Health inspection·June 4, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #1) reviewed for pharmacy services. LVN A administered Resident #1's insulin from a flex pen (Aspart) for diabetes at lunchtime to Resident #1, when it was not labeled with the resident's name. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: Record review of Resident #1's face sheet, dated 06/03/2025, revealed she was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: cerebral palsy (a group of neurological disorders that affect movement, balance and posture), type 2 diabetes mellitus (the most common form of diabetes characterized by the body's inability to properly use insulin, leading to high sugar levels), mild intellectual disabilities (deficits in intellectual functions pertaining to abstract/theoretical thinking), anxiety (a feeling of worry, unease, or nervousness, often accompanied by physical symptoms like a racing heart or rapid breathing and need for assistance with personal care. Record review of Resident #1's Annual MDS assessment, dated 05/04/2025, revealed the resident rarely or never understood others and could rarely or never understand. She was not a candidate for a BIMS which indicated she was severely cognitively impaired. She was dependent on staff for her ADLs, and she received insulin injections daily. Record review of Resident #1's physician's order, dated 12/27/2024, revealed the resident had the order of Fiasp (brand name) Pen Fill Subcutaneous Solution Cartridge 100 UNIT/ML (Insulin Aspart (with Niacinamide, a form of Vitamin B3) Inject as per sliding scale: if 150 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10, subcutaneously with meals for DM If greater than 401notify MD Phone Active 03/25/2025. Record review of Resident #1's MAR, dated from 06/01/2025 to 06/30/2025, revealed Resident #1 was receiving Fiasp Pen Fill subcutaneous Solution Pen Injector 100 unit/ml (insulin Aspart) inject as per sliding scale. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 455732 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 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)