Inspection·January 26, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few related to confusion, deconditioning, gait/balance other areas to include communication/ comprehension, psychoactive drug use and unaware of safety needs. The care plan had interventions which included keeping needed items within reach, be sure the call light was within reach and encourage Resident #30 to use the call to call for assistance. Review of Resident #30's Fall Risk assessment dated [DATE] revealed the resident was at high risk for falls with a score of 14.0. Observation on 01/23/2024 at 11:19 a.m. of Resident #30 lying in bed asleep on a scoop mattress and her call light was lying on the floor at the foot of the bed and not within reach of the resident. Interview on 01/24/2024 at 9:45 a.m. with the Administrator concerning the call light being found on the floor in Resident #30's room, the Administrator revealed he was not aware of call lights on the floor but, knows if the resident was not able to call for assistance they could fall. The Administrator further revealed it was everyone's responsibility to make sure the call lights were in place and within reach of the resident when in the bed. Interview on 01/24/2024 at 10:00 a.m. with CNA A revealed she works Monday through Friday and works the same rooms daily. CNA A confirmed she had taken care of Resident #30 on 01/23/2024. CNA A revealed when she gets here in the morning she is moving, moving fast to get her work done. CNA A stated if the resident cannot get to the call light they could fall. It is the aide's responsibility to make sure the call lights are within reach for the resident. Review of the Facility Call Light/Bell Policy and Procedure with a revision date of 05/2007 revealed under Procedures number 5 Place the call device within resident's reach before leaving the room FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 2 of 32 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 01/26/2024 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to follow up on concerns discussed in resident's council meeting for 7 of 9 residents reviewed for resident council. Residents Affected - Some The facility failed to show follow up on complaints and grievances made in resident council. This failure could place residents that participate in a resident council at risk of not having the right to their concerns and grievances followed through with. Finding included: Review of resident council minute meetings revealed complaints about food but no information regarding how the concerns and complaints were followed up on. In a group interview on 1/24/24 at 2:00 p.m. seven residents in a confidential resident group interview said they have made the same complaints about food over the last year. They stated they have continued to have the same issues with food being cold, not appetizing, not receiving follow up or follow through with the voiced concerns regarding food. The same example was given by multiple residents in the confidential group meeting of the meal prior to the day of the meeting that consisted of green beans, blackeye peas, pork loaf, a piece of wheat bread, and a fruit for desert not being hot and not being appetizing. Interview on 01/25/2024 at 1:03 p.m. with the Administrator, the Administrator said he eats the resident meals about once a quarter, not as often as he should. We have had some complaints about the food, and we had addressed those with the dietary manger. Food is one of the hardest things in a facility. Interview on 01/25/2024 6:21 p.m. with the AS stated she does record the resident council meeting minutes and there have been complaints about the food including the temperature. AS said the residents have said the meals are cold, I report that in meetings and to the dietary manager but I don't write down any resolutions or grievances. She stated, I didn't know I need to write down a resolution, no one has ever told me to do that. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 3 of 32 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 01/26/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents had the right to formulate an advanced directive for 2 of 2 residents (Resident #33, #92) reviewed for advance directives. Resident #33's OOH-DNR form was invalid because the attending physician's date signed was missing from the form. Resident #92's OOH-DNR form was invalid because the notary's date signed was missing from the form. This failure could result in resident DNR's not being properly executed. The findings included: Record review of Resident #33's face sheet dated, 01/26/2024, reflected a [AGE] year-old resident initially admitted on [DATE] with a diagnosis of Cerebral Infarction (the pathologic process that results in an area of necrotic tissue in the brain). Record review of Resident #33's comprehensive person-centered care plan, dated 09/27/2023 reflected [Resident #33] and family have elected DNR status with an initiated date of 09/22/2022. Record review of Resident #33's clinical records reflected an OOH-DNR, dated 09/26/2023, lacked a physician's date signed. Record review of Resident #92's face sheet, dated 1/26/2024, reflected a [AGE] year-old resident initially admitted on [DATE] with a diagnosis of Dementia (A group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #92's comprehensive person-centered care plan, dated 12/21/2023, reflected Resident has elected DNR status with an initiated date of 07/26/2023. Record review of Resident #92's clinical records reflected an OOH-DNR, dated 05/17/2023, lacked a notary date signed. Interview on 01/25/2024 at 2:12 PM, the SW stated she was the sole staff responsible for coordinating advance directives for the existing residents. The SW stated when an existing resident wished to execute an advance directive, she would review it to determine whether it was complete and can be entered into the EHR. The SW stated she was not aware of Resident #33's current documented DNR missing a primary physician's date signed and stated this DNR was received via a fax from Resident #33's hospice agency. The SW stated she was not aware of Resident #92's current documented DNR missing a notary public's date signed and stated this DNR was received via a fax from Resident #33's hospice agency. The SW stated hospice residents' DNRs are not reviewed differently or at a different quality and was still expected to affirm its completion before entering it into the electronic record. The SW stated the risk associated with entering an incomplete DNR would be that a resident could have their DNR not executed. Interview on 01/26/2024 12:11 PM the ADM stated he was not aware of Resident #33's DNR missing a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 4 of 32 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 01/26/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete primary physician's date signed. The ADM stated he was not aware of Resident #92's DNR missing a notary public's date signed. The ADM stated his expectation was that resident DNRs were to be reviewed for completion prior to being admitted to the EHR Record review of facility policy, titled Advance Directives and Associated Documentation, dated December 2023, reflected When an advanced directive is completed: a. review the advanced directive to validate the document reflects the resident choices and that the document is signed and dated by the resident or responsible agent. Event ID: Facility ID: 455732 If continuation sheet Page 5 of 32 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 01/26/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 1 of 5 (Resident #87) resident room bathrooms. The bathroom sink faucet sprayed out water onto the floor when turned on. This failure could place residents at risk for an unsafe and unsanitary environment. The Findings included: Interview and observation with Resident #87 of room [ROOM NUMBER] in the resident's bathroom on 1/23/2024 at 11:17 a.m., revealed the resident showed the State Surveyor while in the bathroom and stated you have to turn on the faucet like this and low because if you don't it spray you and it gets all on the floor, sometimes I forget and it all gets wet, It just makes a mess. Interview and observation on 01/24/2024 at approximately 6:30 p.m. with the MS, the MS said the faucet should not be like that. I have not seen that was reported but these things do happen. The MS stated, the town water supply causes a lot of build up in the faucet aerator causing them to need to be replaced. The MS said that should have been noticed by staff making rounds, many staff make rounds and we even have an Ambassador program plus all of the other staff that works here and goes in and out of the rooms, It could have caused an accident and that would not be good for the resident, I will get that fixed first thing and I can clean that up and look at the seal and floor and get that taken care of too. That should not have been missed. Interview with the Administrator on 01/24/2024 at approximately 6:50 p.m., the Administrator said the MS told him about the issues in the bathroom and they will be addressed. He was unaware there was an issue in the bathroom and no staff had put any information into their maintenance work order request system. The Administrator explained any staff can put a work order request in the system and he was not sure why a work order was not created previously. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 6 of 32 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 01/26/2024 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on interview and record review, the facility failed conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity within 14 calendar days of admission, excluding readmissions in which there was no significant change in the resident's physical or mental condition for 2 of 8 residents (Resident #164 and # 108) reviewed for Comprehensive Assessments and timing. The facility failed to ensure an MDS Assessment for Resident #164 was completed within 14 days after admission. The facility failed to code the MDS Assessment for Resident #108 correctly after discharge from the facility. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings included: Record review of resident #164's face sheet dated 01/24/2024, revealed an admission date of 01/11/2024, Record review of resident #164's medical record revealed that as of 01/25/2024, the MDS assessments showed as due or overdue. Interview with MDS Coordinator A on 1/25/2024 at 10:11 a.m. revealed the time frame for an initial MDS to be completed was 14 days from admission. He stated the MDS was completed but had not been submitted because the Resource RN finalizes it. He stated the facility follows RAI (resident assessment instrument). Record review of resident #108's Face sheet dated 1/26/2024 showed a discharge date of 12/7/2023. Record review of resident #108's Discharge MDS showed resident was discharged with code 04 which indicated that the resident was discharged to a Short-Term General Hospital. Record review of progress notes showed resident was discharged to home and MDS should have had a code of 01 to indicate a discharge to Home/Community. Record review of the mds-3.0-rai-manual-v1.17.1_October_2019 revealed The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if: -this is the resident' s first time in this facility, OR -the resident has been admitted to this facility and was discharged return not anticipated, OR -the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 7 of 32 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 01/26/2024 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 record review and interview the facility failed to accurately assess and reflect the resident's status for 1 of 26 residents (Resident #96) reviewed for accuracy of assessments in that: Residents Affected - Few Resident #96's diagnosis for hypertension (high blood pressure) was not reflected on the comprehensive assessment dated [DATE]. This failure could place other residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: Review of Resident #96's electronic face sheet dated 01/26/2024 revealed Resident #96 was [AGE] years old and was admitted on [DATE] with diagnoses which included congestive heart failure, CVA (stroke), peripheral vascular disease (a slow and progressive circulation disorder. Narrowing, blockage, or spasms in a blood vessel), diabetes, anxiety, depression, hypertension (high blood pressure), paroxysmal atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), hemiplegia and hemiparesis ( hemiplegia is defined as paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one?sided weakness, but without complete paralysis) affecting left side. Review of Resident #96's physician orders dated 01/26/2024 revealed Resident #96 was taking Amlodipine Besylate, Hydralazine HCL and Lisinopril for hypertension (high blood pressure) Review of Resident #96's Comprehensive Care Plan dated 11/15/2023 with revision 11/24/2023 revealed a focus area for hypertension with interventions to give hypertensive medications as ordered and to monitor for side effects. Review of Resident #96's admission MDS dated [DATE] revealed under Section I- Active Diagnoses, Heart/Circulation, I0700. Hypertension was not marked to indicate the resident had a diagnosis for hypertension (high blood pressure). Interview on 01/26/2024 at 6:20 p.m. with MDS A revealed there was a diagnosis on the face sheet dated 01/26/2024 indicating Resident #96 had hypertension. Also, on the physician orders dated 01/26/2024 indicating medication used for hypertension. The comprehensive care plan dated 11/15/2023 with revision 11/24/2023 had a focus area and interventions for hypertension. Further review and interview with MDS A revealed the admission MDS dated [DATE] Section I- Active Diagnoses, Heart/Circulation, I0700 had hypertension listed but, was not checked indicating the resident had hypertension (high blood pressure). Review of the facility policy and procedure, Resident Assessment and Associated Processes stated in part, Using the RAI (Resident Assessment Instrument) and will include at least the following: Disease diagnosis and health conditions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 8 of 32 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 01/26/2024 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** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for three (Resident #23, # 74, and #164) of three residents reviewed for care plans in that: 1. The facility failed to ensure Resident #23's comprehensive care plan addressed the residents individual needs and indicated Resident #23 needed to stop smoking. 2. The Facility failed to ensure Resident #74's comprehensive care plan addressed Resident #74's fluid restriction due to kidney failure/dialysis. 3. The facility failed to ensure a comprehensive care plan for Resident #164 was completed since the resident's admission. This failure could place residents at risk of receiving inadequate or unnecessary interventions not individualized to their health care needs. The Findings included: 1. Review of Resident #23's most recent face sheet dated 01/26/2024 revealed Resident #23 was admitted on [DATE] and had diagnoses that included: Cerebral infarction (Stroke), hypothyroidism (low thyroid levels), type 2 diabetes mellitus without complications, depression, essential primary hypertension, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, gastro esophageal reflux disease, and benign prostatic hyperplasia (enlargement of the gland) with lower urinary tract symptoms. Review of Resident #23's care plan dated reflected Resident #23 most recent care plan reflected Resident #23 has a DX of Diabetes Mellitus type 2, with the following goal will have no complications related to diabetes through the review date, with one of the interventions listed as Encourage the resident to practice good general health practices that included encourage to stop smoking. Interview on 01/24/2024 at 9:05 a.m. with Resident #23 denied he currently smoked. Interview on 01/25/2024 at 2:00 p.m. with the ADON revealed the facility is a non smoking facility and Residents are not allowed to smoke on the grounds of the facility, The ADON explained that was a generic pre populated type of intervention and was not individualized for Resident #23 as it should have been by the MDS Coordinator. Interview on 01/26/24 at 5:27 p.m. with the MDS A revealed the goal for Resident #23 was not a personalized goal, it is a generic goal and should have been changed or taken out if the resident does not smoke. 2. Review of Resident #74's face sheet revealed the resident was admitted on [DATE] with diagnoses which included end stage renal disease, cerebral palsy (uncontrolled muscle movement), anemia, diabetes with diabetic neuropathy (feeling in area affected by diabetes), hypertension, anxiety, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 9 of 32 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 01/26/2024 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 depression, peripheral vascular disease (affecting the blood vessels) and chronic obstructive pulmonary disease. Review of Resident #74's physician orders dated 01/26/2024 revealed Resident #74 had orders for a 1200 cc fluid restriction. Residents Affected - Some Review of Resident #74's care plan dated 11/20/2023 revealed a care plan that addressed hemo-dialysis related to renal failure with an intervention for Fluid Restriction: 1200 ml per day. Another care plan for a nutritional problem related to Resident #74 being on dialysis and had a fluid restriction dated 11/14/2023 and an intervention for a fluid restriction: 1200 ml per day. Further review of the care plan revealed no docmentation related to the change in fluid restriction to 1000 ml per day. Review of Resident #74's dialysis communication form dated 11/13/2023 revealed Resident #74 had an order for a 1200cc fluid restriction. Review of the Communication Form (no date) from nursing without checking which department it was to be sent to revealed the resident was on a 1200 cc fluid restriction with no breakdown. Further review revealed a Dialysis Communication Record sent to the facility dated 01/19/2024 recommending Resident #74 be placed on a 1 liter fluid restriction. Review of the Facility Diet Master (Roster) dated 01/26/2024 and provided by the DM revealed Resident #74 had a regular, NAS (no added salt) diet with a 1200 cc fluid restriction and no fluid breakdown. Observation on 01/26/2024 at 4:45 p.m. while a dietary staff member and diet manager were sorting the meal tickets for the supper meal, revealed Resident #74's meal ticket dated 01/25/2024 revealed the resident had documented beside DIET Regular, NAS and a 1200 cc fluid restriction. Interview on 01/26/2024 at 4:14 p.m. with MDS A confirmed she was the person who completed Resident #74's MDS and care plan. During the interview MDS A confirmed there was a physician's order for a 1200 cc fluid restriction for Resident #74 and was also documented on the care plan. When asked about a recommendation MDS A stated nursing will call the physician to let the doctor know what the recommendation from dialysis was and then the orders comes to me (MDS A) and then I (MDS A) will update the care plan. MDS A was not aware of any changes with Resident 74's fluid restriction from 1200 cc to 1,000 cc of fluid. Interview on 01/26/2024 at 4:40 p.m. with Resident #74 revealed she had a fluid restriction and did not have a water pitcher in her room. Resident #74 went on to say nursing and dietary give her fluids. When Resident #74 was asked if she knew how much her fluid restriction was, Resident #74 stated 1 liter of fluid or 1,000 cc. Interview on 01/26/2024 at 4:48 p.m. with the DM confirmed Resident #74 had a dietary slip and the diet on the diet roster for a 1200 cc fluid restriction. When DM was asked about the fluid breakdown, DM stated nursing takes and tells dietary how much to give on a dietary communication form. The DM was not aware of a change with Resident #74's fluid restriction from 1200 cc to 1,000 cc. 3. Record review of Resident #164's face sheet, dated 01/24/2024, revealed he had an admission date of 01/11/2024 and diagnoses that included: Alcohol dependence with withdrawal and, schizoaffective disorder (mental health disorder marked by a combination of hallucinations, delusions, mood disorders and depression or mania.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 10 of 32 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 01/26/2024 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 Record review of Resident #164's medical record revealed there was no comprehensive care plan addressing the use of nicotine since his admission. Observation on 1/25/2024 at 1:30 p.m., revealed 2 cans of Copenhagen smokeless tobacco were on the resident's bedside table. Residents Affected - Some Interview with Resident #164 on 1/25/2024 at 1:30 p.m. he stated, they know about it. My niece brought it to me. Interview on 01/25/24 at 01:31 p.m. LVN G stated the residents dip was approved prior to admission by the administration. The potential for harm can be abuse of the nicotine product. In an interview on 01/25/24 at 01:45 p.m. the DON and the Administrator stated they were aware of the dip. They stated, they Did not know why it was not cared plan and they did not know it was in his room. The DON stated the long-term effect could be cancer. The facility is a smoke free facility and did not have a policy regarding smoking or nicotine products. The Comprehensive Person- Center Care Planning Policy provided by the facility, with a revision date of 12/2023, indicated the following: It is the policy of this facility that the interdisciplinary team shall develop a comprehensive person- centered care plan for each resident that includes measurable objective and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Interventions are actions, treatments, procedures, or activities to meet an objective FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 11 of 32 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 01/26/2024 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 - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure the resident environment remains as free of accident hazards as was possible for 1 of 4 (Resident #44) residents reviewed for accident hazards in that: Resident #44's bed was left in a high position after receiving incontinent care from CNA B. This deficient practice could affect residents emotionally and could result in injury. The findings included: Record review of Resident #44's face sheet dated 01/25/2024 revealed an [AGE] year-old female who was originally admitted on [DATE] and readmitted on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Diabetes a chronic (long-lasting) health condition that affects how your body turns food into energy, chronic obstructive pulmonary disease (COPD)(diseases that cause airflow blockage and breathing-related problems), muscle wasting and atrophy of right and left shoulder and right and left upper arm (Muscle wasting is a loss of muscle mass due to the muscles weakening and shrinking), contracture of right and left knee (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of the joints), unsteadiness on feet and repeated falls. Record review of Resident #44's Quarterly MDS assessment, dated 12/29/2023, revealed Resident #44 had a BIMS score of 15 indicating the resident had intact cognitive response, the resident had no impairment with upper and lower extremities (diagnoses and interview with Resident #44 indicated resident had a problem with upper and lower extremities) and had not had any falls since admission or reentry into the facility. Review of Resident #44's Comprehensive Care Plan with a Focus problem initiated on 05/08/2020 and revised on 02/21/2023 revealed Resident #44 was at risk for falls related to dementia, pain, weakness, debility, muscle contractures/wasting, hearing difficulty and ADL deficit. Two of the interventions was to make sure the bed was in lowest position and follow facility fall protocol. Review of the latest Fall Risk Evaluation dated 11/07/2023 for Resident #44 revealed she had a score of 10 (medium risk). Further review of the assessment revealed in part the following: A. Mental StatusDisoriented x 1; B. No falls in past 3 months; C. Regularly incontinent; D. Vision adequate; E. Gait/Balance/Ambulation- Requires use of assistive devices to include wheelchair; F. Systolic Blood Pressure- No noted drop; G. Medications- 1-2 that includes antihypertensives, psychoactive meds; H. Predisposing disease- 1-2 present to include CVA (stroke). Observation on 01/24/2024 at 9:15 a.m. revealed the door to Resident #44's room was closed and after knocking and getting permission to go into the room, Resident #44 was found lying in her bed and the bed was in high position and the resident could fall out. Interview on 01/24/2024 at 9:15 a.m. with Resident #44 revealed she did not know why she was in the bed in the high position. Resident #44 stated she had been in the high position since early morning. Resident #44 was asked if she was supposed to get a shower today and Resident #44 stated no. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 12 of 32 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 01/26/2024 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 Resident #44 was asked if she was able to get out of bed on her own and Resident #44 stated no, they (aides) have to help me get up and also dress me. Interview on 01/24/2024 at 9:18 a.m. with AD confirmed Resident #44 was in the high position in her bed and would go get the CNA (certified nurse aide). Residents Affected - Few Interview on 01/24/2024 at 9:20 a.m. with MA A revealed she not only was a Medication Aide but, also a CNA, worked central supply and medical records. MA A confirmed Resident #44 was in a high position in bed, she did not know why and stated she would go get the aide who was taking care of Resident #44. Interview on 01/24/2024 at 9:25 a.m. with CNA B, confirmed she had left Resident #44 in the bed in high position because she had changed her brief and took the soiled brief to the dirty utility room. CNA B stated she knew she should not have left Resident #44 in the high position. She stated she was not taught about leaving a resident in the bed in high position. CNA B stated, I guess she could fall out of the bed and get hurt because of leaving the bed in high position . CNA B stated she does look back at the resident when she leaves the room but, she got busy and just forgot about Resident #44. Interview on 01/24/2024 at 9:51 a.m. with the Administrator concerning Resident #44 being left in bed in the high position, the Administrator stated the resident could fall and hurt themselves worse in a higher bed position than in a low bed position. The Administrator stated, it is every ones responsibility to make sure the beds are in the lowest position when the resident is in the bed. Review of the Facility Fall Management System Policy and Procedure dated 06/2018 and last revision date 12/2023 had documented under Policy It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of the facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 13 of 32 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 01/26/2024 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 0692 Provide enough food/fluids to maintain a resident's health. 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 were provided the fluids to maintain proper hydration for 1 of 1 (Resident #74) resident reviewed for fluid restriction in that: Residents Affected - Few Resident #74's fluid restriction was not maintained as ordered, broken down as to how much nursing and dietary was to serve for meals, and nursing to use for medications being given. This failure could place residents at risk of not receiving proper hydration and could result in the residents being dehydrated. The findings included: Review of Resident #74's face sheet revealed the resident was admitted on [DATE] with diagnoses which included end stage renal disease, cerebral palsy, anemia, diabetes with diabetic neuropathy, hypertension, anxiety, depression, peripheral vascular disease and chronic obstructive pulmonary disease, Review of Resident #74's care plan dated 11/20/2023 revealed a care plan that addresses hemo-dialysis related to renal failure with an intervention for Fluid Restriction: 1200 ml per day. Another care plan for a nutritional problem related to Resident #74 being on dialysis and had a fluid restriction dated 11/14/2023 and an intervention for a fluid restriction: 1200 ml per day with no fluid breakdown. No documentation of the fluid breakdown or a new care plan for the order of 1,000 cc of fluid restriction. Review of Resident #74's physician orders dated 01/26/2024 revealed Resident #74 had orders for a 1200 cc fluid restriction. Review of the Facility Diet Master (Roster) dated 01/26/2024 and provided by the DM revealed Resident #74 had a regular, NAS (no added salt) diet with a 1200 cc fluid restriction and no fluid breakdown. Review of Resident #74's physician orders dated 01/26/2024 revealed Resident #74 had orders for a 1200 cc fluid restriction. Review of Resident #74's dialysis communication form dated 11/13/2023 revealed Resident #74 had an order for a 1200cc fluid restriction. Review of the Communication Form (no date) from nursing without checking which department it was to be sent to revealed the resident was on a 1200 cc fluid restriction with no breakdown. Further review revealed a Dialysis Communication Record sent to the facility dated 01/19/2024 recommending Resident #74 be placed on a 1 liter (1,000 cc) fluid restriction. By giving Resident #74 more fluids can lead to fluid overload. Observation on 01/26/2024 at 4:45 p.m. while a dietary staff member and diet manager were sorting the meal tickets for the supper meal, revealed Resident #74's meal ticket dated 01/25/2024 revealed the resident had documented beside DIET Regular, NAS, and a 1200 cc fluid restriction. Interview on 01/26/2024 at 4:14 p.m. with MDS A confirmed she was the person who completed Resident #74's MDS and care plan. During the interview MDS A confirmed there was a physician's order for a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 14 of 32 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 01/26/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1200 cc fluid restriction for Resident #74 and it was also documented on the care plan but, there was no fluid breakdown. When asked about who takes care of the fluid amount given for nursing and dietary, MDS A stated nursing handles the breakdown. When asked about a recommendation MDS A stated nursing will call the physician to let the doctor know what the recommendation from dialysis was and then the orders comes to me (MDS A) and then I (MDS A) will update the care plan. MDS A was not aware of any changes with Resident 74's fluid restriction from 1200 cc to 1,000 cc. Interview on 01/26/2024 at 4:40 p.m. with Resident #74 revealed she had a fluid restriction and did not have a water pitcher in her room. Resident #74 went on to say nursing and dietary give her fluids. When Resident #74 was asked if she knew how much her fluid restriction was, Resident #74 stated 1 liter of fluid or 1,000 cc. Interview on 01/26/2024 at 4:48 p.m. with the DM confirmed Resident #74 had a dietary slip and the diet on the diet roster for a 1200 cc fluid restriction. When DM was asked about the fluid breakdown, DM stated nursing takes and tells dietary how much to give on a dietary communication form. The DM was not aware of a change with Resident #74's fluid restriction from 1200 cc to 1,000 cc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 15 of 32 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 01/26/2024 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 a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 8 (Resident #72) reviewed for respiratory care. Residents Affected - Few Resident #72's oxygen was set at 2 liters rather than the physician's order for 4 lpm and there was no humidifier bottle. This failure could affect residents administered oxygen and could lead to residents not receiving the therapeutic effects of oxygen; and could lead to a diminished quality of life. The findings were: Record review of Resident#72's face sheet, dated 1/24/2024,revealed the resident was admitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease (disease that cause airflow blockage and breathing-related problems) and chronic respiratory failure with hypoxia (not enough oxygen in your blood). Record review of Resident#72's MDS assessment (minimum data set), dated 12/12/23 Admissions revealed: BIMS Score was 12 (cognitively intact). Record review of Resident# 72's Care Plan, dated 12/15/23, read: O2 AT 4 L/MIN CONTINUOUS PER NC every shift. Record review of Resident#72's Physician' Orders, dated January 2024, read: O2 AT 4 L/MIN CONTINUOUS PER NC every shift. Observation and interview on 1/25/2024 at 11:27 a.m., Resident #72 was in his room on continuous O2 at 2 lpm. The resident was not in distress. The Resident stated, It should be on 4. During an interview on 1/25/2024 at 12:45 p.m., LVN G verified that there was no humidifier bottle and that the oxygen should be at 4 lpm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 16 of 32 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 01/26/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to provide pharmaceutical services. Including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications on 3 of 3 medication storage rooms reviewed for pharmacy services. The facility did not dispose of loose medications, expired syringes and expired odor eliminators bottles from the medication storage room. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: During an observation on 1/23/20204 at 11:24 a.m., of the medication room for 100 and 500 halls, there were 17 of 32 bottles of expired Assure C Odor Eliminator bottles. An expired 12 pack of beer. A loose white round pill was found in a cat food box under the sink. During an interview on 1/23/2024 at 11:24 a.m., RN A verified the expired odor eliminators, beer and loose pill. She stated that the medication aides or nurses should be reconciling the medication rooms. She stated that any loose medication should be identified and disposed of according to facility policy. She stated the expired beer and odor eliminator could cause undue side effects to residents. During an observation on 1/23/2024 at 11:43 a.m., of the medication room for 200 and 400 halls, there were 2 expired Safety Syringe 25gX1.0. During an interview on 1/23/2024 at 11:43 a.m., RN B stated that nursing staff was in charge of medication reconciliation. She stated that expired syringes should be disposed of according to facility protocol and that using expired syringes could cause a risk of infection. During an observation on 1/23/2024 at 12:10 p.m., of the medication room for 600 halls, there were 2 loose pills in a plastic bag for a resident that had been discharged . During an interview on 1/23/2024 at 12:10 p.m., with ADON, he stated that unidentified loose medications could be mistakenly administered to the wrong resident and cause side-effects. He stated that the medications are supposed to be scanned for medication return or destruction. He stated only controlled medications are counted upon resident admission and discharge. During an interview on 1/25/2024 at 10:26 a.m. with the DON, he stated that ADON's are ultimately responsible to check the medication rooms. The ADON's should check units daily and do monthly spot checks on each other. The expectation would be that the items were checked and rotated. The goal was to complete checks monthly and if issues were found it was to be done more often. The expired items have a log in system with the pharmacy medications would be destroyed with the pharmacist. The medications would be disposed per facility, federal and state guidelines. Record review of the facility policy titled Controlled Medications - Storage and Reconciliation dated 12/2023 indicated, The facility will maintain a process for monitoring, administration, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 17 of 32 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 01/26/2024 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 0755 documentation, reconciliation and destruction of controlled substances. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 18 of 32 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 01/26/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' pharmacist medication regimen review recommendations were reviewed by the resident's attending physician and what, if any, action has been taken to address them, for 3 of 7 residents (Residents #33, #65, and #12) whose records were reviewed for pharmacy services. The facility failed to ensure the physician provided a precise clinical rationale in response to the consulting pharmacist's recommended changes for medication regimen review. This failure could place residents at risk for significant health status declines. The findings included: Record review of Resident #33's face sheet dated, 01/26/2024, reflected a [AGE] year-old resident initially admitted on [DATE] with diagnosis including cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain). Record review of Resident #33's quarterly MDS Assessment, dated 11/20/2023, reflected Resident #33 was taking antidepressant medication. Record review of Resident #33's Care Plan, dated 03/21/2023, reflected that Resident #33 was on antidepressant medication due to a diagnosis of depression. Record review of Resident #33's MRR, dated 10/4/23, reflected a recommendation by the consulting pharmacist to consider discontinuing one of the two medications Lexapro (an antidepressant used to treat depression) and Linezolid (an antibiotic used to treat bacterial infections) [due to] the high risk for serotonin syndrome to which the physician checked the decline box without any details in the description section. Record review of Resident #65's face sheet, dated 01/26/2024, reflected a [AGE] year-old resident initially admitted on [DATE] with diagnoses including cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain) and major depressive disorder. Record review of Resident #65's MDS, dated [DATE], reflected Resident #65 was not taking an antidepressant. Record review of Resident #65's care plan, dated 10/4/2023, reflected Resident #65 was on antidepressant medication due to a diagnosis of depression. Record review of Resident #65's MRR, dated 01/04/2024, reflected a recommendation by the consulting pharmacist to consider a temporary dose reduction for the medication Trazodone (an antidepressant used to treat depression) to which the physician checked the decline box without any details in the description section. Record review of Resident #12's face sheet, dated 01/26/2024, reflected a [AGE] year-old resident initially admitted on [DATE] with diagnoses including dementia (a group of thinking and social (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 19 of 32 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 01/26/2024 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 0756 symptoms that interferes with daily functioning) and major depressive disorder. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #12's MDS, dated [DATE], reflected Resident #12 was taking an antidepressant. Residents Affected - Some Record review of Resident #12's care plan, dated 01/26/2024 reflected Resident #12 was taking an antidepressant for depression. Record review of Resident #12's MRR, dated 10/4/23, reflected a recommendation by the consulting pharmacist to consider discontinuing the medication Remeron (an antidepressant used to treat depression) to which the physician responded with cont. current dosing without any further details in the description section. Interview on 01/26/2024 at 10:21 AM, the DON stated that pharmacist recommendations were sent to the physician by the pharmacist at the end of the day after the pharmacist had finished their review of medications. The DON stated it was regular for the facility to not receive a precise rationale for declining a pharmacy recommendation and stated he was not aware if the physician was aware this was a requirement. The DON stated it was not his expectation at the time that the physician provides a clinical rationale for declining a recommendation and stated the risk with not doing so would be that the medication reviews might not be fully reviewed. Interview on 01/26/2024 at 12:11 PM, the ADM stated he was not aware of the physician not indicating clinical rationale in response to pharmacy recommendations. The ADM stated he was not aware this was a requirement and stated he believed the potential risk of the physician not providing a precise clinical rationale could be that the medication might not be reviewed adequately by a medical doctor. Record review of Medical Director Services Agreement, dated 09/1/2023, reflected Medical Director Scope of Services .Professional Services: 14. Helps the facility ensure that a system is in place for monitoring the services of healthcare practitioners. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 20 of 32 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 01/26/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents were given psychotropic medications to treat specific diagnoses for 2 (Resident #12 & #99) of 7 Residents, reviewed for unnecessary psychotropic medications. The facility failed to 1. Ensure the medication (Ativan) was administered to treat a specific, clinically diagnosed illness for Resident #12. 2. Ensure a PRN psychotropic medication order was limited to fourteen days for Resident #12. 3. Ensure the medication Sertraline was administered to treat a specific, clinically diagnosed illness for Resident #99. This failure could affect residents who received psychotropics in the facility and put them at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. The findings included: Record review of Resident #12's face sheet, dated 01/26/2024, reflected a [AGE] year-old resident initially admitted on [DATE] diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) and major depressive disorder. Record review of Resident #12's MDS, dated [DATE], did not reflect a diagnosis of restlessness. Record review of Resident #12's physician orders dated 01/26/2024 reflected an order for Ativan (a short-term relief of the symptoms of anxiety or anxiety associated with depressive symptoms) that reflected Give 0.25 ml by mouth every 2 hours as needed for Mild restlessness for 90 days and an order date 01/16/2024. Record review of Resident #99's face sheet, dated 01/26/2024, reflected a [AGE] year-old resident initially admitted on [DATE] with a primary diagnosis including Osteomyelitis (a serious infection of the bone that can be either acute or chronic). Record review of Resident #99's MDS, dated [DATE], did not reflect a diagnosis of depression. Record review of Resident #99's physician orders dated 01/26/2024 reflected an order for Sertraline (an antidepressant medication used to treat depression) with a start date of 12/07/2023 for the purpose of treating depression. Interview on 01/25/2024 at 4:41 PM, RN C stated she was aware of Resident #12's active physician order for Ativan and stated it was for the resident recently having been placed on hospice care and experiencing an end-of-life decline. RN C stated Resident #12 did not have a diagnosis of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 21 of 32 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 01/26/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few restlessness. RN C stated she was not certain of the risk posed by Resident #12 taking Ativan without being diagnosed with restlessness and stated a resident could have medications that they don't need. Interview on 01/25/2024 at 4:59 PM, LVN F stated she was aware of Resident #99's active physician order for Sertraline and stated Resident #99 has been receiving the medication since before admission and believed Resident #99 was taking the medication at home. LVN F stated she was not aware Resident #99 did not have a listed diagnosis of depression in his clinical record and stated she was not sure why it was not listed. LVN F stated the ADON and DON do regular audits of the medications for their uses. LVN F stated she was uncertain of the risk posed to Resident #99 for taking a medication for a diagnosis that they do not clinically have. Interview on 01/26/2024 at 10:21 AM, the DON stated he was not aware of Resident #12's order for Ativan being over 14 days as a PRN and stated Resident #12 was recently placed on hospice with an added order for Ativan. The DON stated hospice residents were not reviewed differently from other residents. They were still reviewed by the physician for unnecessary medications. The DON stated Resident #12 did not have restlessness diagnosed but that the admitting nurse likely followed the physician's script. The DON stated the physicians will generally provide a precise diagnosis but sometimes will only list a symptom. The DON stated the received scripts from the MD's are expected to be for precise diagnoses. The DON stated he was also not aware of Resident #99's physician order being indicated as for depression while also indicating Resident #99 did not have diagnosed depression. The DON stated he believed Resident #99 did have depression, but it was likely not reflected appropriately on the MDS. The DON stated the risk associated with not having physician's orders for precise, clinically diagnosed illness could be that medications can be administered for unnecessarily. Interview on 01/26/2024 at 12:11 PM, the ADM stated he was not aware of the physician's orders for Resident's #12 and #99 for diagnoses that Resident's #12 and #99 did not have. The ADM stated he believed the potential risk of the physicians orders not being administered for precise, clinically diagnosed illness would be that these medications may be provided unnecessarily. Record review of the facility's psychotropic medication policy titled Psychotropic Medications, dated revised 12/2023, reflected It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Psychotropic medications shall not be administered for the purpose of discipline or convenience. Based on a comprehensive assessment, the facility will ensure that: Residents do not receive psychotropic drugs pursuant to an as needed (PRN) order unless medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. and PRN orders for psychotropic drugs are limited to 14 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 22 of 32 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 01/26/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for 1 of 1 kitchen reviewed for kitchen sanitation during the initial tour. A. Food items were not clearly labeled to indicate safe preparation for or consumption by residents. B. Kitchen spatulas were not in good working condition and the rubber parts had tears. C. Food stored in the walk-in cooler were not completely covered. D. Kitchen Equipment was damaged and dirty. E. Areas of the kitchen floor appeared to be holding water and was dirty F. Kitchen equipment was stored on the floor. G. Nourishment rooms contained inoperable freezing units, contained expired food, and unlabeled food. These deficient practices could place residents at risk for cross-contamination and foodborne illness. Findings included: 1. The following items were viewed in the walk-in cooler: a. 6 large bags of a clear yellow substance had been removed from the manufacturer's box were unlabeled by name, and were lacking identifiable dates on the packaging in the walk-in cooler. b. 6 large plastic tubes cylinder shaped items removed from the manufacturer's box, were unlabeled by name, and were lacking identifiable dates on the packaging in the walk-in cooler. c. Approximately 24 items identified by the DM as deserts for the day were partially covered with wax paper allowing the contents of the individual serving containers to be exposed to air and odors from other items in the walk-in cooler. d. 1 (5) lb container of pimento cheese with a date of 1/12, identified as the receive date by the DM, and a best by date of 4/16/24 partially used with no open date. e. 1 (5) lb container of cottage cheese with a date 0/23, identified as the receive date by the DM, and a best by date of 2/01/24 partially used with no open date. f. 2 large containers labeled s. pudding 1/22 with no other date or labeling. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 23 of 32 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 01/26/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm g. 1 large, sealed plastic bag identified by the DM as chicken legs, with the date 1/22 with no other date of labeling. h. 1 (46) ounce container of thickened liquid partially used and labeled, with a date identified by the DM as the received date of 1-19, and a best by date of 06/26/2024 Residents Affected - Many 2. Observation of the dry storage and interview with the DM revealed: a.1 large plastic tub with lid labeled tomato sauce 05/29 that contained 1 large plastic bag previously opened with manufacturer's writing Ambrosia. No other label or date on the large plastic container labeled with the following information written on a label, Date 12-30, CMP: 12/30/24, use by R8. The DM stated the staff must have forgotten to relabel the lid on the container and took a marker and began writing on the lid. b. 2 (46) ounce containers of thickened sweetened tea with no date or manufacturer's date of any type. 3.Observation of the open kitchen area revealed: a. 1 large plastic bag placed in an approximately 5 gallon plastic container labeled Thickener R 1/19 of 1/19with a clear plastic flip style lid designed for repeated use with a clear plastic bag of thickener with no manufacturer's label or date, facility stored thickener, they put the date they receive the bag and the date they open the bag on the outside of the container the kitchen staff placed it in. 4. Observation of Refrigerator #2 revealed multiple items identified by the DM personal items belonging to multiple kitchen staff stored with items purchased by the facility for and intended for resident use. The items included the following: a. 1 large white thermos unlabeled or dated. b. 2 (16) ounce water bottles (one labeled with a what the DM said was a staff member name) c. 1 large container of French vanilla coffee creamer d. 1 white plastic bag unlabeled and undated containing unknown items, identified as personal food items of staff by the DM. 5. The floor and wall behind the juice dispenser had standing water in the corner and a brown substance under the juice stand. 6. The juice dispenser and hoses running from the containers that supply the juice sitting on a metal stand had a black and brown substance on the juice hoses and on the juice dispensing system. 7. 2 rubber style spatulas with breaks and cracks in the rubber in the food preparation area. 8. 3 dish racks stored under the dishwashing area on the floor Interviews with the DM during the initial tour and observation on 01/23/24 at 10:11 a.m. revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 24 of 32 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 01/26/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the facility does not have any specific written rules regarding dating and labeling of food items. The DM did say the thickened liquid with no dates on them should not be used and the DM went on to explain that was only two of the 6 containers of thickened liquids that were not labeled. The DM said items should be labeled so that you know if they should be used for residents. He stated some of the dates were not like they should have been, but did not elaborate. When asked why or if the employees food items were supposed to be stored with the resident's food items, the DM said no they should not be. He said there was not enough room in the employee break room for the kitchen staff to store their personal food items, so they do keep them in the kitchen. In addition, the DM said while looking at the juice system, kitchen staff has tried to clean it but it has been hard to clean. When asked about the standing water and brown substance on the floor behind the juice system the DM explained there has been multiple inquiries about why the water stands there but there but it has not been successfully addressed to date. The DM said it was not known for sure why the water is staying behind there. The DM did say the spatulas should not be used for the residents because things could get in the cracks. The DM told other staff in the kitchen to get the dish racks off the floor and to wash them and clean them up before they used them. Observation on 01/25/2024 at 10:57 AM of the 200/400 hall nourishment refrigerator revealed undated/unlabeled salsa, and the tray inside the freezer compartment of the refrigerator with a bag of ice cream cups and ice cream sandwiches frozen in place due to the tray they were on top of frozen to the freezer units making the labels and dates unable to be read. Observation on 01/25/2024 at 11:13 AM of the 100/300 hall nourishment refrigerator revealed an undated and unlabeled bag of white solids, a unit of cream cheese dated 06 [DATE], and the freezer section of the refrigerator nearly entirely obstructed by ice rendering the items within the unit inaccessible and unreadable. Interview on 01/25/2024 at 11:17 AM, the ADON stated he was not aware of the status of the nourishment refrigerators and stated they were not currently available to be used by residents if they had a need to use them and frozen food provided would have needed to go to the kitchen. The ADON stated the charge nurses overnight were expected to evaluate the refrigerators for cleanliness. The ADON stated no one else completes an audit of the nourishment refrigerators apart from the overnight charge nurses. Interview with the Administrator on 01/25/2024 at 12:50 PM, the Administrator stated the kitchen and nourishment refrigerators should be clean and explained the expectation is for the staff to ensure the residents are getting food that is safe to be served with good equipment. The Administrator said he would investigate the concerns with the kitchen observations. Review of FDA Food Code 2022 Section 3-501.17 Ready to Eat/Temperature Control for Safety Food, Date Marking: (A) (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 25 of 32 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 01/26/2024 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 0812 Policy titled, Policies & Procedures 33 Food Storage, Revised 08/2007 revealed: Level of Harm - Minimal harm or potential for actual harm It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner. Residents Affected - Many 1. Food storage areas shall be clean at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 26 of 32 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 01/26/2024 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 0840 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to arrange an appointment with an outside resource for 1 of 3 residents (Resident #94) reviewed for the use of outside resources, in that: The facility did not have an order in Resident #94's electronic medical record for follow up care with the neurologist, nor follow up appointment. This failure could place residents at risk of not receiving needed medical care. Findings included: Resident #94's face sheet, dated 01/26/2024, revealed Resident #94 was admitted on [DATE] and had diagnoses that included: intellectual disability, unspecified, epilepsy, deaf nonspeaking, cerebral palsy, muscle wasting and muscle atrophy. Review of Resident #94's electronic medical record revealed a progress note from a community neurologist stating Resident #94 was seen on 10/23/2023 by the neurologist and had been referred by MD Z . Review of Resident #94's electronic medical record and order summary page dated did not reveal an order for continued neurological services, nor any information regarding any future appointment with a neurologist. Interview with MD Z on the phone on 1/26/24 at 11:45 a.m., MD Z said Resident #94 should be seen by a neurologist to manage her medications because she takes five medications to treat her seizures, he would manage medications for that resident if they had two or three medications but not five, the resident should be seeing a neurologist and there should have been an order in Resident #94's electronic medical record but there was not. Interview on 1/26/2024 at 3:26 p.m. with LVN D stated she participated in Resident #94's care since the resident's admission and believed the resident should have an order for a follow up with a neurologist. LVN D stated she believed Resident #94's mother made the appointments but said there should have been an order for Resident #94 to see a neurologist and there was not. Interview on 1/26/24 at 3:37 p.m. the DON stated there was no current order for Resident #94 to see the neurologist in the resident's electronic medical record. The DON did not know why there was not an order for Resident #94 to see a neurologist as ordered in a previous progress note by MD Z. The DON further stated as a standard of care when a physician gives a verbal order or a written order the order should be placed in the electronic medical record to ensure the resident's needs are met and the physician's order is followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 27 of 32 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 01/26/2024 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 - Few 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 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 1 of 1 residents (Resident #94), The facility failed to document the clinicial rationale or complete medication regimen for Resident #94. This failure could place residents at risk of not having accurate medical records and could create confusion in services provided or needed to be provided. The findings included: Review of Resident #94's face sheet, dated 01/26/2024 revealed, Resident #94 was admitted on [DATE] and had diagnoses that included: intellectual disability, unspecified, epilepsy, deaf nonspeaking, cerebral palsy, muscle wasting and muscle atrophy. Review of Resident's most recent medical provider progress note with a service date of January 5, 2024 written by NP X and signed on 01/13/2024 at 6:25 p.m. did not document the resident's complete medication regimen nor provide clinical rationale. Interview with MD Z via telephone, the facility's medical director and the resident's primary care physician on 01/26/2024 at 11:45 a.m. MD Z said NPX should have documented clinical rationale. MD Z was offsite but said he was able to view Resident #94's provider not completed by NP X. MD Z stated, NP X is a new I will have a talk with her, I am reviewing the notes for Resident #94 right now and the other notes from the former provider are complete and include the clinical rationale for each medication as NP X should have done. Interview with the DON on 01/26/2024 at 3:27 p.m., the DON stated he was did not know exactly what needed to be in the Nurse Practitioner or physician's note but he could look into that. Review of Medical Director: Services Agreement Rev 8/22 Contract ID: 64269 provided by the facility revealed, 1.8 Service Provider acknowledges the Facility desires to maintain all permits and licenses that may be necessary for the operation of the Facility and to obtain and maintain certification for participation in federal health care programs, including Medicare and Medicaid and Service Provider covenants to cooperate as necessary in said endeavors. Service Provider further covenants not willfully jeopardize the Facility's participation in or reimbursement from Medicare, Medicaid, or other third-parties. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 28 of 32 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 01/26/2024 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 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on record review and interview, the facility failed to include as part of its QAPI program, mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program, for 14 of the 15 staff members (the ADM, the DON, ADON, LVN H, RN C, LVN I, SW, AD, DM, DOR, CNA B, CNA A, CNA C, CNA D, CNA E) reviewed for mandatory training, in that: Fourteen staff members (the ADM, the DON, ADON, LVN H, RN C, LVN I, SW, AD, DM, DOR, CNA B, CNA A, CNA C, CNA D, CNA E) reviewed for mandatory training had not received training regarding the facility's QAA-QAPI program. This failure could place residents at risk of receiving inadequate care from staff who are unfamiliar with the facility's QAPI program. The findings included: Record review of employee files reflected no documented evidence the following employees received training regarding the QAPI program: -ADM was hired on 11/01/2019 -DON hired on 12/15/2023 -ADON, hired on 06/07/2021 -LVN H, hired on 05/09/2022 -RN C, hired on 09/05/2023 -LVN I, hired on 07/01/2022 -SW, hired on 08/03/2021 -AD, hired on 08/02/2022 -DM, hired on 11/01/2019 -DOR, hired on 11/01/2019 -CNA B, hired on 07/25/2022 -CNA A, hired on 11/07/2023 -CNA C, hired on 01/02/2024 -CNA D, hired on 01/02/2024 -CNA E hired on 02/06/2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 29 of 32 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 01/26/2024 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 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Interview 01/26/2024 at 10:01 AM, the HRD stated she began in her role as the HRD in the last few weeks and was not aware of the requirement for all facility staff to receive the QAPI training. The HRD stated all staff trainings were assigned by corporate and she did not have control over what staff were assigned prior to her assuming the role. Interview on 01/26/2024 at 12:11 PM, the ADM stated he was not aware of his facility staff not being trained on the facility's QAPI plan and protocols. The ADM stated he was not aware all staff being trained on the facility QAPI plan and protocols was a requirement and stated he was not sure what the risk associated would be. The ADM stated the QAPI plan was the facility's policy. Event ID: Facility ID: 455732 If continuation sheet Page 30 of 32 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 01/26/2024 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 0946 Provide training in compliance and ethics. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure all staff received training in compliance and ethics for 14 of the 15 staff members (the ADM, the DON, ADON, LVN H, RN C, LVN I, SW, AD, DM, DOR, CNA B, CNA A, CNA C, CNA D, CNA E) reviewed for mandatory training, in that: Residents Affected - Some Fourteen staff members (the ADM, the DON, ADON, LVN H, RN C, LVN I, SW, AD, DM, DOR, CNA B, CNA A, CNA C, CNA D, CNA E) reviewed for mandatory training had not received training regarding compliance and ethics. This failure could place residents at risk of receiving inadequate care from staff who are uneducated on compliance and ethics. The findings included: Record review of employee files reflected no documented evidence the following employees received training regarding compliance and ethics: -ADM was hired on 11/01/2019 -DON hired on 12/15/2023 -ADON, hired on 06/07/2021 -LVN H, hired on 05/09/2022 -RN C, hired on 09/05/2023 -LVN I, hired on 07/01/2022 -SW, hired on 08/03/2021 -AD, hired on 08/02/2022 -DM, hired on 11/01/2019 -DOR, hired on 11/01/2019 -CNA B, hired on 07/25/2022 -CNA A, hired on 11/07/2023 -CNA C, hired on 01/02/2024 -CNA D, hired on 01/02/2024 -CNA E hired on 02/06/2023 Interview 01/26/2024 at 10:01 AM, the HRD stated she began in her role as the HRD in the last few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455732 If continuation sheet Page 31 of 32 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 01/26/2024 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 0946 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete weeks and was not aware of the requirement for all facility staff to receive a compliance and ethics training. The HRD stated all staff trainings were assigned by corporate and she did not have control over what staff were assigned prior to her assuming the role. Interview on 01/26/2024 at 12:11 PM, the ADM stated he was not aware of his facility staff not being trained on compliance and ethics. The ADM stated he was not aware all staff being trained on compliance and ethics was a requirement and stated he was not sure what the risk associated would be. Event ID: Facility ID: 455732 If continuation sheet Page 32 of 32