Health inspection·November 30, 2023

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 residents/resident representatives were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 of 2 Residents (Resident #1) reviewed for resident rights in that: Residents Affected - Few The facility failed to notify Resident #1's Medical Power of Attorney or emergency contact after a behavioral incident when the resident did not have the cognitive ability to make informed medical decision before before receiving psychiatric services. This failure could place residents and their resident representatives at risk for not being informed about care and treatments that may affect the resident's well-being. The findings included: Review of a resident's face sheet dated 11/30/2023 indicated Resident #1 was an 82 - year- old initially admitted on [DATE] with diagnoses that included but not limited to the following: myopathy (disease that affects the muscled that control voluntary movement in the body), Cerebral infarction ( stroke due to disrupted blood flow in the brain), and diabetes ( disease that results in too much sugar in the blood). Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 had a BIMS of 2 indicating severe cognitive impairment. Review of a incident report dated 08/31/2023 at 1:02 pm revealed an unidentified resident was sitting at their usual dining table when another resident reported to a staff member that Resident #1 slapped a different resident in the face during lunch. Camera was reviewed by the SW and revealed the incident occurred. During an interview on 11/29/2023 at 11:30 a.m the Social Worker stated she did not call Resident #1's Medical Power of Attorney or emergency contact after determining Resident #1 slapped another resident in the face or before initiating and scheduling behavioral health services by a contracted entity and she should have. She explained that would usually be involved in assisting with tasks related to such events were not in the building at the time, therefore she was completing additional tasks and did not make the family notification. The Social Worker said it was a resident's right to have their family member contacted when there is a change of condition and in this case the resident's rights were not respected. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 455732 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 11/30/2023 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)