Health inspection·February 10, 2026

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers to meet the needs of each resident for 1 of 1 (Resident #1) that received Enteral Feedings.LVN A failed to administered Resident #1's Enteral feeding for two hours after his feeding bag of nutrition ran out on 12/22/25. This deficient practice placed Resident #1 at risk for dehydration and insufficient caloric intake.Findings Included:Record Review of Resident #1's Face Sheet dated 02/10/26 revealed a [AGE] year-old male, initially admitted to the facility on [DATE] with the latest return date of 11/08/25. Resident #1 had a primary diagnosis of Parkinson's Disease (progressive neurological disorder that primarily affects movement) and additional diagnosis of moderate protein-calorie Malnutrition (an imbalance between the nutrients your body needs and the nutrients it gets), dysphagia (swallowing disorder), aphasia (absence of speech) and quadriplegia (paralysis that affects all a person's limbs and body from the neck down). He received his nutrition by enteral feeding (a method of delivering nutrition directly into the gastrointestinal tract via a feeding tube).Record review of Resident #1's Quarterly MDS assessment, dated 11/12/25 revealed a BIMS score of 99 (unable to complete interview). The resident was positive for tube feedings. Record review of Resident #1 Care Plan, initiated on 12/23/22, revealed Resident #1 required tube feeding related to dysphagia. Record Review of Resident #1's Physician Orders dated 02/10/26 revealed the order: Enteral Feed, every shift, related to moderate protein-calorie malnutrition. Tube Feeding Continuous: Formula Jevity 1.5 at 70 cc/hr with H20 flush at 50 cc/hr, for 22 hours to allow for ADL care. Record Review of the Medication Administration Record for December dated 12/22/23 revealed Resident #1 Enteral feeding was given on the night shift 6:00 pm - 6:00 am, time was not specified. Resident #1 received a one-time bolus order on 12/22/23 at 9:30 pm for Jevity 1.5. Give 240 ml via PEG-Tube one time only due to extended period without feeding.In an interview with the DON on 2/10/26 at 9:15 am, she said she reported and investigated the incident. She said Resident #1 had an order for enteral continuous feeding for 22 hours in a 24-hour period. On 12/22/25 at approximately 2:30 pm, CNA B noted that Resident's #1 feeding pump was beeping. His assigned nurse, LVN A, was on break at that time, so she went and told RN C. RN C reported to LVN A when she came back from her break at 3:30 pm. LVN A said she did not know about it until 5:30 pm, at dinner time, when CNA D told her. LVN A told LVN E at shift change at 6:00 pm, his feeding pump needed to be changed, and he said he would take care of it. Resident #1 failed to receive his enteral feeding for approximately 2 hours. The Medical Director was notified of the incident, and he ordered a one-time bolus feeding. The resident was assessed with no injury, nor did he display any reported effects from the incident. In an Page 1 of 2 675128 675128 02/10/2026 Midwestern Healthcare Center 601 Midwestern Pkwy Wichita Falls, TX 76302

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some observation on 2/10/26 at 11:50 am, Resident #1 was sitting in the lobby area in a specialized wheelchair receiving enteral feeding. He was not interviewable. In an interview on 2/10/26 at 1:33 pm, the Medical Director said the facility contacted him regarding the incident, and he ordered a bolus one-time feeding. He said Resident #1 did not experience any negative outcomes and was not harmed.In an interview on 2/10/26 at 1:46 pm, Resident #1's Responsible Party said the facility contacted him concerning the incident. He said he came to the facility frequently and asked Resident #1 if he experienced any negative outcomes and Resident #1 shook his head no. In an interview on 2/10/26 at 2:30 pm, RN C said CNA B reported to her Resident #1's feeding pump was beeping. She said LVN A was on break at that time and told LVN A, at 3:30 pm, when she returned from her break, and LVN A acknowledged. In an interview on 2/10/26 at 2:40 pm, CNA D said she reported to LVN A, at dinner time at 5:30 pm, that Resident #1's feeding pump needed to be changed. She said LVN A acknowledged.In an interview on 2/10/26 at 2:54 pm, CNA B said she told RN C that Resident's #1's feeding pump was beeping while LVN A was on her break. She said RN C said she would tell LVN A when she returned. In an interview on 2/12/26 at 10:25 am, LVN A said she did not remember RN C telling her Resident #1's feeding pump was beeping. She stated during dinner time at 5:30 pm, CNA D reported to her Resident #1's feeding pump was beeping. While she was on her way to replace Resident #1's nutritional bag, another resident needed some assistance, and she did not get it done. At shift change at 6:00 pm, she told LVN E, and he said he would change it for Resident #1.In an interview on 2/10/26 at 3:30 pm, the DON said possible negative outcomes would be the resident would get dehydrated and not receive sufficient caloric intake. She expected physician orders to be followed. LVN E no longer works at the facility and was not available for interview. Record review of the facility';s policy Enteral Nutrition, dated as reviewed on 6/25/2025, revealed the following [in part]: Policy Statement: Adequate nutritional support through enteral nutrition is provided to residents as ordered.Policy Interpretation and Implementation:. 9. The nursing staff and provider monitor the resident for signs and symptoms of inadequate nutrition. 675128 Page 2 of 2