Inspection visit
Inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0732
Post nurse staffing information every day.
Level of Harm - Potential for
minimal harm
Based 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.
Residents Affected - Many
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.
These failures could place the residents and visitors to the facility at risk for not knowing the daily staffing
pattern and the number of staff scheduled to provide direct care to the residents to meet their needs.
The findings included:
Observation on 2/06/24 at 8:55 AM revealed a daily nurse staffing form was taped to the window of the
front office reception area, where the Staffing Coordinator worked at a desk.
Record review on 2/09/24 at 11:31 AM revealed the daily nurse staffing form revealed it was for Friday,
2/09/2024. It documented the current resident census was 32. The form did not include the name of the
facility. The form documented the first names of the licensed nurses and CNAs and their assigned locations
for each of two shifts, 6 AM - 6 PM and 6 PM - 6 AM. The form documented the first names of the DON and
ADON as being on duty for the 6 AM - 6 PM shift. The names of 2 LVNs charge nurses and 2 CNAs and the
CNA Business Office Manager and DON were listed as direct care staff for the 6 AM - 6 PM day shift. The
name of the CNA who had left had not been marked off or noted as having left early. The form documented
the names of the 2 LVN charge nurses and 2 CNAs scheduled to work on the 6 PM - 6 AM night shift. The
form did not include columns to document the number of staff scheduled or actual staff hours worked for
each shift.
In an interview on 2/07/24 at 10:02 AM, the Staffing Coordinator stated the nursing staff worked 12 hour
shifts from 6-6. She stated the usual staffing pattern for the Day shift, 6 AM - 6 PM, was 2 charge nurses
and 3 CNAs. She stated the usual staffing pattern for the Night shift, 6 PM - 6 AM, was 2 charge nurses
and 2 CNAs. She stated sometimes a nurse would work as an aide on the night shift.
In an interview on 2/09/24 at 8:32 AM, the Staffing Coordinator stated she was also a CNA. She
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
455901
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455901
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/09/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Swan Health at Wichita Falls
1101 Grace St
Wichita Falls, TX 76301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0732
stated she was not scheduled to work the floor as a direct care staff.
Level of Harm - Potential for
minimal harm
In an interview on 2/09/24 at 9:54 AM, the Business Office Manager stated she was also a CNA and was
working the floor today to help out. She stated she came in at 7:00 AM. She stated she was not sure if
someone called in or was a no call - no show. She stated she would not be staying to work until 6:00 PM
this evening.
Residents Affected - Many
In an interview on 2/09/24 at 11:33 AM, the LVN charge nurse assigned to the North Hall stated there were
currently 2 LVN charge nurses on duty and 2 CNAs. She stated the Business Office Manager was a CNA
and was working the floor. The LVN stated one of the CNAs who was scheduled to work had just left 30
minutes ago due to having a sick child. The LVN charge nurse stated the DON was working the floor with
the CNA Business Office Manager on the North Hall. She stated one CNA was working on the South Hall.
The LVN stated no staff numbers or staff hours worked were ever documented on the daily nurse staffing
form, just the names of the staff and their assigned location for each shift.
In an interview on 2/09/24 at 11:39 AM, the DON stated she did not usually work the floor as an aide but
had a staff member who had to leave due to a family emergency with a sick child at day care. She stated
one CNA had a medical appointment and was not able to work as scheduled. The DON stated the Staffing
Coordinator totaled the staff hours worked and wrote them on the staffing sheets.
In an interview on 2/09/24 at 2:07 PM, the Staffing Coordinator stated she had been using the same daily
nurse staffing form for the past 8 years. She stated she took the form the next morning and totaled the
hours on the paper and put the hours in the computer. The Staffing Coordinator state she had never listed
the staff numbers for scheduled nurses and certified nurse aides and the actual hours worked for each shift
on the posted daily nurse staffing form.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455901
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455901
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/09/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Swan Health at Wichita Falls
1101 Grace St
Wichita Falls, TX 76301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0865
Have a plan that describes the process for conducting QAPI and QAA activities.
Level of Harm - Minimal harm
or potential for actual harm
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.
Residents Affected - Many
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, printed from an internet website and provided by the
Administrator for review, revealed the program was a generic plan. It had not been modified or revised to be
specific to the facility.
In an interview on 2/09/24 at 3:28 PM, the DON stated she participated in the facility's QAPI committee
meetings every month. She stated no PIPs had been developed to address resident quality of care
concerns during the past year.
In an interview on 2/09/24 at 3:32 PM, the Administrator stated she had developed the facility's QAPI
program plan in March 2022 when she began employment in the facility. She stated QAPI meetings were
held monthly and were attended by the required committee members. The Administrator stated the QAPI
committee had not developed any PIPs during the past year as no needs were identified.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455901
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455901
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/09/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Swan Health at Wichita Falls
1101 Grace St
Wichita Falls, TX 76301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**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.
Residents Affected - Few
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
originally admitted to the facility on [DATE]. Her BIMS score was 15 out of 15 revealing the resident was
cognitively intact. Her skills for daily decision making were intact. Resident #5 required extensive assistance
with the support of staff for toileting. Resident #5 had an indwelling catheter and was frequently incontinent
of bowel.
Review of Resident #5's Care Plan dated 01/23/24 for Care Area ADL's revealed the following
interventions: clean peri-area with each incontinence episode, check as required for incontinence. wash,
rinse, and dry perineum change clothing PRN after incontinence episodes, monitor/document for signs and
symptoms urinary tract infection including pain, burning, blood-tinged urine, cloudiness, no output,
deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever,
chills, altered mental status, change in behavior, change in eating patterns.
During an observation on 2/8/24 at 11:05 am CNA A provided incontinent/catheter care to Resident #5.
CNA A entered the room pushing resident in wheelchair and donned gloves without performing hand
hygiene. CNA A assisted resident to standing position, then removed her pants and soiled brief. CNA A
then changed gloves without sanitizing between glove change. CNA A then assisted Resident #5 by
checking catheter bag for urine leakage and found leaking urine. CNA A changed gloves without sanitizing
between glove change. CNA A assisted Resident #5 with clean brief and bottoms all without performing any
hand hygiene.
During an interview on 2/8/24 at 11:20am, CNA A stated that she did a lot of things wrong. She also stated
that she did not have access to hand sanitizer for use when providing incontinent care for any residents.
CNA A said the negative effects on residents caused by not performing hand hygiene could be lots of stuff.
During an interview on 2/8/24 at 11:45am, DON stated her expectation was proper hand hygiene, gloves,
wipe front to back and follow policy. DON stated staff should use gel sanitizer or wash hands between
changing gloves. DON stated not following proper hand hygiene could result in increased urinary
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455901
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455901
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/09/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Swan Health at Wichita Falls
1101 Grace St
Wichita Falls, TX 76301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
tract infections.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 2/9/24 at 10:31 am, Administrator stated her expectations for staff and proper hand
hygiene would be to follow their facility training; stating infection control is my main priority. Administrator
stated that the last in-service for CNA A was on 2/7/24 . Administrator stated that the ADON provided
supervision and instruction to CNAs as well as monitored their return demonstrations, she also stated that
CNAs to have access to their own hand sanitizers to use while providing incontinent care. Administrator
stated that lack of proper hand hygiene would spread infections and was not their goal of care.
Administrator also stated that CNA A was probably nervous.
Residents Affected - Few
Review of a policy titled Standard Precautions; revised December 2007 revealed the following elements [in
part]:
Standard precautions will be used in the care of all residents. 1. Hand Hygiene: A. Hand hygiene refers to
handwashing with soap (anti-microbial or non-antimicrobial) OR using alcohol-based hand rubs (gels,
foams, rinses) that do not require access to water . C. In the absence of visible soiling of hands,
alcohol-based hand rubs are preferred for hand hygiene. D. Wash hands after removing gloves. 2. Gloves:
A. Wear gloves (clean, non-sterile) when you anticipate direct contact with blood, body fluids, mucous
membranes, non-intact skin, and other potentially infected material. E. Change gloves, as necessary, during
the care of a resident to prevent cross-contamination from one body site to another (when moving from a
dirty site to a clean one. F. Do not reuse gloves. G Remove gloves promptly after use, before touching
non-contaminated items and environmental surfaces, and before going to another resident and wash hands
immediately to avoid transfer of microorganisms to other residents or environments.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455901
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455901
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/09/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Swan Health at Wichita Falls
1101 Grace St
Wichita Falls, TX 76301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0947
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in
dementia care and abuse prevention.
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 was also a CNA. She stated the
DON did annual NA Proficiency Evaluations and kept them in a binder in her office.
In an interview on 2/09/24 at 11:39 AM, the DON stated she did NA proficiency evaluations on hire and
annually. She stated all of the currently employed CNAs were certified and no nurse aides waiting to test.
In an interview on 2/09/24 at 4:04 PM, the DON stated she had some printed certificates of completion
from computer-based training courses that were 2 hours each, which she kept in staff file folders in her
office. She stated the HR Manager maintained records for other computer-based training completed by the
staff. The DON stated she did not have a system for documenting individual employee annual in-service
training hours to monitor attendance and completion. She stated she did not use a form to record each
individual's training hours, the topic, or the date of attendance or completion of the training.
Review of the facility's policy for In-Service Training Program - Nurse Aide, dated as revised May 2019,
revealed the following [in part]:
Policy Statement
All nurse aide personnel participate in regularly scheduled in-service training classes.
Policy Interpretation and Implementation
1. All personnel are required to attend regularly scheduled in-service training classes.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455901
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455901
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/09/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Swan Health at Wichita Falls
1101 Grace St
Wichita Falls, TX 76301
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0947
2. The facility completes a performance review of nurse aides at least every 12 months.
Level of Harm - Minimal harm
or potential for actual harm
3. In-service training is based on the outcome of the annual performance reviews, addressing weaknesses
identified in the reviews.
Residents Affected - Some
4. Annual in-services:
a. Ensure the continuing competence of nurse aides;
b. Are no less than 12 hours per employment year;
c. Address areas of weakness as determined by nurse aide performance reviews .
8. All training classes attended by the employee are entered on the respective employee's Record of
In-service by the department supervisor or other person(s) as designated by the supervisor.
9. Records are filed in the employee's personnel file or are maintained by the department supervisor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455901
If continuation sheet
Page 7 of 7
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F865 - Quality assurance and performance improvement (QAPI) program
Have a plan that describes the process for conducting QAPI and QAA activities.
F947 - Training Requirements
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0521GeneralS&S Cno actual harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
FAQ · About this visit
Common questions about this visit
What happened during the February 9, 2024 survey of SWAN HEALTH AT WICHITA FALLS?
This was a inspection survey of SWAN HEALTH AT WICHITA FALLS on February 9, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SWAN HEALTH AT WICHITA FALLS on February 9, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Post nurse staffing information every day."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.