Azle Manor Health Care, L.l.l.p.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Residents #1) reviewed for accidents and supervision. The facility failed to ensure their WG system was properly working, on the facility's front door, allowing Resident #1 to elope. Resident #1 was observed to be outside the facility, in the parking lot, over 100 feet from the front door ambulating in her wheelchair on 7-13-2026 at approximately 7:30 PM. Facility staff were unaware Resident #1 had exited the facility as no staff heard the WG alarm sound when Resident #1 eloped through the front door. Following the elopement, on 7-21-2026, at 6:10 PM, the WG system was observed to not be monitoring the front door and the 300-hall exit door. An IJ was identified on 7-21-2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen in that: 1. The facility failed to ensure food items placed in the refrigerator were sealed, dated, and labeled appropriately. 2. [NAME] B failed to wear gloves during food temperature check for potatoes and did not use sanitized cloth or alcohol wipes to wipe off the thermometer, instead she used her ungloved fingers to slide the potatoes pieces off the thermometer back into the potato pan to be served on 02/18/26. 3. The facility failed to ensure the large container of bulk sugar was closed and not left open. 4. The facility failed to ensure two large garbage containers in the kitchen had lids on them, when trash was in the containers and they were not being used on 02/18/26. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide safe and secured storage of drugs and biologicals by not keeping medication in locked compartments, for 1 of 3 carts reviewed for medication storage in that:MA A failed to lock medication cart while not in use. This failure could result in physical injuries to residents; drug diversions, ingestion of medications causing adverse effects and violation of HIPAA (Health Insurance Portability and Accountability Act).

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of nine residents (Residents #16) reviewed for infection control. CNA D failed to change her gloves or perform hand hygiene before and after incontinent care for Resident #16 on 02/19/26. This failure could place residents at risk of contamination and infections. Record review of Resident #16's admission record, dated 02/19/26 reflected an [AGE] year-old female who admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (Resident #1) of 2 residents reviewed for supervision. The facility failed to use an assistive device to reposition Resident #1 when on date_06/18/2025 CNA A and CNA B lifted resident by way of underarms instead of using a mechanical lift or gait belt when Resident #1 sustained an injury and was sent to the hospital. The noncompliance was identified as PNC. The PNC began on 06/18/2025 and ended on 07/17/2025. The facility had corrected the noncompliance before the investigation began. This failure could place residents requiring reposition assistance at risk for injury and accidents with potential for more than minimal harm.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 12 residents (Residents #1) reviewed for accidents/hazards. 1. The facility failed to remove a mechanical lift that was missing a metal clip from service from 04/15/25-04/25/25. 2. The facility failed to ensure CNA A and CNA B safely transferred Resident #1. CNA A and CNA B placed Resident #1 in the lift and did not secure the sling resulting in the resident falling out of the sling on 4/15/25. This fall caused an orbital fracture to the face of Resident #1. An IJ was identified on 04/25/25. The IJ template was provided to the facility on [DATE] at 2:31 PM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, and accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure stored food was properly labeled (marked or identified with the contents in the bag), dated ( date the item was received into the facility) . 2. The facility failed to ensure dented cans were not stored in the dry goods area. 3. The facility failed to ensure scoops were not stored in the Dry goods. These failures could place all residents at risk of cross contamination and food-borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys and provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility used single unit package drug distribution system in which the quantity stored is minimal and a missing dose could be readily detected for 3 of 8 residents (Residents #71, #304 and #305), 1 of 2 medication rooms (Med room A), and 1 of 1 treatment carts (Treatment cart A) reviewed for medication storage. 1. [...]

Inspectors wroteBased on interview and record review the facility failed to provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive for 1 of 8 residents (Resident #72) reviewed for advanced directives. The facility failed to ensure Resident #72 had a current copy of an advance directive in his medical record. This deficient practice could place residents at risk of not having their wishes known, which could delay emergency treatment .

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 (Residents #86 and #304) residents reviewed for infection control. 1. The facility failed to ensure medication were dispensed directly into a medication cup and not into LVN D's palm. 2. The facility failed to implement an infection control and prevention that included wound care procedures and cross contamination for Resident #304. These failures could place residents at risk of infectious diseases, cross contamination, staph infection and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 8 residents (Resident #50) reviewed for effective pest control on Hall 6. 1) The facility failed to effectively treat for the flies in Resident #50's room. 2) The facility failed to implement preventative measures to prevent flies. These failures could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 12 residents reviewed for accidents. The facility failed to provide Resident #1 with ADL care in a safe manner, allowing Resident #1 to fall off her bed on 5-21-2024 between 4:00-4:30 PM, while her shirt was being changed by a staff member. An immediate Jeopardy (IJ) situation was identified on 6-5-2024 at 5:41 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of its corrective systems. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that adequate pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #1) of 12 residents reviewed for pain management. The facility failed to ensure Resident #1 was properly assessed, monitored, and received effective pain management after Resident #1 fell on 5-21-2024 at approximately 4:30 PM and sustained a comminuted fracture of the left distal femur just above the femoral condyles and was not sent to the hospital for treatment for 6.5 hours at approximately 11:00 PM. The nurse was not notified for 1 to 1.5 hours of the fall until Resident #1's family member intervened and notified the nurses of Resident #1's pain. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (Resident #14) of 20 residents reviewed accidents and hazards. 1. The facility failed to ensure Resident #14 was accurrately assessed for hot liquids, failed to measure temperature of the coffee at serve, and failed to ensure environment was clear of accidents, causing Resident #14 to spill hot coffee on himself. This failure could affect the residents at the facility by placing them at risk for accidents related to hot liquid that led to injuries such as burns.