Swan Health at Wichita Falls

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post daily nurse staffing information which included the total number and actual hours worked by licensed nurses and certified nurse aides directly responsible for resident care per shift for 1 of 1 day reviewed. 1. The facility posted a daily nurse staffing form that documented the day of the week, date, resident census, and the first names of the direct care staff licensed nurses and certified nurse aides and their assigned hall location for each of two shifts, 6 AM - 6 PM and 6 PM - 6 AM for 2/09/2024. 2. The daily nurse staffing form did not include the name of the facility and did not document the number of staff scheduled to work and the actual hours worked by the staff for each shift for 2/09/2024. [...]

Inspectors wroteBased 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.