Inspection·November 9, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #98's Quarterly MDS, dated [DATE], revealed the resident was unable to complete the BIMS interview. Further review revealed the staff assessment for mental status indicated moderate cognitive impairment. Record review of Resident #98's care plan revealed a problem area which read, [Resident #98] has chosen DNR status. Date initiated: [DATE], and a goal which read, wishes will be honored throughout review date. Record review of Resident #98's clinical record, revealed DNR / Do Not Attempt Resuscitation on a physician's order summary report, dated [DATE]. Record review of Resident #98's OOH-DNR, signed by the resident's wife in section B however not at the bottom where the form is noted all persons who have signed above must sign below, acknowledging that this document has been properly completed. Further review of the OOH-DNR revealed the signature of a physician in section D, without one of the two options chosen by the physician depicting what previous knowledge of the resident's wishes he was using to make the declaration. The physician had also not provided a second signature at the bottom of the document. Further record review of Resident #98's clinical record revealed a second copy of the OOH-DNR with a physician's signature added in both the physician's statement section and at the bottom of the document. Further review of the OOH-DNR revealed the wife's second signature was not at the bottom of the document. During a record review and interview with the SW on [DATE] at 8:50 a.m., the SW stated she is the one responsible for advanced directives. The SW stated she thought she recognized the physician's signature on the document however she was not completely certain. The SW confirmed Resident #7's OOH-DNR would not be valid without the physician's printed name and license number to correctly identify the physician. The SW reviewed Resident #98's OOH-DNR and confirmed it did not have all of the signatures needed from the required parties and stated it therefore would not be valid. The SW identified the potential harm could be the resident's wishes would not be followed. During an interview on [DATE] at 9:38 a.m., the DON confirmed the SW had consulted her about the OOH-DNRs following the surveyor's interview and the DON verified that Resident #7 and Resident #98's OOH-DNRs would not be valid at this time and the SW would be working with the families and physician to correct them as soon as possible. Record review of the Texas Health and Human Services webpage, www.dshs.texas.gov/emstraumasystems/dnr.shtm, titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], revealed, Frequently Asked Questions for DNR: Filling out the Out-of-Hospital Do-Not-Resuscitate Form. Physician's Statement: The patient's attending physician must sign and date the form, print or type his/her name and give his/her license number. Record review of the facility's policy titled, Advance Directives and Associated Documentation, dated 11.2016, and revised 1.2022, revealed, Policy: It is the policy of this facility to implement the resident decisions and directives that are in compliant with State and/or Federal Law and the policies of this facility. Procedure: 5. When an Advance Directive is completed: a. Review the Advance Directive to validate the document reflects the resident choices and that the document is signed and dated by the resident or responsible agent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 2 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a MDS was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 1 discharged residents (Resident #102) reviewed for transmitting assessments in that: Residents Affected - Few Resident #102's discharge MDS assessment was not completed and transmitted within 14 days of completion. This deficient practice could place residents at risk of not having assessments completed and submitted timely as required. The findings were: Record review of Resident #102's face sheet, dated 11/8/22, revealed a [AGE] year old male admitted on [DATE] and discharged on 9/14/22 with diagnoses that included displaced trimalleolar fracture of the right lower leg (a fracture that occurred on 3 different parts of the ankle), orthopedic aftercare and unsteadiness of feet. Record review of Resident #102's Order Summary Report, dated 11/8/22, revealed an order that noted the Resident was, OK to DC (discharge) home with medications, with order date 9/12/22. Record review of Resident #102's Discharge Summary and Post-Discharge Plan of Care, dated 9/14/22 revealed, You are being discharged to: Home. Record review of Resident #102's electronic MDS assessments revealed no documented evidence of a discharge MDS assessment completed or transmitted. During an interview on 11/8/22 at 2:34 p.m., MDS Coordinator B stated, there was supposed to be a discharge MDS completed for Resident #102 but had been overlooked. MDS Coordinator B stated, the discharge MDS signified the resident had discharged from the facility and would clear the resident from the computer system. MDS Coordinator B stated he was uncertain what the time frame was for submitting a discharge MDS to CMS. MDS Coordinator B stated, the facility was supposed to follow CMS guidelines, with the guidance of the RAI to complete resident assessments. During a follow up interview on 11/8/22 at 3:15 p.m., MDS Coordinator B stated, the discharge MDS assessment should have been submitted within 14 days of Resident #102's discharge and the MDS Coordinators were responsible for submitting the assessments in a timely manner. During an interview on 11/8/22 at 3:24 p.m., the DON stated, a discharge MDS assessment should have been completed for Resident #102. The DON stated, the MDS assessment was completed for accuracy and payment purposes. The DON stated, the facility referred to the RAI to complete resident assessments. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.17.1, October 2019, revealed in part, .(1) the assessment accurately reflects the resident's status .09. Discharge Assessment .Must be completed when the resident is discharged from the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 3 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0640 and the resident is not expected to return to the facility within 30 days .Must be completed within 14 days after the discharge date .Must be submitted within 14 days after the MDS completion date . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 4 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the MDS assessments accurately reflected the resident's status for one of 23 residents (Resident #4) reviewed for accuracy of assessments. Residents Affected - Few The facility failed to ensure the Quarterly MDS dated [DATE] reflected an accurate assessment of Resident #4's use of ointments. This deficient practice could place the residents at risk of not receiving the necessary care and services. The findings included: Review of Resident #4's admission record revealed an admission date of 07/29/05 with a diagnosis of Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the order dated 10/18/22 revealed Wound care orders for abrasion to upper lip: cleanse with wound cleanser, pat dry, apply bacitracin (ointment used to help prevent minor skin injuries such as cuts, scrapes, and burns from becoming infected), and leave open to air twice daily (may cover with small bandage if needed due to constant picking). Review of the Quarterly MDS assessment with ARD date of 10/24/22, with a look back period of 7 days, revealed the section M1200 Skin and Ulcer/Injury Treatment revealed no for Applications of ointments/medications other than to feet. During an interview on 11/09/22 at 9:12 a.m., MDS Coordinator B stated it should have been coded as a yes on the MDS and MDS C stated she may have missed it and that's why it was not coded. During an interview on 11/09/22 at 11:55 a.m., the DON stated there was no potential negative outcome for not coding the bacitracin ointment because the resident did not have a wound and that the staff expectations would be to follow the RAI manual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 5 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 of 9 residents (Resident #104 and Resident #363) reviewed for baseline care plan, in that: 1. The facility failed to ensure Resident #104's baseline care plan included information related to resident's use of a CPAP. 2. The facility failed to ensure Resident #363's baseline care plan included information related to resident's use of a CPAP. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. The findings were: 1. Record review of Resident #104's face sheet, dated 11/08/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: anemia, peripheral vascular disease (blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block or spasm, diabetes mellitus and hyperlipidemia (abnormally high levels of fats (lipids) in the blood, which include cholesterol and triglycerides). Record review of Resident #104's admission MDS, dated [DATE], revealed the resident had a BIMS score of 11, which indicated moderate cognitive impairment. Record review of Resident #104's Baseline Care Plan, undated, revealed no focus area or instructions for resident's CPAP use. Record review of Resident #104's electronic medical record Order Summary Report, dated 11/09/2022, revealed an order on 10/04/2022 for CPAP at bedtime. In an interview with Resident #104 on 11/09/2022 at 9:30 a.m., Resident #104 stated he used his CPAP every night since he moved into the facility. The resident stated, it makes me feel better in the morning, because if I don't, I am dragging and tired. 2. Record review of Resident #363's face sheet, dated 11/09/2022, revealed the resident was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses that included: Type 2 diabetes mellitus with hyperglycemia (high blood sugar level), obstructive sleep apnea (repeatedly stop and start breathing while sleeping), acute and chronic respiratory failure and pleural effusion (an excessive accumulation of fluid in the pleura (cushion the lung and reduce any friction that may develop between the lung, rib cage, and chest cavity) space Record review of Resident #363's admission MDS, dated [DATE], revealed the resident had a BIMS score of 14, which indicated the resident's cognition to be intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 6 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #363's baseline care plan, undated, revealed no focus area or instructions for the resident's CPAP use. Record review of Resident #363's electronic medical record Order Summary Report, dated 11/09/2022, revealed an order on 11/09/2022, following surveyor's interview, for: CPAP with home settings while in bed during sleep and nap times as needed. In an interview with Resident #363 on 11/09/2022 at 9:25 a.m., Resident #363 stated he has used his CPAP for several years and brought it from home when he moved in becasue he needs it when he sleeps at night and when he lays down to take a nap. The resident added, I usually take a nap everyday around 2:00 p.m. During an observation and interview with ADON A on 11/09/2022 at 9:47 a.m., ADON A confirmed the residents use of a CPAP machine was not included in the baseline care plan. ADON A stated this was not his area and referred the surveyor to one of the MDS coordinators. During a record review and interview with MDS Coordinator B and MDS Coordinator C on 11/09/2022 at 10:02 a.m., both MDS Coordinators confirmed the resident's CPAP needs were not indicated on the baseline care plan. During an interview with the DON on 11/09/2022 at 10:25 a.m., the DON confirmed Resident #104 and Resident #363's CPAP needs should have been addressed on their baseline care plans. Record review of the facility's policy titled, Comprehensive Person-Centered Care Planning, revised 08/2017, revealed, The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 7 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to develop and implement a comprehensive person-centered care plan for 3 (#4, #33 and #98) of 16 residents reviewed for comprehensive person-centered care plans in that: 1. Facility failed to reflect Resident #4's ted hose and urinary tract infection in her comprehensive person-centered care plan. 2. Facility failed to reflect Resident #33's preference to remove and put on her own nasal cannula in her comprehensive person-centered care plan. 3. Facility failed to reflect Resident #98's 1/2 bed bilateral side rail use in his comprehensive person-centered care plan and his PRN oxygen. This deficient practice could affect residents who require care at the facility and result in missed or inadequate care. The findings were: 1. Review of Resident #4's admission record revealed an admission date of 07/29/05 with a diagnosis of Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the order dated 07/05/22 revealed orders for ted hose (stockings that help prevent blood clots and swelling in your legs) on am for swelling for bilateral legs, ted hose off pm. Review of the care plans revised date 06/09/22 revealed no care plan for the use of ted hose. Review of the Resident #4's Infection Surveillance Report dated 10/26/22 revealed the resident had a urinary tract infection. Review of Resident #4's care plans revised date 06/09/22 revealed no care plan for urinary tract infection. During an interview on 11/09/22 at 9:04 a.m., the MDS Coordinators B and C verified there was no care plan for the use of ted hose for Resident #4 and stated there should be one. MDS Coordinator C stated she may have missed completing the care plan. During a second interview on 11/09/22 at 9:18 a.m., MDS Coordinators B and C stated there was no care plan for the urinary tract infection for Resident #4 because they may have not been informed of the infection. During an interview on 11/09/22 at 11:55 a.m., the DON stated there was no potential negative outcome because the resident received antibiotics and that the staff expectations would be that care plans should be completed. 2. Review of Resident #33's electronic face sheet dated 11/08/2022 revealed she was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 8 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility on [DATE] with diagnoses of pneumonia (respiratory infection), acute respiratory failure with hypoxia (lung disease and low oxygen saturations) and COPD (persistent respiratory symptoms such as breathlessness and a cough). Review of Resident #33's quarterly MDS assessment with an ARD of 07/08/2022 revealed the resident scored a 14/15 on her BIMS which indicated she was cognitively intact. She was coded to have oxygen therapy, and required extensive assistance with her care. Review of Resident #33's comprehensive person-centered care plan with a revised date of 04/212022 revealed she had a diagnosis of COPD. Interventions .Give oxygen therapy as ordered by the physician O 2 at 2-4 L/MIN VIA NC. It did not reflect Resident #33 preferred to take off and to put on her own O 2 NC. Review of Resident #33's Order Summary Report dated 11/08/2022 revealed O 2 at 2-4 L/MIN VIA NC as needed for SOB, RESPIRATORY DISTRESS, CYANOSIS (discoloration of skin related to low oxygen level in blood) LABORED BREATHING .Start Date .02/06/2021. Observation on 11/06/2022 at 10:30 a.m. of Resident #33 revealed she was sitting in her room in a wheel chair beside the bed and she had her O 2 NC lying on the bed. Interview on 11/06/2022 at 10:32 a.m. with Resident #33 revealed she took off her own O 2 NC and then would put it back on. She stated she preferred to do that. Interview on 11/08/2022 at 3:10 p.m. with the DON revealed that resident preferences needed to be in the person-centered care plan and that Resident #33's preference to take off and put on her own O 2 NC needed to be care planned because she also needed a bag or something clean to place it on when she rested from having it to prevent dirt or dust particles from getting into it. She stated it was important for staff to know her preference and for Resident #33 to maintain as much independence as possible. Interview on 11/09/2022 at 10:00 a.m. with MDS B revealed he should have had Resident #33's preference to take off and put on her O 2 NC care planned because it was part of her routine and care. 3. Review of Resident #98's electronic face sheet dated 11/06/2022 revealed he was admitted to the facility on [DATE] with diagnoses of anxiety (restlessness) and mood disturbance (irritability). Review of Resident #98's quarterly MDS assessment with an ARD of 10/16/2022 revealed he scored a 99 on his BIMS which indicated the interview was not successful. Further review revealed under staff assessment for mental status revealed Resident #98 was Moderately impaired - decisions poor; cues/supervision required. He required extensive assistance with his ADL's to include A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. Review of Resident #98's comprehensive person-centered care plan dated 07/13/2022 revealed Focus .ADL Self Care Performance Deficit r/t generalized weakness .requires extensive one person assistance to reposition and turn in bed. Resident #98's comprehensive person-centered care plan did not reflect his use of 1/2 side rails on his bed for mobility. Resident #98's care plan did not reflect his PRN oxygen order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 9 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #98's Order Summary Report dated 11/06/2022 revealed Bed mobility bars to assist with turning and repositioning while in bed .start date 07/13/2022 .O 2 at 2-4 L/MIN VIA NC PRN to maintain SPO2 >90% as needed for SOB, Respiratory distress, cyanosis, labored breathing .start date 07/09/2022 .check and record O 2 saturation every shift .start date 07/09/2022. Review of Resident #98's MAR dated [DATE] revealed Check and Record O2 saturation every shift, day, PM, and NOC which were initialed. Observation on 11/06/2022 at 11:00 a.m. of Resident #98 revealed he was sitting up in a tall wheel chair. His bed had 1/2 metal side rails in the up position on both sides. Observation on 11/08/2022 at 2:45 p.m. with the DON of Resident #98 revealed he was lying in bed with 1/2 metal side rails up on both sides of his bed. There was a noticeable gap between the mattress and side rails with Resident #98 lying on the bed. Interview on 11/08/2022 at 3:10 p.m. with the DON revealed that bed side rails for mobility needed to be care planned because it was part of the residents routine. She stated Resident #98's mobility bars should have been reflected so that his required care needs were communicated to staff. She stated that Resident #98's oxygen and management of his oxygen needed to be reflected on his person-centered comprehensive care plan. Interview on 11/09/2022 at 10:00 a.m. with MDS B revealed he should have had Resident #98's mobility bars needed to be on the care plan and he did not know why they were not. He stated he was not sure when Resident #98 received the bed with the metal 1/2 side rails. He stated Resident #98's oxygen and care associated with management of the oxygen needed to be care planned to make sure staff knew what care the resident required. Review of the facility policy and procedure titled Comprehensive Person-Centered Care Planning revised 08/2017 revealed It is the policy of this facility that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that includes .to meet a resident's medical, nursing, mental and psychological needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 10 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview. and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 7 residents (Resident #31) reviewed for care plan revisions, in that: The facility failed to ensure Resident #31's comprehensive care plan was revised to include an intervention for nebulizer treatments. This failure could place residents at risk of inadequate respiratory treatments and could result in a decline in health. The findings included: 1. Record review of Resident #31's face sheet dated 11/08/2022 revealed an admission date of 10/07/2021 and diagnoses which included cerebral infarction (stroke), Parkinson's disease, diabetes mellitus and dysphagia (difficulty swallowing). Record review of Resident #31's Annual MDS, dated [DATE], revealed a BIMS score of 99 which indicated the resident was unable to complete the assessment, has moderately impaired cognitive skills for daily decision making and disorganized thinking. Record review of Resident #31's Care Plan, undated, revealed no focus area or instructions for Resident #31's nebulizer treatments. Record review of Resident #31's electronic medical record Order Summary Report, dated 11/07/2022, revealed an initial order on 11/07/2021 for: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally every 6 hours as needed for congestion via nebulizer. During a record review and interview with MDS Coordinator B and MDS Coordinator C on 11/09/2022 at 10:10 a.m., both MDS Coordinators confirmed interventions for nebulizer treatments had not been revised for Resident #31. During an interview with the DON on 11/09/2022 at 10:30 a.m., the DON stated Resident #31 had received a renewal order on 10/29/2022 for the nebulizer treatments. The DON then confirmed Resident #31's comprehensive care plan had not been updated following the new order for nebulizer treatments. Record review of the facility's policy titled, Comprehensive Person-Centered Care Planning, dated 08/2017, revealed, 6. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 11 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the state for 1 of 1 Activity Director, reviewed in that: Residents Affected - Few The facility failed to ensure the AD was qualified to serve as the director of the activities program. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident. The findings were: Record review of staff roster, provided by the facility, undated, revealed the AD was listed as Activities Director. Further review revealed AD hired on 08/02/2022. Record review of the AD employee file on 11/09/22 revealed a Bachelor of Science in Recreation Management degree from [University name] dated 12/15/2021. Further review revealed no documentation of certification or CEU (Continuing Education Units). Record review of [University name] webpage www.byu.edu/management/recreation-management revealed the AD's degree to be focused on preparing students for the recreation, venue, and experience management professions in private, public, and nonprofit venues. Designed with the recognition that providing and managing recreation experiences and venues have emerged as an important factor of economic activity for communities, cities, states, and countries. Further review revealed the university offered a separate degree plan for Therapeutic Recreation students to then be eligible to become certified. Record review of the AD's job application provided by the facility revealed the AD had no previous experience working as an Activities Director or as a volunteer for an Activity department. Record review of the AD's job description provided by the facility revealed a section, Education and/or Experience: May be a qualified therapeutic recreation specialist or an activities professional who is certified by a recognized accrediting body or qualified occupational therapist or occupational therapist assistant. Further review revealed a section, Certificates and Licenses: Is certified or licensed, if applicable, by the state in which practicing; and is: Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990. In an interview with the Administrator on 11/09/2022 at 11:15 a.m., the Administrator revealed the AD did not have a certification or license to qualify as an Activities Director. The Administrator stated, we are trying to let her get acclimated and then plan to get her enrolled in the certification course. The Administrator then added, she does have a recreation therapy degree. In a record review and interview with the AD on 11/09/2022 at 11:23 a.m., the AD revealed her degree did not credential her to be a therapeutic recreational specialist. The AD stated, I would have had to take some more math and science classes for that degree. The AD provided copies of her degree and certification confirming the Recreation Management degree was different than the TR degree plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 12 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0680 Level of Harm - Minimal harm or potential for actual harm The AD revealed she has been working at the facility since early August and plan to start the certification course soon. The AD further revealed the AD from a sister facility has assisted her some over the last couple of months to learn how to do assessments and plan activities. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 13 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 of 6 residents (Resident #1and #55) reviewed for treatment and services in that: Residents Affected - Few 1. The facility did not maintain physician orders and medical information needed to monitor Resident #1's cardiac pacemaker (electronic device that is implanted in the body to monitor heart rate and rhythm that stimulates the heart with electrical impulses to maintain or restore a normal heartbeat) parameters for proper functioning. 2. The facility did not ensure Resident #55's protective arm sleeves were utilized to protect from skin integrity issues. This failure could place residents of risk for not receiving proper care and treatment. The findings were: 1. Record review of Resident #1's face sheet, dated 11/8/22 revealed a [AGE] year old male admitted on [DATE] and re-admitted on [DATE] with diagnoses that included diabetes, kidney transplant status, morbid (severe) obesity due to excess calories, hypertension (high blood pressure), heart disease, atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart) and presence of cardiac pacemaker. Record review of Resident #1's most recent admission MDS assessment, dated 10/8/22 revealed the resident was cognitively intact for daily decision-making skills. Further review of the admission MDS, under section I, I8000, Additional active diagnoses, revealed the resident had an active diagnosis that identified the presence of a cardiac pacemaker. Record review of Resident #1's comprehensive person-centered care plan, revision date 10/11/22 revealed the resident had a pacemaker related to atrial fibrillation with interventions that included pacemaker checks and document in chart: Heart rate, Rhythm, Battery check. Record review of Resident #1's Order Summary Report, dated 11/8/22 did not have orders for the pacemaker or parameters. During an interview on 11/6/22 at 1:57 p.m., Resident #1 stated he had a cardiac pacemaker and pointed to an area to the right upper chest. Resident #1 stated the cardiac pacemaker was implanted sometime in 2010 but was replaced in 2021 due to malfunction. During an interview on 11/8/22 at 3:46 p.m., LVN D stated she had worked in the facility for almost 2 years and was familiar with Resident #1. LVN D stated she did not believe Resident #1 had a cardiac pacemaker because if he did, the electronic record in the computer would have identified it. LVN D stated, if the resident had a cardiac pacemaker, the resident's pulse rate would need to be monitored to ensure it was within the parameters specified by a cardiologist. LVN D stated it was necessary to have a physician's order to monitor the cardiac pacemaker. During an interview on 11/8/22 at 3:54 p.m., the DON stated she was aware Resident #1 had a cardiac (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 14 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm pacemaker. The DON stated she had an information board in her office that identified Resident #1 and other residents who had a cardiac pacemaker. The DON stated it was important to have an order for the cardiac pacemaker to monitor for malfunction by obtaining the cardiac pacemaker information and cardiac pacemaker parameters. The DON stated, the cardiac pacemaker parameters determined how to take care of the resident. Residents Affected - Few Record review of the facility policy and procedure titled, Pacemaker, Care of Resident with, revision date 5/2007 revealed in part, .It is the policy of this facility to have a system of monitoring residents with pacemaker, to initiate and maintain the heartbeat when the normal pacemaker fails .2. Attach pacemaker in chart identification stating type of pacemaker. Include physician's name, pacemaker rate and date of insertion .9. Failure of pacemaker to sense when rate drops below pre-set rate should be reported to MD promptly . 2. Record review of Resident #55's face sheet revealed an [AGE] year old male admitted on [DATE] and re-admitted on [DATE] with diagnoses that included muscle wasting (wasting or thinning of muscle mass), peripheral vascular disease (a slow and progressive circulation disorder; narrowing, blockage, or spasms in a blood vessel) and cognitive communication deficit. Record review of Resident #55's most recent Significant Change MDS assessment, dated 10/22/22 revealed the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #55's comprehensive person-centered care plan, revision date 10/10/22 revealed the resident had a potential for pressure ulcer development related to immobility with the goal to have intact skin, free of redness, blisters or discoloration and interventions that included to follow facility policies/protocols for the prevention/treatment of skin breakdown. Record review of Resident #55's Order Summary Report, dated 11/8/22 revealed an order for ARM SLEEVES TO BILATERAL ARMS AT ALL TIMES every shift for PREVENTATIVE with order date 7/5/22 and no end date. Record review of Resident #55's MAR/TAR (medication administration record/treatment administration record), for November 2022 revealed ARM SLEEVES TO BILATERAL ARMS AT ALL TIMES every shift for PREVENTATIVE, with order date 7/5/22 and no end date. Further review of the MAR/TAR revealed documentation the resident was wearing the arm sleeves three times daily indicated by a check mark and staff initials. The MAR/TAR for the arm sleeves was checked on 11/7/22 and 11/8/22 on the day shift and initialed orgf. The MAR/TAR indicated, the initials orgf was used by LVN G. Observations on 11/7/22 at 7:24 a.m. and 2:02 p.m., revealed Resident #55 in bed not wearing arm sleeves and noted with red/purple discoloration to both arms. Resident #55 was not interviewable. Observations on 11/8/22 at 7:45 a.m., 10:28 a.m. and 11:30 a.m. revealed Resident #55 in bed not wearing arm sleeves and noted with red/purple discoloration to both arms. During an interview on 11/8/22 at 11:33 a.m., CNA F stated she had provided care to Resident #55 and the resident used to use the arm sleeves because the resident pinched and scratched his arms. CNA F stated the CNAs were responsible for ensuring the arm sleeves were being utilized but if the arm sleeves were missing then the CNA was to report to the nurse. CNA F stated she would not document the arm sleeves were missing, only report to the charge nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 15 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and observation on 11/8/22 at 11:40 a.m., LVN G stated she was the charge nurse and was responsible for Resident #55's care. LVN G stated she usually worked the 6:00 a.m. to 2:00 p.m. shift and made rounds at the beginning of the shift and every 2 hours, sometimes more. LVN G stated, Resident #55 wore arm sleeves as a preventative to protect his arms against skin tears because the resident's skin was fragile. LVN G stated she had seen Resident #55's arm sleeves on the resident's windowsill. LVN G then went into the resident's room and pointed to the arm sleeves that were on Resident #55's windowsill. LVN G stated she was responsible for ensuring Resident #55 had the arm sleeves in place. LVN G stated she had marked the resident's MAR/TAR indicating the resident was wearing the arm sleeves by accident and didn't pay attention close enough. LVN G stated, the sleeves are here but just not being used. During an interview on 11/8/22 at 2:09 p.m., the DON stated she was very familiar with Resident #55 and believed the order for the arm sleeves were discontinued. The DON stated, the nurse should not have been documenting in the MAR/TAR the arm sleeves were being utilized because if the resident was not wearing them it would be falsifying the record. The DON stated, since the order for the arm sleeves was not discontinued, the arm sleeves should have been utilized. The DON stated it was the responsibility of the charge nurse to ensure the resident was wearing the arm sleeves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 16 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation and interview, the facility failed to ensure the resident environment was free of accident hazards as is possible for 5 of 5 halls (Halls 100, 200, 300, 400, and 500) reviewed for accidents hazards, in that: The facility failed to ensure hot water temperatures were below 110 degrees F on Halls 100, 200, 300, 400, and 500. This deficient practice could affect residents, staff and visitors and result in burns or blisters to the skin. The findings were: Observation on 11/6/22 at 11:18 a.m. of 2 rooms on opposite sides of the 400 Hall revealed hot water temperatures of 123.4 Fahrenheit. Observation on 11/6/22 at 11:21 a.m. revealed the hot water temperature in the staff restroom was 123.2 degrees Fahrenheit. Observation on 11/6/22 at 11:23 a.m. of 1 room on 300 hall revealed the hot water temperature was 121.3 degrees Fahrenheit. Observation on 11/06/22 at 11:38 a.m. of a room on the 200 hall revealed the hot water temperature in bathroom sink was 116.2 Fahrenheit. Observation on 11/06/22 at 11:40 a.m. of a second room on the 200 hall revealed the hot water temperature in bathroom sink was 116.6 F. Observation on 11/06/22 11:44 a.m. of a third room on the 200 hall revealed the hot water temperature in the bathroom sink was 116.9 Fahrenheit. Observation on 11/06/22 at 12:25 p.m., revealed the hot water temperature in the first 100 hall room checked was 123.4 F. Observation on 11/06/22 at 12:30 p.m., revealed the hot water temperature in the second 100 hall room checked was 122.8 F. Observation on 11/06/22 at 12:34 p.m., revealed the hot water temperature in the third 100 hall room checked was 122.4 F. Observation on 11/06/22 at 12:45 p.m., of a room on the 500 hall revealed the hot water temperature was 114.6 degrees Fahrenheit. Observation on 11/06/22 at 1:13 p.m., of a second room on the 500 hall revealed the hot water temperature was 118.2 degrees Fahrenheit. Observation on 11/06/22 at 1:51 p.m., of a third room on the 500 hall revealed the hot water (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 17 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 temperature was 115.3 degrees Fahrenheit. Level of Harm - Minimal harm or potential for actual harm Interview on 11/9/22 at 09:00 a.m. with the MS who had worked at the facility or 8 days and was still in orientation revealed that the hot water temperatures on the boiler were set too high. the MS stated that a log book was kept for the water temperatures and that 2 rooms were checked each day on each hall. He stated he had not started a log book. He stated it was important to check the water temperatures to make sure they were not fluctuating and were safe for visitors, staff and residents to prevent injury or discomfort. Residents Affected - Some Interview on 11/9/22 at 12:00 p.m. with the Administrator revealed he did not know why the water heater temperatures were too high. The Administrator stated that no residents, staff or visitors had complained and there were no incidents involved with hot water temperatures. The Administrator stated that someone had to have turned the temperature control up, but he did not know why someone would do that. The Administrator stated the previous MS left disgruntled on October 8th 2022 and another maintenance person from a sister facility was coming over twice a week to take and record hot water temperatures. The Administrator stated that it was routine to take hot water temperatures daily Monday through Friday to ensure they were monitored randomly and regularly to avoid fluctuations. Review of facility hot water temperature logs dated 10/10/22 revealed that hot water temperatures were recorded twice a week until 11/03/22 three days prior to the surveyors' entrance for inspection. No hot water temperatures recorded were above 110 degrees F. Review of the facility policy and procedure titled Water Safety Management Program, revised date 1.2022 revealed Water temperature should be monitored randomly and regularly to detect fluctuations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 18 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 3 of 3 residents (Resident #31, Resident #104, and Resident #363) reviewed for respiratory care, in that: Residents Affected - Some 1. The facility failed to ensure Resident #31's nebulizer mask was stored in a clean and sanitary manner. 2. The facility failed to ensure Resident #104's CPAP mask was stored in a clean and sanitary manner. 3. The facility failed to ensure Resident #363's CPAP mask was stored in a clean and sanitary manner. These failures could place residents who required respiratory treatments at risk of receiving inadequate respiratory treatments and could result in decline in health. The findings were: 1. Record review of Resident #31's face sheet dated 11/08/2022 revealed an admission date of 10/07/2021 and diagnoses which included cerebral infarction (stroke), Parkinson's disease, diabetes mellitus and dysphagia (difficulty swallowing). Record review of Resident #31's Annual MDS, dated [DATE], revealed a BIMS score of 99 which indicated the resident was unable to complete the assessment, has moderately impaired cognitive skills for daily decision making and disorganized thinking. Record review of Resident #31's Care Plan, undated, revealed no focus area or instructions for Resident #31's nebulizer treatments. Record review of Resident #31's electronic medical record Order Summary Report, dated 11/07/2022, revealed an order on 11/07/2021 for: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally every 6 hours as needed for congestion via nebulizer. During an observation on 11/06/2022 at 12:38 pm, revealed a nebulizer machine sitting on the bedside table next to Resident #31's bed. Further observation revealed the mask hanging from the tubing into the open top drawer, not covered or bagged for protection. During an observation and interview with the DON on 11/06/2022 at 1:41 p.m., the DON confirmed the nebulizer belonged to Resident #31. The DON further stated the mask should have been in a plastic bag and dated because staff change out the tubing and bags every 7 days. The DON stated masks are stored in plastic bags to prevent them from getting dirty and to avoid infections. 2. Record review of Resident #104's face sheet, dated 11/08/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: anemia, peripheral vascular disease (blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block or spasm, diabetes mellitus and hyperlipidemia (abnormally high levels of fats (lipids) in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 19 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 blood, which include cholesterol and triglycerides). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #104's admission MDS, dated [DATE], revealed the resident had a BIMS score of 11, which indicated moderate cognitive impairment. Residents Affected - Some Record review of Resident #104's Baseline Care Plan, undated, revealed no focus area or instructions for resident's CPAP use. Record review of Resident #104's electronic medical record Order Summary Report, dated 11/09/2022, revealed an order on 10/04/2022 for CPAP at bedtime. In an interview with Resident #104 on 11/09/2022 at 9:30 a.m., Resident #104 stated he used his CPAP every night since he moved into the facility. The resident stated, it makes me feel better in the morning, because if I don't, I am dragging and tired. 3. Record review of Resident #363's face sheet, dated 11/09/2022, revealed the resident was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses that included: Type 2 diabetes mellitus with hyperglycemia (high blood sugar level), obstructive sleep apnea (repeatedly stop and start breathing while sleeping), acute and chronic respiratory failure and pleural effusion (an excessive accumulation of fluid in the pleura (cushion the lung and reduce any friction that may develop between the lung, rib cage, and chest cavity) space Record review of Resident #363's admission MDS, dated [DATE], revealed the resident had a BIMS score of 14, which indicated the resident's cognition to be intact. Record review of Resident #363's baseline care plan, undated, revealed no focus area or instructions for the resident's CPAP use. During an observation on 11/07/2022 at 11:29 a.m., revealed Resident #363 asleep using his CPAP machine. During an observation and interview with Resident #104 and Resident #363 on 11/09/2022 at 9:29 a.m., revealed Resident #104's CPAP mask was lying on the floor near the head of his bed on top of a plastic bag. Resident #104 picked the CPAP mask up and stated, it was on my table, I guess housekeeping knocked it down there. Resident #104 then attempted to put two pieces back together that he said must have come apart when it fell. Further observation revealed Resident #363's CPAP mask hanging over the top of the bed. Resident #363 was asked about a bag for the CPAP mask and the resident stated, I don't know my wife may have taken it home with the dirty clothes not knowing what it was for when they gave them to us yesterday. Resident #104 and Resident #363 were asked if they had been educated to keep their masks in a bag and both residents stated they were only provided bags yesterday. During an observation and interview with ADON A on 11/09/2022 at 9:47 p.m., revealed Resident #104's CPAP storage bag to be on the floor and Resident #363's CPAP mask across the bed. ADON A confirmed with Resident #104 that the CPAP mask had been on top of the bag on the floor and Resident #104 asked ADON A to assist with putting the two pieces back together. ADON A also confirmed Resident #363's CPAP mask was hanging across the bed and further stated the masks should have been in plastic bags and dated. During an interview with the DON on 11/09/2022 at 10:44 a.m., the DON confirmed Resident #104 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 20 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #363's CPAP masks should have been in a plastic bag and dated for sanitary reasons. The DON stated the nursing staff try to make rounds to make sure residents do not move them and ensure they stay bagged. Record review of the facility's policy titled, Oxygen Equipment, undated, revealed, Procedures: 1E. When mask or cannula is temporarily not being used, it will be covered loosely to prevent contamination from airborne microorganisms. It will not be covered tightly. Event ID: Facility ID: 455732 If continuation sheet Page 21 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure correct installation, use, and maintenance of bed rails for 1 resident (#98) of 2 residents reviewed for use of side or bed rails in that: The facility did not ensure Resident #98's bed's dimensions or maintenance was followed for installing and maintaining the bed rails and he did not have a signed informed consent from his responsible party for the bed rails. This deficient practice could affect residents who use bed or side rails as enablers and could result in entrapment. The findings were: Review of Resident #98's electronic face sheet dated 11/06/2022 revealed he was admitted to the facility on [DATE] with diagnoses of anxiety (restlessness) and mood disturbance (irritability). Review of Resident #98's quarterly MDS assessment with an ARD of 10/16/2022 revealed he scored a 99 on his BIMS which indicated the interview was not successful. Further review revealed under staff assessment for mental status revealed Resident #98 was Moderately impaired - decisions poor; cues/supervision required. He required extensive assistance with his ADL's to include A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. Review of Resident #98's comprehensive person-centered care plan dated 07/13/2022 revealed Focus .ADL Self Care Performance Deficit r/t generalized weakness .requires extensive one person assistance to reposition and turn in bed. Resident #98's comprehensive person-centered care plan did not reflect his use of 1/2 side rails on his bed for mobility. Review of Resident #98's Order Summary Report dated 11/06/2022 revealed Bed mobility bars to assist with turning and repositioning while in bed .start date 07/13/2022. Review of Resident #98's Informed Consent For Use of Bed Rails dated 07/09/2022 revealed a check mark in the box that indicated Bed rails are recommended at all times when resident is in bed. Further review revealed No resident or resident representative signature on the consent form. Review of Resident #98's Bed Rail Safety Evaluation dated 07/09/2022 and signed by the DON on 07/19/2022 revealed IDT Recommendation .Bed rail NOT recommended. Observation on 11/06/2022 at 11:00 a.m. of Resident #98 revealed he was sitting up in a tall wheel chair. His bed had 1/2 metal side rails in the up position on both sides. Observation on 11/08/2022 at 2:45 p.m. with the DON of Resident #98 revealed he was lying in bed with 1/2 metal side rails up on both sides of his bed. There was a noticeable gap between the mattress and side rails with Resident #98 lying on the bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 22 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/08/2022 at 3:10 p.m. with the DON revealed that bed side rails for mobility needed to be care planned because it was part of the residents routine. She stated Resident #98's mobility bars should have been reflected so that his required care needs were communicated to staff. She stated that she was not aware that Resident #98 had bed rails. She stated that she thought he was placed in one of the facilities beds when he arrived and she did not know when Hospice brought in the bed he had now. She stated she did not think the bed with the rails was checked by maintenance. Interview on 11/9/22 at 09:00 a.m. with the MS who had worked at the facility or 8 days and was still in orientation revealed that he did not find any evidence of the maintenance or checks of resident bed rails and he had not done any while he was there. He stated that it was important to provide preventive maintenance to prevent injuries from improper use of equipment. Review of the facility policy and procedure titled Bed Rails dated 1/2022 revealed It is the policy of the facility to attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used,the facility must ensure correct installation, use and maintenance of bed rails. Further review revealed The facility should maintain evidence that it has provided sufficient information so that the resident or resident representative could make an informed decision. Information that the facility must provide to the resident, or resident representative includes, but are not limited to: what are the assessed medical needs, benefits and risks, alternatives tried and considered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 23 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 24 residents (Residents #6, #23, and #98) reviewed for medication administration. 1. Resident #6's clinical record included an incorrect order to weigh the resident. 2. Resident #23's clinical record did not include an order for suctioning. 3. Resident #98's oxygen saturation was not being recorded each shift as ordered by the physician. This deficient practice placed the residents at risk of errors for care or treatment. The findings include: 1. Review of Resident #6's admission record revealed a re-admission date of 10/03/22 with a diagnosis of Sepsis (the body's extreme response to an infection). Review of the physician orders revealed an order dated 10/03/22 for weekly weights for four weeks. Review of Resident #6's weight record revealed one weight dated 10/04/22. Further review revealed no weekly weights. During an interview and record review on 11/09/22 8:44 a.m., ADON A stated that upon readmission on [DATE], dietary services assessed Resident #6, and she was not a candidate for significant weight changes and did not require weekly weights. ADON A stated the order weekly weights was accidentally entered and should not have been entered for weekly weights. During an interview on 11/09/22 at 11:52 a.m., the DON stated there was no potential negative outcome since the resident did not require weekly weights. She stated the staff expectation would be to enter orders correctly. 2. Review of Resident #23's admission record revealed an admission date of 08/11/22 with a primary diagnosis of cerebella stroke syndrome (a type of cerebrovascular event involving the posterior cranial fossa, specifically the cerebellum). During an observation on 11/07/22 at 11:02 a.m., LVN E suctioned Resident #23. Review of Resident #23's clinical record for October and November 2022 revealed no order for suctioning. During an interview on 11/09/22 at 8:35 a.m., ADON A stated the order was not entered when Resident #23 returned from the hospital on [DATE] and that it should have been entered. During an interview on 11/09/22 11:49 a.m., the DON stated there would be no potential negative outcome because the staff was aware that Resident #23 had to be suctioned at times. She stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 24 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 staff expectations were that they enter active orders in the record. Level of Harm - Minimal harm or potential for actual harm 3. Review of Resident #98's electronic face sheet dated 11/06/2022 revealed he was admitted to the facility on [DATE] with diagnoses of anxiety (restlessness) and mood disturbance (irritability). Residents Affected - Some Review of Resident #98's quarterly MDS assessment with an ARD of 10/16/2022 revealed he scored a 99 on his BIMS which indicated the interview was not successful. Further review revealed under staff assessment for mental status revealed Resident #98 was Moderately impaired - decisions poor; cues/supervision required. He required extensive assistance with his ADL's to include A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. Review of Resident #98's comprehensive person-centered care plan dated 07/13/2022 revealed Focus .ADL Self Care Performance Deficit r/t generalized weakness .requires extensive one person assistance to reposition and turn in bed. Resident #98's care plan did not reflect his PRN oxygen order, or to check his oxygen saturations every shift and record. Review of Resident #98's Order Summary Report dated 11/06/2022 revealed O2 at 2-4 L/MIN VIA NC PRN to maintain SPO2 >90% as needed for SOB, Respiratory distress, cyanosis (bluish skin color r/t lack of oxygen in blood), labored breathing .start date 07/09/2022 .check and record O2 saturation every shift .start date 07/09/2022. Review of Resident #98's MAR dated [DATE] revealed Check and Record O2 saturation every shift, day, PM, and NOC which were initialed and had a check mark, but no oxygen saturation levels were noted. Review of Resident #98's vital signs in his electronic clinical record revealed from 10/26/2022 to 11/8/2022 he was not getting oxygen saturation checks recorded each shift. Interview on 11/08/2022 at 3:10 p.m. with the DON revealed that Resident #98's oxygen and management of his oxygen needed to be reflected on his person-centered comprehensive care plan, she also stated that the oxygen levels were not being recorded each shift as was ordered by the physician and that was important because his saturation level needed to be kept greater than 90% and he could be in need of oxygen 4. Review of the undated facility policy titled Physician Orders, Telephone Orders and Recapitulation Process revealed in part, .Physician orders shall be obtained prior to the initiation of any medication or treatment .admission order to the facility is necessary to show that the resident was admitted by a physician to this level of care .admission orders must include, but not limited to the following: .Medication .Treatment. Further review revealed All orders must be specific and complete with all necessary details to carry out the prescribed order without any questions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 25 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment for one resident (#98) of 2 residents reviewed for bed rails in that. The facility did not ensure Resident #98's bed's dimensions or maintenance was followed for installing and maintaining the bed rails. This deficient practice could affect residents who use bed or side rails as enablers and could result in entrapment. The findings were: Review of Resident #98's electronic face sheet dated 11/06/2022 revealed he was admitted to the facility on [DATE] with diagnoses of anxiety (restlessness) and mood disturbance (irritability). Review of Resident #98's quarterly MDS assessment with an ARD of 10/16/2022 revealed he scored a 99 on his BIMS which indicated the interview was not successful. Further review revealed under staff assessment for mental status revealed Resident #98 was Moderately impaired - decisions poor; cues/supervision required. He required extensive assistance with his ADL's to include A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. Review of Resident #98's comprehensive person-centered care plan dated 07/13/2022 revealed Focus .ADL Self Care Performance Deficit r/t generalized weakness .requires extensive one person assistance to reposition and turn in bed. Resident #98's comprehensive person-centered care plan did not reflect his use of 1/2 side rails on his bed for mobility. Review of Resident #98's Order Summary Report dated 11/06/2022 revealed Bed mobility bars to assist with turning and repositioning while in bed .start date 07/13/2022. Review of Resident #98's Informed Consent For Use of Bed Rails dated 07/09/2022 revealed a check mark in the box that indicated Bed rails are recommended at all times when resident is in bed. Further review revealed No resident or resident representative signature on the consent form. Review of Resident #98's Bed Rail Safety Evaluation dated 07/09/2022 and signed by the DON on 07/19/2022 revealed IDT Recommendation .Bed rail NOT recommended. Observation on 11/06/2022 at 11:00 a.m. of Resident #98 revealed he was sitting up in a tall wheel chair. His bed had 1/2 metal side rails in the up position on both sides. Observation on 11/08/2022 at 2:45 p.m. with the DON of Resident #98 revealed he was lying in bed with 1/2 metal side rails up on both sides of his bed. There was a noticeable gap between the mattress and side rails with Resident #98 lying on the bed. Interview on 11/08/2022 at 3:10 p.m. with the DON revealed that bed side rails for mobility needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 26 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkwood Manor 2590 Loop 337 N New Braunfels, TX 78130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 Level of Harm - Minimal harm or potential for actual harm to be care planned because it was part of the residents routine. She stated Resident #98's mobility bars should have been reflected so that his required care needs were communicated to staff. She stated that she was not aware that Resident #98 had bed rails. She stated that she thought he was placed in one of the facilities beds when he arrived and she did not know when Hospice brought in the bed he had now. She stated she did not think the bed with the rails was checked by maintenance. Residents Affected - Few Interview on 11/9/22 at 09:00 a.m. with the MS who had worked at the facility or 8 days and was still in orientation revealed that he did not find any evidence of the maintenance or checks of resident bed rails and he had not done any while he was there. He stated that it was important to provide preventive maintenance to prevent injuries from improper use of equipment. Review of the facility policy and procedure titled Bed Rails and dated 1/2022 revealed Check with the manufacturer's or review manufacturer use requirements to verify the bed rails, mattress, and bed frame are compatible .ensure the bed dimensions are appropriate to accommodate the size of the resident .verify the bed rails to be installed are appropriate for the size and weight of the resident .inspect and regularly check the mattress and bed rails for areas of possible entrapment and correct immediately .check bed rails regularly to verify they are still installed correctly and connections are secure as rails may shift or loosen over time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 27 of 27