Swan Health at Wichita Falls

Based on interview and record reviews, the facility failed to maintain documentation and demonstrate evidence of QAPI training requirements for 10 of 16 (MD, LVN A, RN B, RN C, LVN D, CNA E, CNA F, RT G, MAINT H, DA I) employees reviewed for QAPI training. The facility failed to ensure the MD, LVN A, RN B, RN C, LVN D, CNA E, CNA F, RT G, MAINT H, and DA I were trained for QAPI. These failures could place residents at risk of receiving care from incompetent/untrained staff.Findings included:Record review of personnel files revealed the following proof of QAPI training documents could not be provided.MD hired 11/3/2025LVN A hired 8/1/2025RN B hired 4/27/2026RN C hired 2/25/2026LVN D hired 4/29/2026CNA E hired 3/16/2026CNA F hired 8/1/2025RT G hired 8/1/2025Maint H hired 8/1/2025DA I hired 8/1/2025 In an interview on 05/07/2026 at 8:40AM, CNA E stated she had just started at this facility and felt like the training had been very thorough. She stated she was not aware of completing any training regarding QAPI and was not sure what that stood for. She stated she would speak with the DON…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 facility Dietary Kitchen reviewed for environmental concerns. The facility failed to repair damaged ceiling in Dietary Kitchen, damaged ceiling located over clean pot storage rack. This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unsanitary, and unsafe.Observation on 05/05/2026 at 8:40 AM, revealed the ceiling in dietary kitchen was damaged by water leaking from roof. Location of damaged ceiling was on the north wall over clean pot rack. The damaged area to the ceiling measured 14 inches long with an opening of 1.5 inches at its widest part. Interview on 05/06/2026 at 11:50 AM, Dietary Manager said he had not seen the crack in ceiling before. He stated that the crack being over clean pots could cause clean pots to become contaminated with paint chips falling on pots or contaminated water leaking on pots. Interview on 05/07/2026 at 11:18AM, the Maintenance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 2 of 2 residents (Resident #294 and Resident #295) reviewed for advanced directives. 1. The facility failed to complete Resident #294's Out-of-Hospital Do Not Resuscitate (OOH DNR) on admission or in a timely manner. 2. The facility failed to ensure Resident #295's code status was documented on admission or in a timely manner. These deficient practices could place residents at risk of not having their wishes known, which could affect whether they receive emergency medical treatment. The findings include: 1. Record review of Resident #294's electronic face sheet, dated 03/20/2025, revealed a [AGE] year old female who was admitted to the facility on [DATE]. Resident #294 had diagnoses which included; critical illness myopathy, respiratory failure, pneumonitis, severe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 3 of12 Residents (Resident #8, Resident #5, and Resident #35) reviewed for assessments. The facility failed to ensure the MDS reflected the use of bed rails for Resident #8, Resident #5 and Resident #35. This deficient practice could place residents at risk of not receiving care for identified care needs. Findings include: 1. Record review of Resident #8's electronic face sheet revealed a [AGE] year-old female who was re-admitted to the facility on [DATE], original admission date 09/16/24. Resident #8 had diagnoses which included respiratory failure, kidney failure and diabetes. Record review of Resident #8's Significant Change MDS, dated [DATE], revealed: BIMS of 15, which indicated no impaired cognition. Section P Restraints and Alarms revealed bed rails were not used. Record review of Resident #8's electronic Comprehensive Care plan, initiated on 12/26/24, revealed in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure DA A performed hand hygiene while preparing resident food trays. This failure could place residents at risk for contamination and food borne illnesses. Findings include: During an observation and interview on 03/18/2025 at 11:50 AM, revealed DA-A opened the refrigerator with her gloves on and took a container of lettuce out. She then used her gloved hands to take the lettuce out of the container and placed it on a resident's plate. DA-A opened the refrigerator door with the same gloved hands and placed the container back in the refrigerator and grabbed another container of chopped tomatoes and opened the container and removed the chopped tomatoes to put on the same resident plate without changing gloves or washing hands. DA-A opened the refrigerator with the same gloves on and removed a bag of lettuce. She then…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person -centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a residents medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 12 residents (Resident #5 and #26) reviewed for care plans. 1. The facility failed to ensure a care plan was developed to address Resident #5's use of bedrails. 2. The facility failed to ensure a care plan was developed to address Resident #26's ostomy care. These failures could place residents at risk for not receiving necessary care and services or having important care needs identified. Findings include: Resident #5 Record review of Resident #5's electronic face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included respiratory failure, heart failure and diabetes.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that residents with PRN orders for psychotropic drugs were limited to 14 days, except if the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days for 1 of 4 residents (Resident #37) reviewed for unnecessary medications. The facility failed to ensure Resident #37 did not have an order for alprazolam ([Xanax] a benzodiazepine medication) 1 mg by mouth every six hours as needed (PRN) for anxiety disorder beyond 14 days. , This failure could place residents at risk of adverse side effects from prolonged use of psychotropic medications. The findings include: Record review of Resident #37's face sheet, dated 03/20/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included infection of the blood (sepsis), generalized anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), opening in the windpipe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were that were complete and accurately documented for 1 of 12 (Resident # 6) residents reviewed for resident records. The facility failed to ensure Resident #6's physician orders contained orders for the care of Resident # 6's ostomy. This failure could place residents at risk of having errors in care and treatment. The Findings include: Record review of Resident #26's electronic face sheet, dated 03/19/2025, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] with a readmission on [DATE]. Resident #26 had diagnoses which included Chronic Obstructive Pulmonary Disease, congestive heart failure, Respiratory failure, Hight Blood Pressure, Type 2 diabetes. Record review of Resident #26's significant change MDS Assessment, dated 01/25/2025, revealed in Section C - cognitive patterns: Resident #26's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 4 (Resident #1, Resident #2, Resident #3, Resident #4) of 4 residents reviewed for infection control, in that: The facility failed to implement Enhanced Barrier Precautions for residents requiring ventilation via a tracheostomy tube (a surgically created hole with a tube inserted into the windpipe to provide an alternative airway for breathing) that resided on the vent unit. This failure could affect residents and place them at risk for cross contamination and infections. The findings included: Record review of Resident #1's electronic face sheet dated 12/31/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Acute and chronic respiratory failure with hypoxia (not enough oxygen in the blood). The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to evaluate and maintain an effective Quality Assurance and Performance Improvement program that focused on indicators of the outcomes of care and quality of life. The facility failed to have documentation and evidence of its QAPI plan being ongoing and comprehensive. The facility had not implemented Performance Improvement Projects to address resident quality of care concerns. This failure could place the residents at risk for a decreased quality of care and decreased quality of life within their living environment. The findings included: Review of the facility's 2023 Quality Assurance Performance Improvement Plan revealed it consisted of 2 pages and did not include an effective date for the plan. There was no documented evidence the plan had been reviewed for needed revisions after it was developed. The plan included information regarding the purpose of QAPI, vision and mission statements, guiding principles, the QAPI steering committee, and the scope of the QAPI teams. Review of the QAPI Program, revised February 2020,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure 12 hours of annual in-service training was provided to ensure continuing competency for 2 of 6 CNAs (CNA B and CNA C) whose records were reviewed for completion of in-service training, in that: 1. CNA B was hired for employment on 1/27/2023. She completed 8.5 hours of annual in-service training. 2. CNA C was hired for employment on 5/25/2021. She completed 8 hours of annual in-service training. These failures could place residents at risk for not receiving quality care and services to meet their physical and psychosocial needs within their living environment. The findings included: Review of CNA B's personnel file revealed she was hired for employment on 1/27/2023. Review of her in-service training records revealed she had completed 8.5 hours of annual training. Review of CNA C's personnel file revealed she was hired for employment on 5/25/2021. Review of her in-service training records revealed she had completed 8 hours of annual training. In an interview on 2/09/24 at 8:32 AM, the Staffing Coordinator stated she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of5esident (Resident #5) reviewed for infection control. CNA A failed to perform hand hygiene before and during incontinent care for Resident #5. This deficient practice placed residents at risk for cross contamination and/or acquiring an infection. Findings included: Review of Resident #5's Electronic Facesheet dated 02/08/24ncluded the following diagnoses: Chronic respiratory Failure (lungs inability to get enough oxygen into the blood or remove enough carbon dioxide from the body) Hypertension (high blood pressure) COPD (chronic obstructive pulmonary disease a group of lung diseases that block airflow and make it difficult to breathe) Dependance on respirator (inability to breath independently). Review of Resident #5's quarterly MDS dated [DATE] revealed Resident #5 was a [AGE] year-old female…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assure that all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the resident's needs safely and in a manner that promotes each resident rights, physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #1) reviewed for nursing practices. The facility failed to ensure LVN A had the competency to retrieve a physician order before performing an invasive examination. The noncompliance was identified as PNC. The noncompliance began 10/18/23 and ended on 10/27/23. The facility had corrected the noncompliance before the investigation began. This failure could place the residents at risk of physical and psychosocial harm. Findings included: Record review of Resident #1's health record revealed a [AGE] year-old female, admission date 08/09/2022, Diagnoses: other intestinal obstruction unspecified as to partial versus complete obstruction (digested material is prevented from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.