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 0558
Reasonably accommodate the needs and preferences of each resident.
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 ensure residents had the right to reside and
receive services in the facility with reasonable accommodation of resident needs and preferences except
when to do so would endanger the health or safety of the resident or other residents for 3 or 3 Residents
(Resident #18, Resident #94, and Resident #125) reviewed for accommodation of needs.
Residents Affected - Some
The facility failed to provide dining tables with the appropriate height to accommodate residents' needs and
preferences for Resident #18, Resident #94, and Resident #125.
This failure could place residents at risk of decreased nutritional intake and weight loss.
Findings include:
1. Record review of Resident #18's, undated, face sheet revealed an [AGE] year-old female who was
admitted to the facility on [DATE]. The resident had diagnoses which included senile degeneration of brain
(dementia - a group of symptoms that affects memory, thinking and interferes with daily life) and idiopathic
scoliosis (an abnormal curvature of the spine).
Record review of Resident #18's Quarterly MDS, dated [DATE], revealed a BIMS score of score of 1, which
indicated (severe impairment). Section G revealed Resident #18 required extensive assistance with
transfers and used a wheelchair for mobility .
2. Record review of Resident #94's, undated, face sheet, revealed a [AGE] year-old female who was
admitted to the facility on [DATE]. The resident had diagnoses which included unspecific dementia (a group
of symptoms that affects memory, thinking and interferes with daily life), repeated falls, dizziness and
giddiness, fracture of unspecified part of neck and right femur - right hip pinning (broken right hip).
Record review of Resident #94's Quarterly MDS, dated [DATE] revealed a BIMS score of score of 3, which
indicated (severe impairment). Section G revealed Resident #94 required total dependence with transfers
and used a wheelchair for mobility.
3. Record review of Resident #125's, undated, face sheet, revealed an [AGE] year-old female who was
admitted to the facility on [DATE]. The resident had diagnoses which included unspecified dementia (a
group of symptoms that affects memory, thinking and interferes with daily life), anterior dislocation of right
hip, osteoporosis of right hip (a skeletal disorder characterized by low bone mass leading to bone fragility
and increase in bone fracture), generalized muscle weakness, and abnormal posture.
(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 11
Event ID:
455965
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
455965
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Texhoma Christian Care Center Inc
300 Loop 11
Wichita Falls, TX 76306
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 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Record review of Resident #125's admission Assessment MDS, dated [DATE], revealed a BIMS score of
score of 2, which indicated (severe impairment). Section G revealed Resident #94 required extensive
assistance with transfers and used a wheelchair for mobility.
In an observation on the 800-hallway dining room, on 07/03/23 at 12:20 PM revealed, Resident #18 was
sitting at a table eating her lunch in a low wheelchair. The height of the table was to the resident's upper
chest. The resident's plate of food was sitting on the table which required the resident to reach up her arms
above her shoulders to get the food off her plate. The resident was eating unassisted. The resident was not
interviewable and failed to answer if the table was too high for her . Resident #94 was observed sitting at a
table eating her lunch in a low wheelchair. The height of the table was to the resident's neck. The resident's
plate of food sat in her lap. The resident was eating unassisted. The resident was not interviewable and
failed to answer if the table was too high for her.
In an observation in the 800-hallway dining room, on 07/06/23 at 11:47 AM revealed, Resident #18 was
sitting in a low wheelchair with the height of the table to the resident's chin. The resident's plate of food was
on the table, which required the resident to reach up to eat her food. The resident was not interviewable and
failed to state if the table was too high. At that time, a CNA came and raised up her wheelchair which
changed the height of the table to the resident's upper chest. The resident still had to lift her arms to eat her
food. The resident was eating unassisted. Resident #94 was observed sitting at a table eating her lunch in a
low wheelchair. The height of the table was to the resident's chin. The resident had her plate of food sitting
in her lap. The resident was eating unassisted. The resident was not interviewable and failed to answer if
the table was too high for her.
In an interview on 07/06/23 at 11:48 AM, LVN E said Resident #18's wheelchair could be raised up which
helped. Resident #94 always ate with her plate of food in her lap. She was unsure if the height of the tables
could be lowered.
In an observation and interview in the dining room in the north building, on 07/06/23 at 11:55 AM, Resident
#125 was observed sitting in a low wheelchair. The height of the table went up to her neck. The resident's
plate of food was sitting on the table, which required the resident to reach up to eat her food. The resident
was eating unassisted. The State Surveyor asked Resident #125 if the table was too high, she stated
probably .
In an interview on 07/06/23 at 1:37 PM, the DON said the tables were adjustable in the dining rooms. She
said it was her expectation that the tables would be placed at the appropriate height as not to be an
obstruction to the resident's ability to feed themselves. She said a possible negative outcome would be a
dignity issue as the resident's would not be able to feed themselves which could result in a possible decline
in functioning and health. A facility policy was requested but the DON stated there was no policy regarding
this situation .
A policy was requested but not provided by the time of exit. The Administrator said there was not a policy
that addressed table height of residents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455965
If continuation sheet
Page 2 of 11
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
455965
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Texhoma Christian Care Center Inc
300 Loop 11
Wichita Falls, TX 76306
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure a comprehensive care plan was developed within 7
days after completion of the comprehensive assessment prepared by an interdisciplinary team for 6 of 12
residents (Resident #30, Resident #47, Resident #84, Resident #90, Resident #110, and Resident #119)
reviewed for care plan timing and revision.
The facility failed to ensure Resident #30, Resident #47, Resident #84, Resident #90, Resident #110, and
Resident #119 had a comprehensive care plan developed and updated within 7 days following the
completion of the admission comprehensive assessment.
This failure could place residents at risk of not having their care plans completed, accurately and timely.
Findings include:
1. Record review of Resident #30's face sheet, dated 07/05/2023, revealed a [AGE] year-old female who
was admitted to the facility on [DATE]. Resident #30's primary diagnosis included senile degeneration of the
brain (a decline in cognitive abilities that impacts a person's ability to do everyday activities - dementia).
Record review of Resident #30's Annual MDS Assessment, dated 05/28/2023, revealed the resident had a
BIMS score which was blank, which indicated the resident was not able to complete the assessment.
Record review of Resident #30's care plans revealed the facility developed a care plan on 04/27/2023 and
conducted an IDT Care Conference on 04/27/2023. There was no documentation to show the facility
developed a care plan or conducted an IDT care conference within 7 days after the Annual MDS dated
[DATE].
2. Record review of Resident #47's face sheet, dated 07/06/2023, revealed an [AGE] year-old female who
was admitted to the facility on [DATE]. Resident #47's primary diagnosis included senile degeneration of the
brain (a decline in cognitive abilities that impacts a person's ability to do everyday activities - dementia).
Record review of Resident's #47's Annual MDS, dated [DATE], revealed the resident had a BIMS score of 3
which indicated severe impairment.
Record review of Resident #47's care plans revealed the facility developed a care plan on 02/15/2023 and
conducted an IDT Care Conference on 02/15/2023. There was no documentation to show the facility
developed a care plan or conducted an IDT care conference within 7 days after the Annual MDS, dated
[DATE].
3. Record review of Resident #84'sface sheet, dated 07/05/2023, revealed an [AGE] year-old female who
was admitted to the facility on [DATE]. Resident #84's primary diagnoses included unspecified dementia
(mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve
problems), psychoactive disturbance (changes in mood, awareness, thoughts, feelings and behaviors), and
anxiety (state of anxiousness).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455965
If continuation sheet
Page 3 of 11
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
455965
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Texhoma Christian Care Center Inc
300 Loop 11
Wichita Falls, TX 76306
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Record review of Resident's #84's Annual MDS, dated [DATE], revealed the resident had a BIMS score of
3, which indicated severe impairment.
Record review of Resident #84's care plans revealed the facility developed a care plan on 02/15/2023 and
conducted an IDT Care Conference on 02/23/2023. There was no documentation to show the facility
developed a care plan or conducted an IDT care conference within 7 days after the Annual MDS, dated
[DATE].
4. Record review of Resident #90's face sheet, dated 07/05/2023, revealed a [AGE] year-old male who was
admitted to the facility on [DATE]. Resident #90's primary diagnoses included Pneumonia (an inflammation
of the lungs) and seizure Disorder (a sudden uncontrolled burst of electrical activity in the brain).
Record review of Resident #90's Significant Change MDS Assessment, dated 05/01/2023, revealed the
resident had a BIMS score of 15, which indicated the resident was cognitively intact.
Record review of Resident #90's care plans revealed the facility developed a care plan on 05/16/2023 and
conducted an IDT Care Conference on 05/16/2023. There was no documentation to show the facility
developed a care plan or conducted an IDT care conference within 7 days after the Significant change
MDS, dated [DATE].
5. Record review of Resident #110's face sheet, dated 07/06/2023, revealed a [AGE] year-old female who
was admitted to the facility on [DATE]. Resident #110's primary diagnosis included senile degeneration of
the brain (a decline in cognitive abilities that impacts a person's ability to do everyday activities - dementia).
Record review of Resident's #110's Annual MDS, dated [DATE] revealed the resident had a BIMS score of
3, which indicated severe impairment.
Record review of Resident #110's care plans revealed the facility developed a care plan on 06/30/2023 and
conducted an IDT Care Conference on 06/08/2023. There was no documentation to show the facility
developed a care plan or conducted an IDT care conference within 7 days after the Annual MDS, dated
[DATE].
6. Record review of Resident #118's face sheet, dated 07/06/2023, revealed a [AGE] year-old female who
was admitted to the facility on [DATE]. Resident #118's had diagnoses which included vascular dementia
(problems with reasoning, planning, judgment, memory and other thought processes caused by brain
damage from impaired blood flow to your brain), psychotic disturbance (a condition of the mind that results
in difficulties determining what is real and what is not real), mood disturbance (a group of conditions of
mental and behavioral disorder where a disturbance in the person's mood is the main underlying feature),
and anxiety (an emotion which is characterized by an unpleasant state of inner turmoil and includes
feelings of dread over anticipated events).
Record review of Resident's #118's Significant Change in Condition MDS, dated [DATE], revealed the
resident had a BIMS score of 1, which indicated severe impairment.
Record review of Resident #118's care plans revealed the facility developed a care plan on 06/29/2023 and
conducted an IDT Care Conference on 06/29/2023. There was no documentation to show the facility
developed a care plan or conducted an IDT care conference within 7 days after the Significant
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455965
If continuation sheet
Page 4 of 11
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
455965
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Texhoma Christian Care Center Inc
300 Loop 11
Wichita Falls, TX 76306
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 0657
Change in Condition MDS, dated [DATE].
Level of Harm - Minimal harm
or potential for actual harm
In an interview on 07/05/2023 at 2:55 PM, the MDS Coordinator revealed the care plan schedule and care
plans did not go along with the MDS schedule. She said they always conducted the care plans before the
MDS was completed and she did not realize their policy stated to complete it after the comprehensive MDS
was completed. She said she could see how the failure would place the residents at risk of not having the
care plan reflect what the MDS assessment showed, which would result in an inadequate care plan.
Residents Affected - Some
Record review of the facility's care planning policy, dated 2001, and revised in December 2016, titled Care
Plans, Comprehensive Person- Centered revealed: The comprehensive, person-centered care plan is
developed within seven (7) days of the completion of the required comprehensive assessment (MDS).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455965
If continuation sheet
Page 5 of 11
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
455965
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Texhoma Christian Care Center Inc
300 Loop 11
Wichita Falls, TX 76306
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure residents who had not used psychotropic drugs
were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed
and documented in the clinical record for 1 of 5 residents (Resident #30) reviewed for unnecessary
psychotropic medications.
Resident #30 had an order and administered Depakote (an anticonvulsant medication) and Risperdal
(antipsychotic) for a diagnosis of unspecified psychosis not due to a substance or known physiological
condition, which was not an appropriate indication for use.
This failure could place residents at risk for adverse reactions and negative side effects from the
administration of medication that was not indicated for use to treat medical conditions and symptoms.
The findings include:
Record review of Resident #30's face sheet, dated 07/05/2023, revealed a [AGE] year-old female who's
most recent admission to the facility was 10/22/2020. The resident had a diagnosis which included
unspecified dementia with behavioral disturbance (a group of symptoms that affects memory, thinking and
interferes with daily life with behavioral and psychological symptoms such as agitation, anxiety, and
psychosis).
Record review of Resident #30's Physician Order Report, for 06/07/2023 to 07/06/2023, revealed an order
for Depakote (divalproex), 500 mg, twice a day, for unspecified psychosis not due to a substance or known
physiological condition, with a start date of 05/14/2023. Risperdal (risperidone) 1 mg at bedtime, for
unspecified psychosis not due to a substance or known physiological condition, with a start date of
05/14/2023 .
Record review of Resident #30's Care Plan, last reviewed/revised 06/02/2023, revealed a care plan for
Psychotropic Drug Use - Risk for adverse psychotropic side effects., Resident #30 was treated with an
antipsychotic.
Record review of Resident #30's Annual MDS, dated [DATE], revealed in Section C, a Brief Interview of
Mental Status was not conducted due to the resident was rarely/never understood., Section N revealed, the
resident received antipsychotic medications 7 of 7 days and antipsychotics were received on a routine
basis only.
In an interview on 07/06/2023 at 2:21 PM, the DON said her expectation was for nursing to communicate
with the doctor to ensure a medication had a correct diagnosis. She said possible negative outcomes would
be a resident would receive an unnecessary medication and experience side effects to the medication .
Record review of the website drugs.com, https://www.drugs.com/depakote.html, accessed on 07/07/2023,
revealed Depakote therapeutic class is an anticonvulsant that can be used as an adjunctive therapy to treat
manic episodes associated with bipolar disorder; and revealed,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455965
If continuation sheet
Page 6 of 11
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
455965
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Texhoma Christian Care Center Inc
300 Loop 11
Wichita Falls, TX 76306
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 0758
Level of Harm - Minimal harm
or potential for actual harm
https://www.drugs.com/risperdal.html, Risperdal therapeutic class is an antipsychotic used to treat
schizophrenia and bi-polar disorder.
Record review of the facility's policy titled Antipsychotic Medication Use, dated as revised December 2016,
revealed the following [in part]:
Residents Affected - Few
Policy Interpretation and Implementation:
1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for
which they are indicated and effective.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455965
If continuation sheet
Page 7 of 11
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
455965
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Texhoma Christian Care Center Inc
300 Loop 11
Wichita Falls, TX 76306
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
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 in one of one kitchen reviewed for
kitchen sanitation, where male staff with beards and mustaches (FSS. FSM, FSW A, FSW B and FSW C)
were not wearing beard restraints.
The facility failed to ensure staff (FSS, FSM and FSW A, FSW B and FSW C) wore appropriate hair
restraints while working in the kitchen.
This failure could place residents at risk of food borne illness, and contaminated food.
Findings include:
Observation on 07/03/2023 at 09:05 AM, in the main dining kitchen revealed, the FSS walked around inside
the kitchen without covering his beard and mustache. The FSS' whole face was covered by his beard and
the length was longer than a stubble (1/4 to ½ inch in length) and his mustache covered his upper lip
and blended into his beard.
Observation on 07/03/2023 at 09:05 AM, in the main dining kitchen, revealed FSW A prepared lunch and
did not wear a beard and mustache restraint. The length of FSW A's beard was between ¼ to
½ inch in length, and his mustache covered his upper lip.
Observation on 07/03/2023 at 09:13 AM, in the main dining kitchen, revealed the FSM worked in the
kitchen and did not wear a beard or mustache restraint.
Observation on 07/03/2023 at 09:20 AM, in the main dining kitchen, revealed FSW C worked in the kitchen
during meal preparation and did not wear a beard restraint to cover his beard.
Observation on 07/03/2023 at 11:58 AM, in the ancillary kitchen (used only to keep food hot while waiting
to serve residents, no cooking was done here) FSW B plated food for residents and did not have a restraint
or mask to cover his goatee/mustache.
Observation on 07/04/2023 at 09:30 AM, in the main dining kitchen Revealed FSW A wore beard restraint,
however it did not cover his mustache and left his upper lip exposed. FSW C's wore a beard restraint and
did not contain/cover his beard on the lower part of his neck.
In an interview on 07/03/2023 at 09:22 AM with FSW A, the FSW A said the facility allowed them to wear
short beards as long as it did not exceed a certain length which he did not identify.
In an interview with the ADM on 07/30/2023 at 2:33 PM, the ADM said all the training for the kitchen was
what he learned from his administrator courses, and he thought beard restraints were not required. The
ADM said he relied on the FSS for that information and the FSS told him beards were acceptable if, they
were no longer than one-half inch in length.
In an interview on 07/04/2023 at 09:30 AM, the FSS said he thought beards not exceeding ½ inch in
length were acceptable and did not need to be covered. The FSS said a negative resident outcome on
finding hair in the resident's food might be a loss of trust in the kitchen and a dislike of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455965
If continuation sheet
Page 8 of 11
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
455965
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Texhoma Christian Care Center Inc
300 Loop 11
Wichita Falls, TX 76306
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 0812
the food the hair was found in.
Level of Harm - Minimal harm
or potential for actual harm
In an interview on 07/05/2023 at 11:50 AM with the ADM, the ADM said his facility's policy would allow
male staff to have beards up to ½ inch in length without wearing a beard restraint but decided to
have his male staff cover their beards while he waited for the local health department to tell him their
expectations. He then admitted he found the regulation that applied to hair coverings and had the facility
policy revised on 07/05/2023.
Residents Affected - Many
Record review of the 2022 Food Code of the U.S. Food and Drug Administration, January 18, 2023, Version
revealed in part:
Section 2-402 Hair Restraints
2-402.11 Effectiveness.
(A)
Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair
coverings or nets, beard restraints, and clothing that covers body hair, that are designed to effectively keep
their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped
single-service and single-use articles.
Record review of a facility document titled Professional Appearance in the Workplace, from the Employee
Handbook, dated May 2022, revealed in part:
Facial Hair - all facial hair shall be groomed and not to exceed ½ inch in length without the use of a
beard guard when in any food service area throughout the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455965
If continuation sheet
Page 9 of 11
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
455965
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Texhoma Christian Care Center Inc
300 Loop 11
Wichita Falls, TX 76306
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
observations, interview and record review, the facility failed to establish and maintain an infection prevention
and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent
the development and transmission of communicable diseases and infections for 2 (Resident #55 and
Resident #28) of 2 residents (Residents #55 and #28) reviewed for infection control. techniques in that:
Residents Affected - Some
1. The facility failed to ensure the 400 hall Hospitality Aide washed or sanitized her hands in between
rooms.
2. The facility failed to ensure the 400 hall Hospitality Aide closed the ice chest lid in the hallway while
passing ice to Resident #55 and Resident #28 .
These failures could place residents at risk of infections.
The findings were:
1. Record review of Resident #55's face sheet, dated 07/05/2023, revealed she was an [AGE] year-old
female who was admitted to the facility on [DATE] with diagnoses which included Hypertension (high blood
pressure) and Obesity (excessive body weight).
Record review of Resident #55's Quarterly MDS assessment, dated 05/17/2023, revealed the following:
Section C revealed a staff assessment of the BIMS score of 14, which indicated (cognitively intact
cognition). Section G revealed the resident required set up help only with eating.
2. Record review of Resident #28's face sheet, dated 07/05/2023, revealed Resident #28 was an [AGE]
year-old female who was admitted to the facility on [DATE] with a diagnosis ofdiagnoses which included
Cerebrovascular Accident (stroke) and Bronchitis (inflammation of the mucous membrane in the bronchial
tubes).
Record review of Resident #28's Quarterly MDS admission assessment, dated 03/25/2023, revealed the
following: Section C revealed a staff assessment of the BIMS score of 9, which indicated (moderately
impaired cognition). Section G revealed the resident required set up help only with eating.
Observation and interview on 07/05/2023 at 3:30 PM revealed the Hospitality Aide passing passed ice and
water to Resident #55 and Resident #28. During this observation the Hospitality Aide was observed
bringing Resident #55's ice cup out into the hallway to an ice chest filling it with ice using an ice scoop and
pouring water into the cup from a water pitcher and taking taking it back into the residents' room leaving the
ice chest lid open in the hallway, then returning returned to the ice chest and proceeding proceeded to
Resident #28's room and retrieving retrieved her ice cup and filling filled it with ice and water. The
Hospitality Aide left the ice chest lid open and did not perform hand hygiene between residents after
touching the residents bedside table.
Interview on 07/05/23 at 3:40 PM the Hospitality Aide stated, When asked why she had not performed hand
hygiene in between resident's , she stated, she knew she was supposed to wash or sanitize her hands
between resident to resident care and she further stated and I'm supposed to close the ice chest lid when I
get ice from it , but I I didn't do it. She stated, and not washing my her hands in
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455965
If continuation sheet
Page 10 of 11
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
455965
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Texhoma Christian Care Center Inc
300 Loop 11
Wichita Falls, TX 76306
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
between residents could spread germs and disease .
Level of Harm - Minimal harm
or potential for actual harm
Interview on 07/05/2023 at 3:45 PM, the ADON revealed, all of the CNA's and Hospitality aides were
trained to perform hand hygiene before and after resident care.
Residents Affected - Some
Interview on 07/05/2023 at 3:55 PM, the DON revealed, hand hygiene is was to be performed before during
and after all resident care and not doing so would promote the spread of disease. The DON stated the
facility did not have a policy for passing ice, but all of the staff was were trained on hand hygiene .
Interview on 07/05/2023 at 4:15 PM, the Administrator stated, the facility did not have a particular policy on
passing ice, however, the Administrator I expected everyone staff to use best practice , which was to wash
or sanitize his or her hands before and after providing any type of resident care and not doing so could
cause the spread of disease. The facility did not provide surveyor a policy on hand hygiene.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455965
If continuation sheet
Page 11 of 11
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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.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the July 6, 2023 survey of TEXHOMA CHRISTIAN CARE CENTER INC?
This was a inspection survey of TEXHOMA CHRISTIAN CARE CENTER INC on July 6, 2023. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at TEXHOMA CHRISTIAN CARE CENTER INC on July 6, 2023?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.