIRKWOOD MANOR received any fines or penalties?
Who owns KIRKWOOD MANOR?
When was KIRKWOOD MANOR last inspected?
What quality measures are tracked for KIRKWOOD MANOR?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.