Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Swan Health At Wichita Falls during CMS and state inspections, most recent first.
Two residents were admitted without proper documentation or inquiry regarding their advance directives or code status. One resident, who wished to be DNR, had no such order or documentation, while another resident, who wanted to be full code, was not asked about or documented for code status. Staff were unaware of the residents' code statuses, and the facility's policy requiring prompt inquiry and documentation of advance directives was not followed.
Three residents were observed using bed rails, but their MDS assessments did not document this use. In some cases, care plans and consents indicated bed rail use, while the MDS failed to reflect it. Facility leadership confirmed that an outside consultant completed the MDS remotely and acknowledged the omission.
A dietary aide failed to change gloves or wash hands between handling food items and touching refrigerator surfaces while preparing a resident's meal. The aide used the same gloves to handle multiple containers and food items, contrary to facility policy and food safety standards. The dietary manager and administrator confirmed that staff are expected to follow hand hygiene protocols, and the facility's policy requires glove changes and handwashing between tasks.
Two residents did not have comprehensive care plans addressing their specific needs, including bedrail use and ostomy care, despite documented medical conditions and direct observations. The care plans lacked measurable objectives and timeframes for these areas, and staff acknowledged the omissions were due to insufficient monitoring and a transition between electronic medical record systems.
A resident with multiple chronic conditions and moderate cognitive impairment had an ostomy, but the facility failed to include physician orders and care plan documentation for ostomy care, despite staff providing assistance. The DON attributed the deficiency to lack of monitoring and a transition between electronic medical record systems.
The facility failed to implement Enhanced Barrier Precautions for residents with tracheostomies, as staff did not use PPE during direct care, and there was no signage or care plans in place. Four residents with respiratory failure were affected, and staff interviews revealed a lack of awareness and implementation of these precautions, despite having the necessary supplies since August 2024.
Failure to Document and Honor Advance Directives and Code Status on Admission
Penalty
Summary
The facility failed to ensure that two residents' advance directives and code statuses were properly identified, documented, and honored upon admission. For one resident, there was no documentation of an Out-of-Hospital Do Not Resuscitate (OOH DNR) order on the electronic face sheet, care plan, or physician order report, despite the resident expressing a desire to be DNR. The resident was unaware if she had signed an advance directive recently, and staff interviews confirmed that her code status was not known or documented. For the second resident, there was also no documentation of code status on the electronic face sheet, care plan, or physician order report. The resident was unaware if he had signed any advance directive and did not recall being asked about it, but stated he wanted to be a full code. Staff interviews revealed that the LVN did not know the code status of either resident and was unsure how to locate this information. The ADON confirmed that new residents are considered full code until further orders are obtained and acknowledged that staff would have performed life-saving measures in the absence of a DNR order. The facility's policy requires inquiry and documentation of advance directives upon admission, but this was not followed for these residents.
Inaccurate MDS Documentation of Bed Rail Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the use of bed rails for three residents. For each of these residents, observations showed that bed rails were in use, but the corresponding MDS assessments indicated that bed rails were not used. In one case, a resident's care plan documented the use of half side rails as per physician order, and the resident was observed in bed with the rails up, yet the MDS did not reflect this. Another resident was observed with half side rails up, but neither the MDS nor the care plan documented the use of side rails. A third resident's care plan and signed bedrail consent indicated the use of partial rails, and the resident was observed with rails up, but the MDS again did not reflect this use. Interviews with facility leadership revealed that the MDS assessments were completed by an outside consultant who worked remotely and attended daily meetings by phone. Both the Director of Nursing and the Administrator acknowledged that the use of side rails should have been documented in the MDS assessments. The Administrator also stated that there was no MDS policy in place and that she did not have contact information for the MDS consultant. These findings were based on record reviews, resident observations, and staff interviews.
Failure to Follow Hand Hygiene and Glove Use During Food Preparation
Penalty
Summary
A deficiency was identified when a dietary aide (DA-A) failed to follow proper hand hygiene and glove use while preparing food trays for a resident. During observation, DA-A was seen opening the refrigerator with gloved hands, removing containers of lettuce and tomatoes, and placing these items on a resident's plate without changing gloves or washing hands between tasks. DA-A continued to handle multiple food items and surfaces, including a bag of lettuce and an onion, all with the same pair of gloves. When questioned, DA-A acknowledged that she should have changed gloves but did not provide a reason for her actions. Interviews with the dietary manager (DM) and the administrator (ADMN) confirmed that the facility's expectation and policy require staff to wash hands and change gloves between tasks, especially after touching surfaces other than food. The DM stated that all staff are trained and possess food handler certificates, and that she is responsible for monitoring compliance with hand hygiene policies. The facility's written policy and the FDA Food Code were also reviewed, both of which emphasize the importance of handwashing and single-use gloves to prevent cross-contamination during food preparation.
Failure to Develop and Implement Comprehensive Care Plans for Bedrail and Ostomy Care
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by policy and regulation. For one resident with respiratory failure, heart failure, and diabetes, the care plan did not address the use of bedrails, despite direct observation of the resident resting in bed with half side rails up. The resident's Minimum Data Set (MDS) assessment indicated moderate cognitive impairment, and the care plan contained no mention of side rail use, even though this was observed during the survey. For another resident with chronic obstructive pulmonary disease, congestive heart failure, respiratory failure, hypertension, and type 2 diabetes, the care plan did not address ostomy care, despite the resident having an ostomy as documented in the MDS assessment. The resident reported that staff assisted with ostomy care and expressed a preference for the ostomy bag to be emptied nightly before bedtime. There was no physician order for ostomy care prior to the survey, and the care plan lacked any reference to this need. The Director of Nursing acknowledged that these care needs should have been included in the care plans and attributed the failure to a lack of monitoring and a transition between electronic medical record systems.
Failure to Maintain Accurate Medical Records and Physician Orders for Ostomy Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident reviewed for resident records. Specifically, there were no physician orders for the care of a resident's ostomy, and the resident's care plan did not include ostomy care, despite documentation in the Minimum Data Set (MDS) assessment indicating the presence of an ostomy. The resident's electronic face sheet and MDS assessment confirmed her medical history, including chronic conditions such as COPD, congestive heart failure, respiratory failure, hypertension, and diabetes, as well as moderate cognitive impairment and the presence of an ostomy. Observation and interview confirmed that the resident had an ostomy bag and received assistance from staff with emptying and changing it. The resident expressed a preference for her ostomy bag to be emptied before bedtime, regardless of fullness, but noted this was not always done. The Director of Nursing (DON) acknowledged that orders for ostomy care should have been included in the resident's active orders and attributed the failure to a lack of monitoring and a transition between electronic medical record systems. Facility policy required review of the care plan for special needs related to colostomy/ileostomy care, which was not followed in this case.
Failure to Implement Enhanced Barrier Precautions for Residents with Tracheostomies
Penalty
Summary
The facility failed to establish and maintain an effective infection control program, specifically by not implementing Enhanced Barrier Precautions for residents with tracheostomies on the vent unit. Observations and interviews revealed that staff did not use personal protective equipment (PPE) such as gowns and gloves when providing direct care to these residents. There was no signage or indication of Enhanced Barrier Precautions being in place, and the residents themselves were unaware of such precautions. Four residents with tracheostomies were identified as being affected by this deficiency. These residents had diagnoses of acute and chronic respiratory failure with hypoxia or hypercapnia. Despite their conditions requiring careful infection control measures, the facility did not have care plans for Enhanced Barrier Precautions for these residents. Staff members, including CNAs and a respiratory therapist, confirmed the lack of PPE use and signage, and the Director of Nursing admitted that the facility had not implemented the necessary precautions despite having the supplies since August 2024. Interviews with staff, including a Licensed Vocational Nurse and the facility's Administrator, highlighted a lack of awareness and implementation of Enhanced Barrier Precautions. The Administrator was unaware that the precautions had not been put into practice, and the Director of Nursing acknowledged the absence of a policy for these precautions. This oversight placed residents at risk for cross-contamination and infections, as noted in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wichita Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Courtyard Gardens | 0.4 mi | — | 0 | 0 |
| Midwestern Healthcare Center | 2.1 mi | ★★★★★ | 19 | 0 |
| Senior Care Health & Rehabilitation Center - Wichi | 2.1 mi | ★★★★★ | 0 | 0 |
| Texhoma Christian Care Center Inc | 2.3 mi | ★★★★★ | 1 | 0 |
| Rolling Meadows | 3.1 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.