Azle Manor: Student Aide Drops Dementia Patient - TX
The May 21 incident at Azle Manor Health Care and Rehabilitation left the elderly woman with a "comminuted fracture of the left distal femur just above the femoral condyles." She waited 6.5 hours before being transported to a hospital — and only then because her family member arrived and demanded answers about why she was crying.
Federal inspectors found the facility violated pain management requirements by failing to properly assess and treat the resident after her fall. The violation carried an "immediate jeopardy" designation, the most serious level of nursing home deficiency.
The student aide, identified as CNA A, was working without supervision despite facility policy requiring trainees to work with fully trained staff. She told inspectors she went into the resident's room alone around 4:30 PM to prepare her for a mechanical lift transfer and change her shirt.
"CNA A stated Resident #1 needed her shirt changed and sat Resident #1 up from a lying position to a sitting position, on the side of Resident #1's bed facing CNA A," the inspection report states. "CNA A stated Resident #1 started to slip off the bed and she was not strong enough to hold Resident #1. As a result, Resident #1 fell off the bed onto the floor."
The resident, who has Alzheimer's disease and moderate cognitive impairment, landed with her left knee bent underneath her, sitting on her left foot. She made an "ouch noise" as she hit the floor.
Instead of immediately calling a nurse — as required by facility fall protocol — CNA A ran to find another aide. Together, they lifted the injured woman back onto her bed by hand, without any medical assessment.
CMA B, the aide who helped lift the resident, noticed the woman's left leg looked swollen while she cried. But rather than call a nurse herself, she told CNA A to find one and request pain medication.
CNA A found LVN A on another hall and asked for pain medication for the resident. Crucially, she never mentioned the fall.
"CNA A stated that she did not tell LVN A that Resident #1 had a fall but only about needing a pain pill," inspectors wrote. "CNA A stated that she assumed CMA B was going to tell a nurse about Resident #1 falling."
CMA B never told anyone about the fall either.
The resident remained alone in her room, crying and in pain, while both aides returned to their regular duties. LVN A eventually gave the woman a pain pill but had no idea she had fallen.
The cover-up might have continued indefinitely, but the facility's physical therapist noticed something was wrong. Around 5:00 PM, the therapist called the resident's family member to report that the woman was "sitting in a hallway crying" and suggested the family should come check on her.
When the family member arrived at 5:40 PM, she found the resident in the dining room, repeatedly saying she was in pain and her left leg hurt. Only then did CNA A approach the family member and admit what had happened.
"CNA A approached Resident #1's [Family Member #2] and told her that CNA A, earlier in the evening, was attempting to change Resident #1's shirt while she was seated on her bed, and Resident #1 fell," the report states.
The family member wheeled the resident to the nurse's station and asked about the fall. The nurses had no idea it had happened.
"Resident #1's [Family Member #2] said the nurses did not know Resident #1 had fallen earlier in the evening," inspectors found.
The facility's medical director was at the nurse's station and overheard the conversation. LVN A told the family member that the resident had received Tramadol and "was fine."
The family member disagreed. "Resident #1's [Family Member #2] then told LVN A that Resident #1 was not fine and was crying in pain."
Only after the family's intervention did medical staff begin properly assessing the resident. The medical director took her to a TV room for examination and noticed her left knee was swollen. She ordered a stat X-ray and additional pain medication.
The X-ray results came back positive for the serious fracture at 10:40 PM — more than six hours after the fall. The resident was finally transported to the emergency room at 11:00 PM.
During the ordeal, staff had to transfer the injured woman back to her bed for the medical director's examination. When they did, "she screamed in pain," according to the family member, who told inspectors she had "never heard Resident #1 scream like that in pain in her entire life."
The family member rated the resident's pain as "past a 10" on the standard 0-10 pain scale.
The resident, described in records as having a history of stroke, brain dysfunction, and a previous hip fracture from a 2023 fall, required maximum assistance for all transfers according to her care plan. The plan specifically warned staff to "be alert for nonverbal pain cues" and "listen to reports of family members regarding my pain."
Her care plan also stated staff should "follow facility fall protocol" given her fall risk.
The facility's own fall protocol required staff to "get a nurse immediately when a resident fell and to not touch or move them," according to another trainee interviewed by inspectors.
Both CNA A and CMA B violated this protocol by moving the resident without medical assessment.
The Director of Nursing told inspectors that "the problem with the fall incident with Resident #1 was the aides moved Resident #1 without an assessment from a nurse." Both aides received disciplinary action.
The facility's pain management policy states that "pain is whatever the experiencing resident says it is, existing whenever he/she says it is" and requires staff to assess pain "at regular intervals." The policy emphasizes that residents should receive "the best level of pain control that can safely be provided in order to prevent unrelieved pain."
Federal inspectors determined the facility failed to meet these standards, placing other residents at risk of "experiencing significant pain and discomfort."
The immediate jeopardy designation was removed after the facility implemented corrective measures, including mandatory mechanical lift training for all staff and increased supervision of trainees. The facility now conducts mechanical lift rounds three times weekly and requires all new residents to be screened for proper transfer techniques.
But for this resident, the damage was done. A routine shirt change became a devastating injury because a student aide worked alone, failed to follow safety protocols, and then concealed the incident while the resident suffered in pain for hours.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Azle Manor Health Care and Rehabilitation from 2024-06-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Azle Manor Health Care and Rehabilitation in Azle, TX was cited for violations during a health inspection on June 6, 2024.
Federal inspectors found the facility violated pain management requirements by failing to properly assess and treat the resident after her fall.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.