Health inspection·July 16, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few started hurting. Resident #1 was in visible pain with minimal movement. Will transfer to ER for further evaluation. Right arm pain: will transfer to ER for further evaluation Resident #1 is in too much pain to perform effective evaluation. Record Review of Medical Director dated July 1, 2025 revealed; Reason for this visit; asked to see Resident #1 regarding right arm pain. Resident #1 returned from hospital on 6/23 after being diagnosed with UTI treated with 5 day course of merrem iv (is indicated for the treatment of complicated skin and skin structure infections due to Staphylococcus aureus), Resident #1 also diagnosed with right proximal humerus fracture (a break in the upper part of the humerus, the bone in your upper arm, specifically on the right side near the shoulder joint), ortho recommended non-surgical mgt with sling, with out pt ortho follow up. Resident #1 had Robaxin (also known by its generic name methocarbamol, is a muscle relaxer used to alleviate discomfort associated with various musculoskeletal conditions.) added and continued scheduled until Resident #1 is NWB to right upper extremity. Resident stated pain still to right upper extremity worse with movement, better at rest. Record Review of Resident #1's Medication Review Report dated 07/15/2025 revealed; non-weight bearing to right arm/shoulder Q shift. Right arm to remain in sling. Do not use right arm for pushing up, lifting, or supporting weight. every shift. Acetaminophen Tablet 500 MG Give 1 tablet by mouth every 6 hours as needed for pain/fever related to OTHER CHRONIC PAIN. Acetaminophen-Codeine Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) Give 1 tablet by mouth every 4 hours as needed for pain related to LOW BACK PAIN, UNSPECIFIED; PAIN IN RIGHT SHOULDER. Diclofenac Sodium External Gel 1 % (Diclofenac Sodium (Topical)) Apply to right upper arm/shoulder topically every 6 hours as needed for Pain. TraMADol HCl (Tramadol Hydrochloride) Oral Tablet 50 MG (Tramadol HCl Hydrochloride) Give 2 tablet by mouth four times a day for pain. Observation and interview on 07/15/2025 at 12:14 with Resident #1 revealed; Resident #1 was in her room, door open, resident in bed A, HOB elevated, visible sling on right arm. Pillow under right arm and shoulder. She stated, you don't want to know, one of the guys that works here dropped me on my shoulder, I don't usually talk about it. Resident #1 stated Oh, it hurts. She stated that her pain was in her back. She was unable to give a name or description of the guy that dropped her. Interview on 07/15/2025 at 1:10 PM with CNA A stated; I was working on station 1 and Resident #1's CNA B wanted help transfer Resident #1 from the wheelchair to the bed, Resident #1 was in her wheelchair with the mechanical lift sling underneath, she complained of pain and was moving in her wheelchair and it looked like she would slid out of the wheelchair. CNA B asked me to help reposition Resident #1 in the wheelchair. She was too far forward in her wheelchair for us to grab the sling. We needed to get her further back in the chair we were afraid she would fall. CNA B told me to help lift her under the arm, we were moving fast because we did not want her to fall. Resident #1 was complaining of pain in her back, it was common for her to complain of pain. It was common for her to say her back was hurting. After we repositioned her in the wheelchair, we used the mechanical lift to put her in the bed. CNA A stated the risk of repositioning residents without the use of a gait belt or mechanical lift could result in injury to the resident. Attempted interview on 07/15/2025 at 1:30 PM with CNA B revealed; phone number disconnected. Re-interview on 07/15/2025 at 2:10 PM with Resident #1 who stated her pain level was 0- smiling- arm in sling. When asked about the cause of her injury she stated, I don't like to gossip. then she stated she was in a car accident. Interview on 07/15/2025 at 2:34 PM with RN C who stated it was between 9:00 and 10:00 am Resident #1 would not want me to touch her arm. She said she was in a lot of pain and she could not extend her right arm. I do blood sugar checks, and I needed access to her arm, she would not extend it. This was a change from the normal as she complains of pain in her back. Notified the doctor, the doctor was in the building for routine rounds. The doctor sent her to the emergency room (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 07/16/2025 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 Level of Harm - Actual harm Residents Affected - Few acute (present or experienced to a severe or intense degree). She had chronic pain and received PRN pain medication every 4 hours instead of 6 hours. I asked her how it happen, and she stated it was a car accident. I never got a straight answer from her as the cause of the injury. Staff was trained not to pull residents up by their body, use the sling. We have been trained not to pull people up by their body. Interview on 07/15/2025 at 2:42 PM with DON who stated we did not do x-rays in house Resident #1 was sent out acute (present or experienced to a severe or intense degree) to the hospital when the- doctor was in the building and she wanted Resident #1 sent out. Change in condition was increased pain. The incident happened on the 2-10pm shift on 06/18/2025, we discovered this during the investigation. We did not see it on the facility camera because it happened in the resident's room. We were investigating the cause of the injury. We saw that the CNA's provided direct care to Resident #1. When we interviewed them, they stated that they used and underarm lift to reposition the resident. Resident #1 stated, A man dropped me on my shoulder her story was inconsistent. Both CNA's were suspended during the investigation, CNA B resigned and did not return to work. CNA A returned to work and she received one to one training. DON stated that staff should have used the sling to reposition Resident #1. Staff was in-service regarding Repositioning residents. The DON stated there was no delay in treatment for the resident. Interview on 07/15/2025 at 2:54 PM with LVN D who stated, I was the nurse on 2-10 shift on 06/18/2025 when CNA B came to me and stated Resident #1 was in pain, after dinner which is not unusual. I gave her a muscle relaxer and Acetaminophen- checked on her during my shift and she did not report pain after the administration of her medication. There were no signs of extreme distress. Resident #1 does have chronic issue of pain in the back. Interview on 07/16/2025 at 12:22 PM with ADON who stated an investigation was conducted and in-serviced direct care staff on the topic of gait belts and repositioning. The CNA's did not intend to harm Resident #1, they caused harm, their hearts were in the right place. The medical doctor was in the building, and she was notified that Resident #1 was in more pain than usual. The medical doctor asked me to go to the room to assist with Resident #1. Resident #1 stated her arm hurt, ADON's observation of the right arm not swollen, no bruising, and when asked how the injury happen Resident #1 stated about black man caused the injury by dropping her on her shoulder. We could not palpate (examine (a part of the body) by touch, especially for medical purposes) the area and Resident #1 did not have ROM. ADON stated Resident #1 was under pain management. Interview on 07/16/2025 at 12:37 PM with DON who stated, My expectation was when getting a resident ready to reposition they should have used the sling. They should always have a gait belt on them. The residents are fragile, and we should be gentle at all times. Our movements are slow and methodical. If they used the gait belt to pull her up this would not have happened (the injury would not have occurred to Resident #1). We are conducting quarterly in-service for transfers. Interview on 07/16/2025 at 12:37 PM with Administrator who stated staff was trained regarding transfers. Staff were suspended and we investigated. We tell the staff there are no short cuts. Record Review of in-service Training Report titled Repositioning Residents dated 06/20/2025 revealed; training was conducted by ADON- the document reflected NEVER lift or reposition a resident by the arms pulling or grabbing under the arms can cause pain and potential damage to the shoulder/arm. Gait belts and/or mechanical lifts shoulder be used for all repositioning and transfers. Gait belts are part of your uniform. Record Review in-service training report titled Transfers dated 07/03/2025 revealed; ALL C.N.A staff must wear a gait belt. All C.N.A staff must utilize a gait belt during transfers. No staff member should ever lift a resident under the arms. Record Review titled Nursing Assistant Clinical Skills and Competency Evaluation dated 06/23/2025 revealed; CNA A Demonstrated Competency in assists to ambulate using transfer belt. Review of policy titled Safe Resident (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 07/16/2025 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 Level of Harm - Actual harm Handling/transfers dated 03/21/2021 revealed; all residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676003 If continuation sheet Page 4 of 4