Azle Manor Health Care, L.L.L.P.

In the surveyor’s words

From the most serious findings on record at Azle Manor Health Care, L.L.L.P., in the surveyor’s own words.

• Immediate jeopardy, patternF880Nov 10, 2022

  Based on observations, interviews and record reviews, 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 infection for 7 (Residents #3, #7, #9, #11, #13, #16, and #18) of 19 residents reviewed for infection control. The facility failed to cohort residents based upon their COVID-19 status: Residents #9 and #16 contracted COVID-19 after being cohorted with roommates who were COVID-19 positive. Residents #3, #7, #11, #13 and #18 were negative for COVID-19 but their roommates were positive. An Immediate Jeopardy was identified on 11/08/22 at 2:12 PM. […]

• Immediate jeopardy, isolatedF689Jul 23, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF689Apr 26, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Jun 6, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF697Jun 6, 2024

  Based 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 [DATE] 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. […]