Inspection·June 7, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's medical, nursing, and mental and psychosocial needs for two (Resident's #1 and #2) of 3 residents reviewed for comprehensive care plans. The facility failed to ensure Resident #1 and #2 did not consume liquid through a straw. This failure placed residents with special diet requirements at risk of aspiration or choking. Findings included: Review of the current, undated face sheet for Resident #1 revealed she was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease with late onset and Vascular Dementia. Review of Resident #1's Care Plan dated 05/31/23, revealed Dietary- Regular diet 10/28/21 pattern of weight loss. Interventions: Resident is regular, no fried food, no mixed consistencies, and no straws. Review of the current, undated face sheet for Resident #2 revealed she was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including Dementia. Review of Resident #2's swallow test dated 11/15/22, revealed Evaluative/Diagnostic Findings: Mild-oral Dysphagia, Server Pharyngeal Dysphagia with Penetration Before/During/ After swallow of all consistencies, silent aspiration during swallow of thin liquids. Review of Resident #2's Order Summary Report undated, revealed Active order as of 06/07/23 Dietary-Diet: chewing swallowing problems Review of Resident #2's Care Plan dated 04/11/23, revealed Dining/Eating/Nutrition/Fluids preferences and status for care at risk for malnutrition and dehydration. Interventions: No straws. Problem: I have a swallowing problem risk for choking and or aspiration and diagnosis of Dysphagia. Interventions: No straws. (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 2 Event ID: 676003 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 676003 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azle Manor Health Care and Rehabilitation 721 Dunaway LN Azle, TX 76020 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)