Facility profile · CCN 455732
Kirkwood Manor
49 federal citations on record , including 1 at the Immediate Jeopardy level, and 1 federal enforcement actions totaling $29,026.
Record summary
Federal record · Q1 202649
Total citations
36
Last 3 years
1
Actual harm+
1
Federal penalties
$29,026
Total fines
2
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
49 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Jun 4, 2025 | F761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D | Complaint |
| Jun 4, 2025 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Complaint |
| Feb 21, 2025 | F880 | Provide and implement an infection prevention and control program. | E | Standard |
| Feb 21, 2025 | F813 | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | D | Standard |
| Feb 21, 2025 | F761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D | Standard |
| Feb 21, 2025 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Standard |
| Feb 21, 2025 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| Feb 21, 2025 | F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Standard |
| Feb 21, 2025 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard |
| Feb 21, 2025 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard |
| Feb 21, 2025 | F645 | PASARR screening for Mental disorders or Intellectual Disabilities | D | Standard |
| Feb 21, 2025 | F584 | 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. | E | Standard |
| Jan 10, 2025 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Complaint |
| Mar 24, 2024 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E | Complaint |
| Mar 24, 2024 | F760 | Ensure that residents are free from significant medication errors. | E | Complaint |
| Mar 24, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | K | Complaint |
| Jan 26, 2024 | F584 | 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. | D | Complaint |
| Jan 26, 2024 | F946 | Provide training in compliance and ethics. | E | Standard |
| Jan 26, 2024 | F944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | E | Standard |
| Jan 26, 2024 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Standard |
| Jan 26, 2024 | F840 | 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. | D | Standard |
| Jan 26, 2024 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard |
| Jan 26, 2024 | F758 | 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. | D | Standard |
| Jan 26, 2024 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E | Standard |
| Jan 26, 2024 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | Standard |
| Jan 26, 2024 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| Jan 26, 2024 | F692 | Provide enough food/fluids to maintain a resident's health. | D | Standard |
| Jan 26, 2024 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard |
| Jan 26, 2024 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | Standard |
| Jan 26, 2024 | F641 | Ensure each resident receives an accurate assessment. | D | Standard |
| Jan 26, 2024 | F636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | D | Standard |
| Jan 26, 2024 | F578 | 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. | D | Standard |
| Jan 26, 2024 | F565 | Honor the resident's right to organize and participate in resident/family groups in the facility. | E | Standard |
| Jan 26, 2024 | F558 | Reasonably accommodate the needs and preferences of each resident. | D | Standard |
| Nov 30, 2023 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Nov 30, 2023 | F552 | Ensure that residents are fully informed and understand their health status, care and treatments. | D | Complaint |
| Nov 9, 2022 | F909 | Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | D | Standard |
| Nov 9, 2022 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E | Standard |
| Nov 9, 2022 | F700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | D | Standard |
| Nov 9, 2022 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | E | Standard |
| Nov 9, 2022 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | Standard |
| Nov 9, 2022 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| Nov 9, 2022 | F680 | Ensure the activities program is directed by a qualified professional. | D | Standard |
| Nov 9, 2022 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard |
| Nov 9, 2022 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | Standard |
| Nov 9, 2022 | F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | Standard |
| Nov 9, 2022 | F641 | Ensure each resident receives an accurate assessment. | D | Standard |
| Nov 9, 2022 | F640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | D | Standard |
| Nov 9, 2022 | F578 | 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. | D | Standard |
Federal enforcement history
Federal regulators have imposed 1 enforcement actions against this facility, including 1 civil money penalties totaling $29,026 .
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| Mar 24, 2024 | Fine | $29,026 | — |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
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