Swan Health at Wichita Falls

In the surveyor’s words

From the most serious findings on record at Swan Health at Wichita Falls, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF865Feb 9, 2024

  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. […]

• No harm, potential for more than minimal, widespreadF947Oct 8, 2021

  Based on interview and record review, the facility failed to ensure the continuing competence of nurse aides by the provision of a minimum of 12 hours of required in-service training per year for 5 of 5 nurse aides (CNAs F, G, H, I, and J) whose annual training hours were reviewed. CNAs F, G, H, I, and J did not receive sufficient in-service training to meet the requirement of 12 hours annually. The facility's failure placed the residents at risk for not receiving care and services to meet their needs and a decline in health status. […]

• No harm, potential for more than minimal, patternF944May 7, 2026

  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… […]

• No harm, potential for more than minimal, patternF578Mar 20, 2025

  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. […]

• No harm, potential for more than minimal, patternF641Mar 20, 2025

  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 readmitted to the facility on [DATE], original admitted [DATE]. Resident #8 had diagnoses which included respiratory failure, kidney failure and diabetes. […]