Inspection·October 5, 2023

F 0689 Level of Harm - Actual harm Residents Affected - Few Review of Resident #14's hot liquid assessment, dated 09/26/2023, which was after the incident, revealed a score of 6.oo for functional factors of history of spilling liquids, confusion, impaired coordination, upper extremity poor muscle control, decreased range of motion of fingers, hands, arms, and slow reaction time. Record review dated 09/26/2023 of the facility final incident report completed by the DON reflected in part resident reports that he was getting coffee and when he turned his wheelchair around his right elbow bumped a chair and he spilled coffee onto his right thigh. Resident was wearing long pants, he was unable to wipe if off quickly enough Reviewed event on video camera, event occurred as resident described. Interview on 10/04/23 at 1:30 PM with Resident #14 revealed he was getting his own cup of coffee when he bumped into a chair which caused the coffee to splash all over him. He did not inform staff that he had spilled it on himself at the date of the incident. He stated the doctor came the other day to look at it. He also revealed because he had a stroke, he was paralyzed on his left side so he couldn't stand up and go to the bathroom as quickly as he would like whenever he needed to go, however, the coffee burn occurred on his right side, not his left side. Resident #14 stated he was in pain when the coffee spilled on him but was not currently in pain due to the burn. He stated he received pain medication for it. Interview on 10/04/23 at 1:45 PM with the Wound Care Nurse revealed when the incident first occurred, Resident #14 initially had a red exterior where the burn/wound was located with slough interior. The blisters were there and intact initially. It was also red around the edges with a couple of areas open from the blisters. It was now raw from the blisters opening. The bottom of the wound had healed. Resident #14 currently had an open area at the distal (away from the center of the body) portion at the top of the wound. Interview and observation on 10/04/23 with Dietary Aide A at 1:36 PM revealed the coffee temperature of 152.8 degrees Fahrenheit once poured out of the pitcher and into a cup, measured by the facility's thermometer by Dietary Aide A. Dietary Aide A revealed they did not take the temperature of the coffee prior it to being served. The kitchen refilled the pitcher of coffee before every meal. Interview on 10/04/2023 at 1:57 PM with the Dietary Manager revealed she did not take temperatures of hot or cold liquids. She stated the dishwasher was responsible for making coffee and she made the coffee at 6:30 AM in the morning, usually an hour into serving breakfast, and one hour into serving lunch and dinner. The Dietary Manager stated if the coffee ran out, they just make more. She said the Administrator had her take the coffee temperature every 15 minutes about a week ago, and it dropped 3 to 4 degrees, with the lowest temperature at 158 degrees Fahrenheit. She stated she did not know why the Administrator had her take the temperatures and they do not take the temperature of the coffee anymore. The Dietary Manager stated she knew the desired temperature for coffee was 165 degrees Fahrenheit for coffee because it was on the side of the machine. The Dietary Manager stated the risk to residents in not taking the temperature of coffee to know how hot the coffee was could result in residents getting scalded if the liquid spills. Interview on 10/04/2023 at 2:18 PM with the Dietary Manager revealed the commercial coffee machine was connected to the facility ' s hot water. Kitchen staff placed a box of concentrated coffee directly into the machine in which coffee was dispensed from a spout directly into coffee carafes that were placed on the liquid bar for complementary consumption. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676003 If continuation sheet Page 2 of 4 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 10/05/2023 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)

F 0689 Interview on 10/4/23 at 3:12 PM with the Wound Physician revealed the resident had a second-degree burn which includes blisters, a darker tone and a shiny moist appearance. Level of Harm - Actual harm Residents Affected - Few Interview on 10/4/23 at 4:10 PM with the DON revealed the nurse notified her that Resident #14 had poured hot liquid on his leg. She stated he had a BIMS score of 14 (this indicated little to no cognitive impairment). The following day the DON completed an assessment which involved pain assessment every shift as well as a full skin assessment. She asked Resident #14 what happened, and he stated he was pouring coffee, hit a chair and spilled it on himself. The DON revealed there was video footage of the coffee spill, and the video matched the record of events. At the time, the DON completed her assessment of Resident #14 ' s skin which revealed a reddened area with an intact fluid-filled blister. The DON stated, per the doctor, because the skin was intact to just monitor it. The DON felt it was important to obtain a referral from a physician to come look at the burn. She stated she saw the physician yesterday (10/03/23) and the physician gave treatment orders to be put in place. The DON stated Resident #14 denied being in pain at the time and he stated he would allow staff to serve coffee to him instead of the resident getting coffee himself. The DON also had dietary do a temperature check on the coffee brew. The DON stated the coffee brew temperature and the standing temperature were within federal regulation. She stated it wasn ' t the temperature of the time coffee spill that caused the burn but the fact that it stuck to his clothing for a long period of time, which kept the hot liquid against the skin prolonged. The DON stated she talked to Resident #14 and reminded him to let the staff get his coffee and moved chairs away from the coffee bar. She stated this was the first event in which someone had ever spilled coffee on themselves. She also stated she was unsure if the coffee brew temperature and the standing temperature were completed daily. The DON revealed based on her investigation she determined it wasn ' t reportable as Resident #14 was a good historian. Interview on 10/05/23 at 8:49 AM with the DON revealed she had conversation with the Medical Director and the Administrator had a conversation with the attending physician/wound doctor. The DON stated the facility completed an audit and revealed Resident #14 ' s hot-liquid assessment was inaccurate, which did not reflect the correct risk level for hot liquids, placing the risk score lower than it should have been. She stated she conducted in-services with facility staff and reassessed all the residents in building to see intrinsic factors that would put someone at risk for injury relating to burns. The DON stated she completed a PIP (Performance Improvement Project) regarding accuracy of assessments. She stated intrinsic factors were accurate on Resident #14 ' s assessment after the burn, which placed the facility on notice to prevent injury further injury, however with Resident #14, this specific event had nothing to do with intrinsic factors (such as the resident ' s actual diagnoses and functional status) and everything do to with extrinsic factor of bumping into chair, because this specific event involved an extrinsic factor. The DON stated the incident could not have been prevented and was unavoidable. The DON stated her plan was to look at all evaluations including falls, medications, elopements, Braden scores, and AIMS. The DON said the facility would also do an audit on those assessments to see if the inaccuracy was isolated with hot liquids and planned to do IDT meeting on those assessments. The DON revealed the risk of not having an accurate hot-liquid assessment would result in an invalid assessment. Resident #14 did have all the things marked on his second assessment evaluation after the incident. The DON stated they have a clinical meeting every day at 10 AM. Two ADONs check for any new admissions to see if the assessments, including the hot-liquid assessment, were done. She stated after her review some assessments were inaccurate and did not have all the risk factors but none of them were left blank. The DON stated care sheets were updated with a small little flame icon for those triggered as high-risk for burns/hot-liquids so that it communicates to the CNAs, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676003 If continuation sheet Page 3 of 4 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 10/05/2023 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)

F 0689 letting them know which residents need assistance with getting hot liquids and administering them. Level of Harm - Actual harm Observations on 10/05/2023 at 9:30 AM of the coffee bar revealed residents with high risk on the hot-liquid assessment were not observed getting coffee without supervision. Coffee bar was located in an area where residents were in line of sight (open, unobstructed area) due to the foot traffic. Between 11:30 am and 1:00 PM, staff both nursing and dietary staff were observed preparing both hot and cold liquids for residents. During mealtimes, residents were observed with staff nearby when the coffee was dispensed. Residents Affected - Few Review of video footage on of the incident on 09/25/23, revealed Resident #14 propelled himself to coffee bar, got a cup of coffee, held the cup with his right hand (the hand that was not paralyzed) and bumped into a table and trash can in the dining room that was next to the kitchen door, which was in the way of the resident The cup fell and the coffee spilled. A staff member (Activity Assistant) responded immediately and went to the resident, picked up the cup that fell and went to get another coffee for Resident #14. Interview on 10/05/2023 at 11:01 AM with the Activity Assistant revealed she was doing bingo with the residents (including Resident #14) during activities during the time Resident #14 went to go get himself some coffee and spilled. While she was conducting activities, she heard a cup hit the floor. She ran over to Resident #14 immediately and the resident stated he spilled his coffee and he asked her to get him more. She went to get him another cup and went back to bingo. She stated she asked if he was okay and he said yes. The Activity Assistant stated she did not notice a spill on him because he was wearing dark pants. She stated she did not notify anyone because she thought the cup just hit the ground and Resident #14 said he was ok and did not indicate he had spilled coffee on himself. Interview on 10/05/2023 at 5:27 pm, the DON stated for hot liquid assessments, a score of 0 meant no risk and a score of 1-22 was high risk. The facility did not provide temperature logs of the coffee at exit. Review of the facility's Accidents and Injuries policy, dated_08/02/2022, revealed To ensure that all accidents whether it is a staff member and/or resident of any type be reported with or without injury. Review of the facility ' s Hot Liquid Safety policy, dated 10/05/2023, revealed Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions. 1. Hot liquids can cause scalding and burns. The degree of injury depends on the temperature, the amount of skin exposed, and the durations of exposure. 2. The temperatures of hot liquids will be checked in the dietary department prior to distribution to the nursing units. If the temperature is greater than 175 degrees Fahrenheit, hold the liquid in the dietary department until it reaches an appropriate temperature. 3. All residents are assessed for their ability to handle containers and consume hot liquids. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676003 If continuation sheet Page 4 of 4