Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Azle Manor Health Care And Rehabilitation during CMS and state inspections, most recent first.
Kitchen staff failed to follow food safety practices when food was left unsealed or mislabeled, thawed meat was dated incorrectly, a cook handled potatoes without gloves and touched food with bare hands after using a thermometer, bulk sugar was left open, and trash cans were left uncovered while not in use.
Unlocked Medication Cart Observed Unattended: A medication cart was observed left unattended and unlocked between two hallways while staff and residents walked by. MA A stated she was unsure why the cart was left unlocked and acknowledged that carts should be locked when not in use. The ADON stated staff were expected to keep carts locked, and facility training records showed medication/treatment cart safety in-service had been provided.
A CNA failed to perform hand hygiene on entry and did not change soiled gloves after incontinent care before touching a resident’s clothing, blanket, bed remote, and bed controls. The resident was incontinent and had moderate cognitive impairment, and the CNA acknowledged she contaminated the resident by handling clean items with dirty gloves. The DON and infection control preventionist stated hand hygiene and glove changes were expected, and facility policy required hand hygiene before and after resident contact and after handling contaminated objects.
A deficiency was cited when an area of the facility was found to contain accident hazards and lacked adequate supervision to prevent accidents. The report highlights that the environment was not properly maintained to ensure resident safety, and supervision was not sufficient to prevent potential incidents.
A resident with advanced dementia and total dependence on staff for transfers was injured when two CNAs used a mechanical lift missing a critical metal clip, resulting in the resident falling from the sling and sustaining an orbital fracture. The staff did not identify the missing part or properly secure the sling before the transfer, and the defective lift remained in use without being reported or removed from service, contrary to facility policy and manufacturer guidelines.
The facility failed to follow professional standards for food service safety, as observed in their kitchen. An unopened bag of breaded chicken parts was not labeled or dated, a dented can of jalapeno peppers was stored improperly, and a scoop was left in a sugar bin. These actions could lead to cross-contamination and food-borne illnesses, as confirmed by the Dietary Manager.
The facility failed to ensure proper disposal and storage of medications, leading to deficiencies. An LVN improperly disposed of used betadine swabs in a resident's trash can, contrary to infection control practices. Additionally, a treatment cart was left unlocked and unattended, allowing unauthorized access to medical supplies. Narcotic medications were also found unsecured in an unlocked refrigerator, posing a risk of drug diversion.
A facility failed to maintain effective pest control, resulting in flies landing on a resident with limited mobility and a small bloody area on his leg. The resident expressed frustration as he was unable to swat the flies away. The Administrator acknowledged the issue, noting that pest control measures were in place but ineffective in this instance.
A facility failed to honor a resident's advance directive by not documenting his Do Not Resuscitate (DNR) status upon admission, despite having a DNR order from the hospital. The resident, with moderate cognitive impairment and a history of stroke, was incorrectly recorded as Full Code due to a lack of communication and verification by the social worker and nursing staff. This discrepancy placed the resident at risk of receiving unwanted resuscitation efforts.
The facility failed to maintain an effective infection prevention and control program, as evidenced by two incidents involving residents. An LVN dispensed medications into her gloved hand before placing them into a medication cup, without changing gloves or performing hand hygiene. Another LVN disposed of used wound care swabs in a resident's trash can instead of using a biohazard bag. These practices were identified as contamination risks by the infection control nurse and other staff.
A resident with Alzheimer's and a history of falls was injured after a CNA in training improperly attempted a transfer without using a mechanical lift, leading to a fall and fracture. The CNA and a CMA moved the resident without notifying a nurse, delaying medical assessment and pain management.
A resident with Alzheimer's and dementia fell and sustained a fracture, but the LTC facility failed to provide timely pain management and hospital transfer. The CNA in training attempted a transfer alone, leading to the fall, and the incident was not reported to a nurse until a family member intervened. The facility's pain management policy was not followed, resulting in the resident experiencing significant pain.
Kitchen Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards in its only kitchen. During observation, a half loaf of bread was seen on top of the microwave unsealed and undated. In an upright reach-in refrigerator, three sealed bags of lettuce were observed with a use-by date of 02/10/26, and two 3-pound tubes of ground beef were found on the bottom shelf, soft to the touch and thawed, with a received date of 2/10/26 at 09:20 a.m. and a used-by date of 4/10/26 at 9:00 a.m. The large bulk sugar container was also observed open when no staff were using it. During food preparation, [NAME] B transferred potatoes from a baking sheet into a metal steam pan and checked their temperature with a thermometer while not wearing gloves. After removing the thermometer from the potatoes, she used her ungloved thumb and pointer fingers to slide potato pieces that had stuck to the thermometer back into the pan with the rest of the potatoes. Two large black trash containers in the kitchen were also observed with lids off and trash inside while no staff were actively using them. In interview, [NAME] B stated that the lettuce had just been delivered and that the ground beef had been removed from the freezer to thaw, but the label had been written with the received date instead of the thaw date. Dietary Aide C stated she had mislabeled the ground beef and acknowledged that items should be dated when placed in the refrigerator to thaw. She also stated that bulk items were supposed to be closed and that the trash cans had been left open after breakfast cleanup. The Dietary Manager stated that all kitchen staff were responsible for correct food handling, that foods should be labeled with received, opening, and expiration dates, that thawing meat was good to use up to 7 days, and that staff should wear gloves when handling food and keep bulk items and trash can lids closed when not in use.
Unlocked Medication Cart Observed Unattended
Penalty
Summary
The facility failed to provide safe and secured storage of drugs and biologicals by leaving a medication cart unlocked while it was unattended. During observation on 02/19/26 at 1:31 PM, a medication cart was seen left unlocked and facing the wall between the 200 hallway and the 300 hallways, with staff and residents walking by it. When the surveyor asked to look at the cart, MA A took out her key after noticing it was unlocked and stated she was unsure why she had left it unlocked. In interview, MA A stated that all carts should be locked while not in use and that leaving them unlocked could allow residents to get medications and could result in overdose and HIPAA violations because anyone could access the cart. The ADON stated that staff were expected to lock all carts when not in use and identified risks including residents obtaining medications, adverse reactions, injuries from scissors on some carts, and access to resident information. Facility in-service records showed medication/treatment cart safety training on 1/14/2026, and MA A attended that training. The facility's medication storage policy stated that all medications are stored in designated areas sufficient to ensure safety.
Failure to Perform Hand Hygiene and Change Gloves During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one resident reviewed for infection control. Resident #16 was admitted with metabolic encephalopathy and had a BIMS score of 11, indicating moderate cognitive impairment. Her MDS reflected that she was always incontinent, and her care plan addressed ADL self-care difficulty and limited assistance with personal hygiene. During an observation in her room, the resident stated she was soiled and needed incontinent care, and CNA D entered the room to provide care. CNA D provided privacy and gathered supplies, but did not perform hand hygiene upon entering the room. She put on gloves and cleaned the resident, then did not remove the soiled gloves before putting on a new brief, assisting the resident with her pants, covering her with a blanket, adjusting the bed, and handling the resident’s bed remote and clothing while still wearing the same gloves. In interview, CNA D stated she had been trained on peri care and hand hygiene and acknowledged she had contaminated the resident by touching her things with soiled gloves and not performing hand hygiene. The infection control preventionist and DON both stated that hand hygiene was expected before and after incontinent care and that gloves should have been changed before touching the resident’s belongings. Facility policy required hand hygiene before and after each resident contact, after handling contaminated objects, and after PPE removal.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment posed risks that were not addressed, and supervision was insufficient to prevent potential incidents. No further details about the specific hazards, the nature of the supervision, or the residents involved are provided in the report.
Failure to Remove Defective Mechanical Lift and Ensure Safe Resident Transfer
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident dependent on staff for transfers. The facility did not remove a mechanical lift from service that was missing a critical metal clip, which is essential for securing the sling to the lift. This lift remained in use for a period of time, and staff did not identify or report the missing part prior to using the equipment for resident transfers. On the day of the incident, two CNAs attempted to transfer an 83-year-old female resident with advanced Alzheimer's dementia, severe cognitive impairment, and total dependence on staff for transfers. During the transfer, the sling was not properly secured to the lift, and the missing metal clip was not noticed by the staff. As a result, the resident fell from the sling while being lifted, striking her face on the base of the lift and sustaining an orbital fracture and other injuries. Both CNAs involved stated they had received prior in-service training on the use of the mechanical lift, but neither identified the equipment defect before use. Subsequent interviews and observations revealed that the mechanical lift with the missing metal clip continued to be used by other staff after the incident. The Operations Director and Administrator were unaware of the missing clip prior to the incident, and there was no documentation of regular equipment inspections. The manufacturer's guidelines required daily checks of the lift's sling hooks, and facility policy mandated that staff inspect equipment before use and remove any damaged equipment from service, but these procedures were not followed.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Specifically, the facility did not properly label and date stored food items, such as an unopened bag of breaded chicken parts that were not marked with the contents or the date they were received. Additionally, a 10 oz can of jalapeno peppers was found to be dented near the opening, and a scoop was improperly left inside a sugar bin. These practices were identified during an observation of the kitchen, freezer, and dry goods area. An interview with the Dietary Manager confirmed that whole foods should be labeled and dated to ensure they are served before expiration, and cans should be inspected for dents to prevent metal contamination. The scoop left in the sugar bin posed a risk of infection control or contamination, as it should have been removed and washed. The facility's failure to follow these guidelines could potentially expose residents to cross-contamination and food-borne illnesses. The facility's procedures, as outlined in their Labeling and Dating Foods guideline and the U.S. Public Health Service Food Code, were not followed, leading to these deficiencies.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper disposal and storage of medications and biologicals, leading to several deficiencies. In one instance, a Licensed Vocational Nurse (LVN) completed wound care for a resident and disposed of used betadine swabs in the resident's trash can instead of a biohazard bag. This action was contrary to infection control practices, as the swabs were contaminated and could pose a risk if accessed by residents. The infection control nurse confirmed that such items should be disposed of in a red biohazard bag to prevent contamination. Another deficiency was observed when a treatment cart was left unlocked and unattended by the same LVN while performing wound care for another resident. The cart contained various medical supplies and medications, and its unlocked state allowed unauthorized access by staff and residents passing by. The LVN acknowledged the oversight, admitting that the cart should have been locked to prevent unauthorized access to medications and supplies. Additionally, the facility failed to secure narcotic medications properly. In the medication room, narcotic medications belonging to a deceased resident were found in an unlocked silver container inside an unlocked refrigerator. The medications were not secured under double lock as required for controlled substances. Staff interviews revealed that the responsibility for securing these medications was shared among nursing staff, but the oversight led to the medications being left unsecured, posing a risk of drug diversion.
Inadequate Pest Control Leads to Fly Infestation in Resident's Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies in a resident's room. The resident, who had diagnoses including Paroxysmal Atrial Fibrillation, Vascular Dementia, and Paraplegia, was observed with 4 to 5 flies landing on his left leg. The resident was wearing only a hospital gown and had a small bloody area on his left shin, which was attracting the flies. The resident expressed frustration as he was unable to swat the flies away due to his limited mobility. Interviews revealed that the facility's pest control measures were inadequate, as the Administrator acknowledged the problem with flies in the resident's room. Although the pest control company sprays for flies regularly, the facility did not have a history of fly problems. The Maintenance Director was responsible for pest control, and staff were expected to report pest issues immediately. However, the failure to control the flies could lead to the spread of infection and cross-contamination among residents.
Failure to Honor Resident's Advance Directive
Penalty
Summary
The facility failed to provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and to formulate an advance directive, specifically for one resident. This deficiency was identified during a review of the medical records and interviews with staff and family members. The resident in question, a male with a history of non-traumatic intracranial hemorrhage and moderate cognitive impairment, was admitted to the facility with a Do Not Resuscitate (DNR) order from the hospital. However, upon admission, the facility recorded him as Full Code, indicating a failure to honor his advance directive. Interviews with the social worker and nursing staff revealed a lack of communication and verification regarding the resident's code status. The social worker did not verify the resident's DNR status with the family or the resident's responsible party, assuming the resident was his own responsible party due to his alertness and orientation. The acting Director of Nursing (DON) and the admitting Licensed Vocational Nurse (LVN) also failed to ensure the correct code status was documented, leading to a discrepancy between the resident's wishes and the facility's records. The facility's policy required that the plan of care for each resident be consistent with their documented treatment preferences and/or advance directive. However, the failure to verify and document the resident's DNR status placed him at risk of receiving unwanted resuscitation efforts. The administrator acknowledged the importance of discussing code status during the care planning process and ensuring that the social worker was responsible for maintaining current advance directives on file.
Infection Control Deficiencies in Medication Administration and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. In the first incident, a Licensed Vocational Nurse (LVN) was observed administering medication to a resident with multiple health conditions, including chronic obstructive pulmonary disease and diabetes. The LVN dispensed medications into her gloved hand before placing them into a medication cup, without changing gloves or performing hand hygiene between tasks. This practice was acknowledged by the LVN as a contamination risk, as she touched various surfaces with the same gloves, potentially compromising the sterility of the medications. In the second incident, another LVN was observed performing wound care on a resident with diabetic foot ulcers and cellulitis. After applying betadine to the resident's wounds, the LVN disposed of the used swabs in the resident's trash can and left them there, rather than using a biohazard bag for disposal. This practice was identified as unacceptable by the infection control nurse, who noted the potential for contamination and harm if the resident or others came into contact with the used swabs. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Administrator, revealed a lack of adherence to established protocols for medication administration and waste disposal. The facility's policies on standard precautions and enhanced barrier precautions were not followed, leading to a risk of infection. The Administrator emphasized the importance of staff accountability and adherence to protocols to prevent such deficiencies.
Failure to Provide Adequate Supervision and Assistance Devices
Penalty
Summary
The facility failed to ensure a safe environment for a resident, leading to a fall and subsequent injury. The resident, who had a history of Alzheimer's Disease, dementia, and a previous hip fracture, required maximum assistance for transfers and was dependent on staff for activities of daily living. On the day of the incident, a CNA in training attempted to change the resident's shirt and sat her up on the side of the bed without assistance, contrary to the care plan that required a mechanical lift and two-person assistance for transfers. This action resulted in the resident slipping off the bed and sustaining a fracture. The CNA, who had completed in-house training but was not yet certified, did not follow the facility's protocol for handling such situations. After the fall, the CNA and a CMA lifted the resident back onto the bed without notifying a nurse or conducting an assessment, which was against the facility's fall prevention policy. The resident was left in pain for an extended period before receiving appropriate medical attention, as the staff failed to communicate the fall incident to the nursing staff promptly. Interviews with staff revealed a lack of adherence to established protocols and inadequate supervision of the trainee CNA. The DON acknowledged that the aides moved the resident without a nurse's assessment, and both the CNA and CMA were written up for the incident. The facility's fall prevention policy was not followed, as the resident's fall was not immediately reported to a nurse, and the necessary precautions for a resident requiring a mechanical lift were not taken.
Inadequate Pain Management Following Resident Fall
Penalty
Summary
The facility failed to provide adequate pain management for a resident who required such services, leading to a deficiency identified by surveyors. The incident involved a resident with a history of Alzheimer's Disease, dementia, and other medical conditions, who fell and sustained a comminuted fracture of the left distal femur. The resident was not sent to the hospital for treatment until 6.5 hours after the fall, and the nurse was not notified of the fall for 1 to 1.5 hours until a family member intervened. The resident's care plan indicated a need for maximum assistance with transfers and highlighted the risk of pain and falls due to a previous hip fracture. Despite this, a CNA in training attempted to transfer the resident alone, resulting in the fall. The CNA and a CMA moved the resident back to bed without notifying a nurse or conducting a proper assessment. The resident was left in pain, and it was not until the family member's intervention that the medical team was alerted to the severity of the situation. Interviews with staff revealed a lack of communication and adherence to protocols, as the CNA did not inform the nurse of the fall, and the CMA assumed the nurse was aware. The resident was left unattended in pain, and the facility's pain management policy was not followed, as the resident's pain was not assessed or managed effectively. This failure placed the resident at risk of significant pain and discomfort.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Azle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Lodge Nursing & Rehabilitation | 7.9 mi | ★★★★★ | 12 | 0 |
| The Lodge Of Saginaw Health And Wellness | 9.6 mi | ★★★★★ | 12 | 0 |
| Springtown Park Rehabilitation And Care Center | 9.7 mi | ★★★★★ | 4 | 0 |
| Fort Worth Wellness & Rehabilitation | 10.7 mi | ★★★★★ | 0 | 0 |
| White Settlement Nursing Center | 11 mi | ★★★★★ | 6 | 0 |
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