Azle Manor Health Care, L.l.l.p.
Azle Manor Health Care, L.L.L.P. in Azle, TX — inspection on June 6, 2024.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
met all the requirements for OBRA nurse aide training regulations per the Nurse Aide Training and
jeopardy to resident health or Long-Term Care Facilities.
The OBRA nurse aide training regulations include: safety o
Placed on the Nurse Aide Registry o The first 16 hours of training must be completed prior to any direct contact with a resident. o After the first 16 hours, nurse aides can perform only those skills for which they have been trained and found to be proficient by the instructor.
Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 6/5/24 with the Medical Director.
The Medical Director has reviewed and agrees with this plan.
On 6-6-2024, at 1:20 PM, Resident #12 was observed being properly transferred from her wheelchair to her bed by way of mechanical lift.
676003 06/06/2024
Azle Manor Health Care and Rehabilitation 721 Dunaway LN Azle, TX 76020
and provide medication as ordered, then monitor them. if the pain medication was not effective, she
jeopardy to resident health or non-verbal signs of pain she would look for.
She said they did not want their residents to be in pain. safety In an interview on 6-6-2024 at 2:45 PM, CNA F stated she had been taught pain protocols to get the
followed could be the resident being in increased pain.
In an interview on 6-6-2024 at 3:53 PM, CNA G stated she has been in-serviced on pain management on 6-4-2024 and it included signs of pain on a resident, and how to respond.
In an interview on 6-6-2024 at 4:15 PM, LVN C stated she was in-serviced on pain, and how do proper pain assessment, find out why a resident was in pain, where the pain was, different signs of pains, non-verbal expression of pain. LVN C said the risk for not following the correct protocols were residents need not being met, and something worse happening, they could stay in pain, and not knowing the cause of pain in their bodies.
In an interview on 6-6-2024 at 5:00 PM the DON said going forward, to ensure this kind of situation did not take place again, the residents would be assessed for pain at each shift, and on MDS on admission quarterly and with significant change.
She said she was currently auditing pain assessments for accuracy and to see if pharmaceutical and non-pharmaceutical interventions were effective and updating the plans of care.
In an interview on 6-6-2024 at 5:15 PM, the Administrator stated he thought the reason the Immediate Jeopardy occurred was that the student took on more than what they were capable of doing. He said to ensure this type of incident did not occur again, the facility was restructuring the CNA training classes to allow more training and mentorship before being put on the floor. He was not aware that CNAs were being put on the floor as fast as they were. He said they extended the course from a 5-day class to an 8-day class, and the CNA trainer would follow the trainee on the floor for 7 days.
After that, they would be paired with a mentor and take their test. He said everyone was an individual and trained at different paces.
An immediate jeopardy (IJ) situation was identified on 6-5-2024 at 5:41 PM.
While the IJ was removed on 6-6-2024 at 3:14 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of its corrective systems.
The facility failed to ensure Resident #1 was properly assessed, monitored, and received effective pain management after Resident #1 fell on [DATE] at approximately 4:30 PM and sustained a comminuted fracture of the left distal femur just above the femoral condyles and was not sent to the hospital for treatment for 6.5 hours at approximately 11:00 PM.
The nurse was not notified for 1 to 1.5 hours of the fall until Resident #1's family member intervened and notified the nurses of Resident #1's pain.
An immediate Jeopardy (IJ) situation was identified on 6-5-2024 at 5:41 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of its corrective systems.
These failures placed residents at risk of experiencing significant pain and discomfort.
Findings Included:
Record review of Resident #1's Face Sheet dated 6-4-2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Alzheimer's Disease with late onset, and secondary diagnosis of Dementia, Cerebral Infarction (Stroke), and Need for Assistance with Personal Care.
Record review of Resident #1's Comprehensive MDS Assessment, dated 3-25-2024, revealed Resident #1 had a BIMS Score of 11 indicating moderate cognitive impairment.
The Functional abilities and goals section revealed Resident #1 was Dependent (Helper does all of the effort.
Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers were required for the resident to complete the activity) for upper body/lower body dressing, bathing, and Chair-to-bed transfers.
Because of Resident #1's medical conditions or safety concerns, Resident #1 was coded for there to be no attempt made by staff to move Resident #1 from Lying to sitting on side of bed. Resident #1 had a diagnosis of stroke, brain and spinal cord dysfunction, amputation, hip and knee replacement, fractures, and other multiple traumas.
Record review of Resident #1's doctor orders revealed an order for Norco Oral Tablet 325 MG to being on 5-28-2024 to be given for pain every 6 hours as needed for pain.
676003
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676003 B.
Wing 06/06/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Azle Manor Health Care and Rehabilitation 721 Dunaway LN Azle, TX 76020
F-F697 related to the alleged action of pain by not providing pain medication. By submitting this plan of removal Azle Manor does not admit to the accuracy of the alleged deficient practice.
What corrective actions have been implemented for the identified residents?
o Residents residing in the facility are assessed for pain every shift and after incidents/accidents.
On 6/5/24 the DON/designee completed audits on residents receiving routine and PRN pain medications to determine appropriate timing and resident response to effectiveness of treatment modalities; and
On 6/5/24 the DON/designee completed audits on residents with active pain assessments to determine accuracy in level of pain and update the treatment plan
How were other residents at risk to be affected by this deficient practice identified?
All residents residing in the facility are at risk for pain.
Pain assessments are completed every shift, as needed, and following incidents/accidents.
What does the facility need to change immediately to keep residents safe and ensure it does not happen again?
The DON/designee initiated immediate training on 6/5/24 and completed training on 6/6/24 with CNA Student(s), CNA(s), Medication Aides, and Licensed Nurses to include areas of:
o Assessing pain/pain complaints.
o Modalities of assessment to include those with communication difficulties and/or cognitive issues.
How will the system be monitored to ensure compliance?
676003
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676003 B.
Wing 06/06/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Azle Manor Health Care and Rehabilitation 721 Dunaway LN Azle, TX 76020
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.