Kirkwood Manor

In the surveyor’s words

From the most serious findings on record at Kirkwood Manor, in the surveyor’s own words.

• Immediate jeopardy, patternF684Mar 24, 2024

  Based on interview and record review the facility failed to, based on the comprehensive assessment of a resident, ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (Resident #1) reviewed for quality of care . 1. The facility staff administered Resident #1's digoxin (medication used to manage and treat heart failure and certain abnormal heart rhythms) without documenting the ordered blood pressure and pulse per the physician ordered parameters from [DATE] to [DATE], [DATE] to [DATE], and [DATE] to [DATE] (23 days) and failed to hold the medication as ordered per parameters on [DATE] and [DATE] . 2. […]

• No harm, potential for more than minimal, widespreadF812Jan 26, 2024

  45307 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. […]

• No harm, potential for more than minimal, patternF641Apr 10, 2026

  Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 4 residents (Residents #10, #13, #81 and #106) of 24 residents reviewed for MDS assessments. 1. The facility failed to ensure Resident #10 was coded Yes on her Quarterly MDS assessment, signed as completed on 01/14/2026, for Did the resident have a fall anytime in the last 2-6 months prior to admission/entry or reentry? because the resident had fall incident on 01/05/2026. 2. The facility failed to ensure Resident #13 and Resident #81's annual MDS was coded accurately for Preadmission Screening and Resident Review (PASRR). 3. […]

• No harm, potential for more than minimal, patternF584Feb 21, 2025

  39049 Based on observations, interviews, and record review, the facility failed to ensure the resident received care and services safely and the physical layout of the facility maximized resident independence and did not pose a safety risk; provided maintenance services necessary to maintain an orderly, and comfortable interior; provide adequate and comfortable lighting levels in all areas; for 2 of 2 shower rooms (600 hall shower on E and W side), maintained shower free of saftery hazards for 1 of 2 Showers (600 Hall Shower), and 1 of 1 Resident's room (Resident #68) reviewed for safety hazards. 1. The water temperature in the 600 E shower room reached 95.5 degrees and the water temperature in the W shower room reached 97.1 degrees. […]

• No harm, potential for more than minimal, patternF880Feb 21, 2025

  39049 Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 3 residents (Residents #52, #109, and #27) of 29 residents and for 1 of 2 shower rooms (600 W hallway) reviewed for infection control practices. 1. LVN-C provided colostomy (opening for the colon through the belly) care for Resident #52 and failed to change her gloves without sanitizing or washing her hands. 2. LVN-A entered Resident #109's room, who was on EBP, on 02/19/2025 at 4:40 p.m. and failed to put on a gown when the LVN-A was administering medications to the resident via gastrostomy tube. 3. […]