Cycle 1
Health 2025-03-20 · Fire 2025-03-20
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Wichita Falls, TX
Swan Health At Wichita Falls
3-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1101 Grace St, Wichita Falls, TX
(940) 322-3393
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
72
Certified beds
Average residents
37
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Swan Health
Operator or chain grouping
Approved since
1990-11-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
2 facilities
Chain averages 2 overall / 3 health / 1 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.85
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
2.07
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
5.21
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
2.92
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.66
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.69
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
2.09
Higher values indicate more complex resident acuity
RN turnover
100%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
100%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,494
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0
Baseline 7.46% · Performance 8.19% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.98
Performance 43.33% · Measure score 4.98 · Achievement 4.98 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.59 hours · Performance 2.87 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.05% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 18.6% · Lower 95% interval 7.32% |
| Discharge to community | 55.95% |
50.57%
5.4 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 43.24% · Lower 95% interval 40.17% |
| Medicare spending per beneficiary | 1.25 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 94.34% |
95.27%
0.9 pts worse
|
Numerator 50 · Denominator 53 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 53 |
| Discharge self-care score | 58.62% |
53.69%
4.9 pts better
|
Numerator 17 · Denominator 29 |
| Discharge mobility score | 51.72% |
50.94%
0.8 pts better
|
Numerator 15 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 53 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.19% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 17.24% · Lower 95% interval 4.32% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 50 |
| Staff flu vaccination coverage | 48% |
42%
6 pts better
|
Numerator 36 · Denominator 75 |
| Discharge function score | 58.62% |
56.45%
2.2 pts better
|
Numerator 17 · Denominator 29 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 24 · Denominator 24 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 3.3 · Expected 3.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.3 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
97.1%
2.2 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.4% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.3%
0.3 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.3% · Q3 2.9% · Q4 3.3% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.9% |
2.7%
7.2 pts worse
|
11.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 6.9% · Q3 3.8% · Q4 4.2% · 4Q avg 9.9% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
3.3%
1.9 pts worse
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 0.0% · Q3 3.6% · Q4 3.6% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 48.8% |
18.9%
29.9 pts worse
|
19.6%
29.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.4% · Q2 47.2% · Q3 54.8% · Q4 51.7% · 4Q avg 48.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.2% |
10.8%
1.4 pts worse
|
16.7%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 17.4% · Q3 20.0% · Q4 9.1% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 42.0% |
15.4%
26.6 pts worse
|
16.3%
25.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 42.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.4% |
16.1%
11.3 pts worse
|
14.9%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.7% · Q2 18.8% · Q3 21.4% · Q4 30.8% · 4Q avg 27.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.3% |
0.5%
3.8 pts worse
|
1.0%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 9.1% · Q3 5.0% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
0.8%
0.8 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 0.0% · Q4 3.4% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.7% |
15.0%
4.3 pts better
|
19.8%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 15.3% · Q3 3.9% · Q4 14.6% · 4Q avg 10.7% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
4.2%
1.2 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.2% · Q3 7.1% · Q4 3.6% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.5% |
89.7%
0.2 pts worse
|
81.7%
7.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.4% · Q2 97.6% · Q3 93.5% · Q4 79.5% · 4Q avg 89.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
12.0%
About the same
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 14.3% · Expected 13.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.5%
0.6 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 8.3% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.8% |
88.0%
6.2 pts worse
|
79.7%
2.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.5% |
25.9%
3.6 pts worse
|
23.9%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.5% · Observed 38.1% · Expected 30.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-09 · Fire 2024-02-09
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2022-12-09 · Fire 2022-12-09
16 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-10
C · Minimal harm
2025-03-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-10
C · Minimal harm
2024-02-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-14
C · Minimal harm
2022-12-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-04
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-20
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-03-30
E · Potential for more than minimal harm
2025-03-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-30
E · Potential for more than minimal harm
2025-03-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-03-20
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-20
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-30
E · Potential for more than minimal harm
2025-01-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-02-09
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-04-10
E · Potential for more than minimal harm
2024-02-09
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-03-09
D · Potential for more than minimal harm
2024-02-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-09
C · Minimal harm
2024-02-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-03-09
D · Potential for more than minimal harm
2023-11-04
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-10-27
E · Potential for more than minimal harm
2022-12-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-01-13
E · Potential for more than minimal harm
2022-12-09
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-12-09
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-01-31
E · Potential for more than minimal harm
2022-12-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-12-10
E · Potential for more than minimal harm
2022-12-09
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-12-30
E · Potential for more than minimal harm
2022-12-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-30
E · Potential for more than minimal harm
2022-12-09
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-01-31
E · Potential for more than minimal harm
2022-12-09
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-12-10
E · Potential for more than minimal harm
2022-12-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-31
E · Potential for more than minimal harm
2022-12-09
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-01-31
D · Potential for more than minimal harm
2022-12-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-12-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-31
D · Potential for more than minimal harm
2022-12-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-01-31
D · Potential for more than minimal harm
2022-12-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-12-10
B · Minimal harm
2022-12-09
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-01-31
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Midwestern Healthcare Center
Wichita Falls, TX
1-star overall rating with 1-star inspections with abuse icon flag with $45,975 in total fines with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Senior Care Health & Rehabilitation Center - Wichi
Wichita Falls, TX
4-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Texhoma Christian Care Center Inc
Wichita Falls, TX
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
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