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 the right to reside and receive services
in the facility with reasonable accommodation of resident needs and preferences for two (Resident #2 and
Resident #3) of six residents review for resident rights. The facility failed to keep Resident #2's bell within
reach to call for assistance. The facility failed to provide an alternative way for Resident #3 to call for staff
assistance. These failures place residents at risk of not getting their needs met timely.Findings
included:Review of Resident #2's face sheet printed 01/29/2026 reflected a [AGE] year-old female who was
admitted on [DATE] with remission date of 12/15/2022 with the following dx: Osteoarthritis to the right
shoulder (a degenerative condition where cartilage wears down, causing pain, stiffness, grinding (crepitus),
and reduced range of motion, often affecting sleep), Osteoarthritis of the knee, Chronic Obstructive
Pulmonary Disease (a progressive, incurable lung disease-primarily caused by smoking-that causes airflow
obstruction, making it difficult to breathe.), Muscle weakness, pain specific joints, history of falling. Review
of Resident#2's admission MDS assessment dated [DATE] reflected a BIMS score 15, indicating no
cognitive impairment. Section GG functional Abilities reflected 3 for Chair/bed-to-chair transfer: The ability
to transfer to and from a bed to a chair (or wheelchair) which indicated Resident #2 required
Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports
trunks or limbs, but provides less than half the effort. Toilet transfer 1- The ability to get on and off a toilet or
commode. Dependent - Helper does ALL of the effort. Residents do none of the effort to complete the
activity. Or the assistance of 2 or more helpers is required for the residents to complete the activity. Review
of Resident #2's care plan initiated 03/24/2025 reflected Resident #2 had pain r/t impaired mobility,
neuropathy (nerve damage or dysfunction that causes symptoms like numbness, tingling, pain, muscle
weakness, and loss of coordination, and can also affect body functions like digestion and blood pressure.),
right shoulder pain, joint pain, had an actual fall with Poor Balance, Unsteady gait, impaired physical
functioning r/t debility, cognitive impairment. Review of Resident #3's face sheet printed 01/29/2026
reflected a [AGE] year-old female who was admitted on [DATE] with readmission date of 12/06/2023 with
the following dx: Repeated falls, Muscle weakness, lack of coordination, other abnormality of the gait and
mobility, need for assistance with personal care. Review of Resident#3's admission MDS assessment dated
[DATE] reflected a BIMS score 10, indicating moderate cognitive impairment. Review of Resident #3 's care
plan initiated 10/27/2024 reflected Resident #3 had impaired cognitive function/dementia or impaired
thought processes r/t Dementia, Difficulty making decisions, impaired decision making, psychotropic drug
use, impaired physical functioning r/t debility, cognitive impairment. Observation on 01/29/2026 at about
09:40 am with the Maintenance Director, in Resident #2 and Resident #3's room revealed their call light
system was not functioning, and the entire box was out of the wall. It was observed Resident #2's call
button was placed on the bed within reach even though it was non-functioning and
Residents Affected - Some
(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 9
Event ID:
455638
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
455638
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/29/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Greenview Nursing and Rehabilitation
401 Owen LN
Waco, TX 76710
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
a bell on top of Resident #2's nightstand was out of reach. Observation also revealed Resident #3's call
light was placed within reach even though it was non-functioning. There was no visible bell for Resident
#3.During an interview on 01/29/2026 at 09:43 am the Maintenance Director stated the call system in
Resident #2 and Resident #3's room broke sometimes last week and he had ordered a replacement part.
The Maintenance Director stated he gave both residents bells to use until the call system was replaced.
The Maintenance Director stated he verbally told staff of the broken call system. The Maintenance Director
stated the nursing staff put in maintenance requests in the facility's TELS system (Streamlines
maintenance, housekeeping, and repairs, allowing staff to track, manage, and complete tasks efficiently.).
The Maintenance Director stated he checked the TELS system daily in addition to his daily routines. The
Maintenance Director stated he tried to address concerns within a day or at most 72 hours based on the
priority of the concern.During an interview on 01/29/2026 at 09:47 am Resident #2 stated her call system
had been broken for about 6 months. Resident #2 stated she was not able to reach the bell on the
nightstand. Resident #2 stated whenever she needed help, she would go to the restroom and use the call
button in the restroom. Resident #2 stated she was not able to use the toilet in the restroom, she only goes
to the toilet to use the call button to call for help.During an interview on 01/29/2026 at 09:51 am Resident
#3 stated she did have a bell to call for help as needed. Resident #3 stated she sometimes yells to call for
help.During an interview on 01/29/2026 at 1:05 pm the DON stated she was aware of the call system
problem in Resident #2 and Resident #3's room. The DON stated she was not sure of how long the call
system in their room had been broken but the Maintenance Director was working on it. The DON stated the
Maintenance Director had given Resident #2 a bell to call for help. The DON stated the bell was supposed
to be positioned within Resident #2's reach, where she could be able to use it, and if she was not able to
reach the bell, it was a safety issue.During an interview on 01/29/2026 at 1:49 pm the Administrator stated
he was aware Resident #2, and Resident #3‘s room call system was broken and they were given a bell. The
Administrator stated the call system had been broken for a couple of months, maybe 2 months. The
Administrator stated he expected the staff to make frequent rounds to Resident #2 and Resident #3's room
and place the bell within Resident's reach as if it was the call light, and if not there was a problem. The
Administrator stated any damage to the facility should be fixed immediately.Review of facility's TELS
documentation reflected:Order # 2891-- Call light malfunctioning. Unscrewed and unplugged from
wall-undated -medium priority-room [Resident #2 and Resident #3's room number]Order # 3053- Call light
completely broken out of wall, separated from wiring-dated 12/12/2025-medium priority-room [Resident #2
and Resident #3's room number]. Review of facility's invoice completed by the Maintenance Director dated
11/18/2025 reflected: Patient Station, Bedside: 0.25 Dual 2-Jack 2-Gang Replacement Patient Station
Review of facility's policy titled Accommodation of Needs revised 06/06/2025 reflected: Policy:The facility
will treat each resident with respect and dignity and will evaluate and make reasonable accommodation for
the individual needs and preferences of a resident, except when the health and safety of the individual or
other resident would be endangered.Policy Explanation and Compliance Guidelines:1. The facility will make
reasonable accommodations to individualize the resident's physical environment including their personal
bathroom and bedroom and the common living areas within the facility.2.The facility will ensure that
common areas frequented by residents are accommodating physical limitations and enhance their abilities
to maintain independence.3.Facility staff shall make efforts to reasonably accommodate the needs and
preference of the resident as they make use of their physical environment.4.Based on individual needs and
preferences, the facility will assist the resident in maintaining and/or achieving independent functioning,
dignity, and wellbeing to the extent
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455638
If continuation sheet
Page 2 of 9
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
455638
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/29/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Greenview Nursing and Rehabilitation
401 Owen LN
Waco, TX 76710
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
possible. Review of facility's policy titled Resident Rights dated 2018 reflected: Policy statement:Employees
shall treat all residents with kindness, respect, and dignity.Policy Interpretation and ImplementationI.
Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the
residents' right to:a. a dignified existence.b. be treated with respect, kindness, and dignity.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455638
If continuation sheet
Page 3 of 9
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
455638
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/29/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Greenview Nursing and Rehabilitation
401 Owen LN
Waco, TX 76710
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and records review the facility failed to develop and implement a person-centered
comprehensive care plan for each resident consistent with resident rights set forth that include measurable
objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that
are identified in the comprehensive assessment. for one (Resident #1) of six residents reviewed for care
plan. The Facility failed to include in Resident #1's care plan that she needed 2-person physical assist with
transfer via mechanical lift.The facility failed to have an order for Resident #1 to be transferred via
mechanical lift. This deficient practice placed Residents at risk for not getting the right interventions, risk for
harm and hospitalization. Findings included:Review of Resident #1's face sheet printed 01/29/2026
reflected a [AGE] year-old female who was admitted on [DATE] with the following dx: Chronic Obstructive
Pulmonary Disease (a progressive, incurable lung disease-primarily caused by smoking-that causes airflow
obstruction, making it difficult to breathe.), Muscle weakness, pain unspecified, Type 2 Diabetes Mellitus
with unspecific complications (is a chronic metabolic condition where the body resists insulin or fails to
produce enough, causing high blood sugar.), cerebral infarction (a critical medical condition where
restricted blood flow causes tissue death (necrosis) in the brain.). Review of Resident #1's admission MDS
assessment dated [DATE] reflected a BIMS score 11, indicating moderate cognitive impairment. Section
GG functional Abilities reflected 1 for Chair/bed-to-chair transfer: The ability to transfer to and from a bed to
a chair (or wheelchair) which indicated Resident #1 was Dependent - Helper does ALL of the effort.
Residents do none of the effort to complete the activity. Or the assistance of 2 or more helpers is required
for the resident to complete the activity. Review of Resident #1's care plan initiated 10/25/2025 reflected
Resident #1 was at risk for pressure injury r/t (specify)decreased bed mobility/transfers, incontinence, poor
nutrition, hx of skin breakdown, fragile skin, Braden risk score [a tool used by healthcare professionals to
assess a patient's risk of developing pressure ulcers (bedsores), with lower scores indicating higher risk
and scores ranging from 6 (highest risk) to 23 (no risk)], sensory perception). Resident #1's care plan did
not address ADLs and means of transfers. Review of Resident #1's mode of transfer printed on 01/29/2026
from the CNA Kardex (is a centralized, frequently updated, and easy-to-reference paper or electronic
system that provides a concise summary of essential patient information, including daily care plans,
medication, and, allergies) reflected: GG-CHAIR/BED-TO-CHAIR TRANSFER: The ability to transfer to and
from a bed to a chair (or wheelchair) 2 person.Review of Resident #1's physician orders reflected no order
for mechanical lift transfer.During an interview on 01/29/2026 at 1:05 pm the DON stated if a resident
required a mechanical lift transfer, there would be a physician order. The DON also stated the staff would
know a resident required a mechanical lift transfer from daily shift change report. The DON stated the CNAs
would know a resident required a mechanical lift transfer from the Kardex. The DON stated there was safety
issue if there was no order for mechanical lift transfer and the Resident was not care planned for
mechanical lift transfer. The DON stated she initiated an in-service on mechanical transfers. During an
interview on 01/29/2026 at 2:27 pm the MDS nurse stated she was responsible for completing care plans.
The MDS Nurse stated Resident #1's mechanical lift transfer was supposed to be care planned and she
must have overlooked it. The MDS Nurse stated the CNAs always look in the Kardex to provide care for
Residents and Resident #1's mode of transfer was in Kardex. The MDS Nurse stated she just updated
Resident #1's care plan when it was brought to her attention by the DON. The MDS Nurse stated every
care area of a Resident was supposed to be care planned. The MDS Nurse stated it was noted in
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455638
If continuation sheet
Page 4 of 9
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
455638
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/29/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Greenview Nursing and Rehabilitation
401 Owen LN
Waco, TX 76710
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Resident #1's MDS that she was dependent on staff for transfers. Review of facility's policy titled
Comprehensive Care plan revised 05/05/2025 reflected: Policy:It is the policy of this facility to develop and
implement a comprehensive person-centered care plan for each resident, consistent with resident rights,
that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and
psychosocial needs and services that are identified in the resident's comprehensive assessment and meet
professional standards of quality.Definitions:Person-centered care means to focus on the resident as the
locus of control and support the resident in making their own choices and having control over their daily
lives.Professional standards of quality means that care and all services are provided according to accepted
standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a
specific clinical situation or setting. Policy Explanation and Compliance Guidelines:The care planning
process will include an assessment of the resident's strengths and needs and will incorporate the resident's
personal and cultural preferences in developing goals of care. All services provided or arranged by the
facility, as outlined by the comprehensive care plan, must meet professional standards of quality, and
incorporate culturally competent and trauma-informed care as indicated.2. The comprehensive care plan
will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care
Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other
factors identified by the interdisciplinary team, or in accordance with the residents' preferences, will also be
addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will
be evidenced in the clinical record.3. The comprehensive care plan will describe, at a minimum, the
following:a. The services that are to be furnished to attain or maintain the resident's highest
practicablephysical, mental, and psychosocial well-being.b. Any services that would otherwise be furnished,
but are not provided due to the resident 'sexercise or his or her right to refuse treatment5. The
comprehensive care plan will be reviewed and revised by the interdisciplinary team after each
comprehensive, quarterly MDS assessment and when a resident experiences a status change.6. The
comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs
as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the
resident's progress. Alternative interventions will be documented, as needed.
Event ID:
Facility ID:
455638
If continuation sheet
Page 5 of 9
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
455638
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/29/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Greenview Nursing and Rehabilitation
401 Owen LN
Waco, TX 76710
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interviews, and record review, the facility failed to ensure each resident receives adequate
supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for
mechanical lift transfer. The facility failed to ensure Resident #1 was transferred safely when CNA A
transferred her by mechanical lift by herself on 01/29/2026. This failure placed residents at risk of
injury.Review of Resident #1's face sheet printed 01/29/2026 reflected a [AGE] year-old female who was
admitted on [DATE] with the following dx: Chronic Obstructive Pulmonary Disease (a progressive, incurable
lung disease-primarily caused by smoking-that causes airflow obstruction, making it difficult to breathe.),
Muscle weakness, pain unspecified, Type 2 Diabetes Mellitus with unspecific complications (is a chronic
metabolic condition where the body resists insulin or fails to produce enough, causing high blood sugar.),
cerebral infarction (a critical medical condition where restricted blood flow causes tissue death (necrosis) in
the brain.). Review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score 11,
indicating moderate cognitive impairment. Section GG - functional Abilities and goal reflected 1 for
Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) which
indicated Resident #1 was Dependent - Helper does ALL of the effort. Residents do none of the effort to
complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the
activity. Review of Resident #1's care plan initiated 10/25/2025 reflected Resident #1 was at risk for
pressure injury r/t (specify) decreased bed mobility/transfers, incontinence, poor nutrition, hx of skin
breakdown, fragile skin, braden risk score [a tool used by healthcare professionals to assess a patient's risk
of developing pressure ulcers (bedsores), with lower scores indicating higher risk and scores ranging from
6 (highest risk) to 23 (no risk)], sensory perception). Resident #1's care plan did not address ADLs and
means of transfers. Review of Resident #1's mode of transfer printed on 01/29/2026 from the CNA Kardex
((is a centralized, frequently updated, and easy-to-reference paper or electronic system that provides a
concise summary of essential patient information, including daily care plans, medication, and, allergies)
reflected: GG-CHAIR/BED-TO-CHAIR TRANSFER: The ability to transfer to and from a bed to a chair (or
wheelchair) 2 person.During an observation on 01/29/2026 at about 10:10 am, CNA A was observed
transferring Resident #1 all by herself without another staff present from Resident#1's bed to the chair via
mechanical lift. The DON then walked to the scene and stated 2 people were needed for mechanical
transfers.During an interview on 1/29/2026 at 10:12 am CNA A stated she had been trained on mechanical
transfers and 2 people were required for mechanical transfers. CNA A stated 2 people were needed for the
safety of the residents and staff. CNA A stated Resident #1 was her family member, and Resident #1 kept
telling her (CNA) to get her (Resident #1) up quickly. CNA A stated the other CNA on the hall was busy and
she did not have anyone else to help her that is why she transferred Resident #1 via mechanical lift all by
herself. During an interview on 01/29/2026 at 1:05 pm the DON stated 2 people needed to transfer a
resident via mechanical lift, and this was done for safety, spotting, and making sure the transfer was done
safely. The DON also stated the staff would know a resident required a mechanical lift transfer from daily
shift change report. The DON stated the CNAs would know a resident required a mechanical lift transfer
from the Kardex. The DON stated she initiated an in-service on mechanical transfers. During an interview
on 01/29/2026 at 2:27 pm the MDS nurse stated she was responsible for completing care plans. The MDS
Nurse stated Resident #1's mechanical lift transfer was supposed to be care planned and she must have
overlooked it. The MDS Nurse stated the CNAs always look in the Kardex to provide care for Residents and
Resident #1's
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455638
If continuation sheet
Page 6 of 9
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
455638
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/29/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Greenview Nursing and Rehabilitation
401 Owen LN
Waco, TX 76710
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
mode of transfer was in Kardex. The MDS Nurse stated she just updated Resident #1's care plan when it
was brought to her attention by the DON. The MDS Nurse stated every care area of a Resident was
supposed to be care planned. The MDS Nurse stated it was noted in Resident #1's MDS that she was
dependent for transfers. Review of facility's in-services reflected the following:Safe lifting and movement to
Residents and Lifting Machine /Mechanical lift dated 05/07/2025-CNA A signedReview of facility's policy
titled Lifting Machine, using a Mechanical dated 2018 reflected: Purpose -The purpose of this procedure is
to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for
manufacturer's training or instructions.GuidelinesAt least two (2) nursing assistants are needed to safely
move a resident with a mechanical lift. (Note: Review Manufacturer guidelines for specific machine
use/directions)Review of facility's policy titled Safe Resident Handling/Transfers revised 05/05/2025
reflected: Policy:It is the policy of this facility to ensure that residents are handled and transferred safely to
prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for
the residents while keeping the employees safe in accordance with current standards and guidelines.Policy
Explanation:All residents require safe handling when transferred to prevent or minimize the risk for injury to
themselves and the employees that assist them. While manual lifting techniques may be utilized dependent
upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be
used. Compliance Guidelines:3. Mechanical lifting equipment or other approved transferring aids will be
used based on the resident's needs to prevent manual lifting except in medical emergencies.4. Mechanical
lifts may include equipment such as full body lifts, sit-to-stand lifts, or ceiling track mounted liftsTwo staff
members must be utilized when transferring residents with a mechanical lift.11. Staff will be educated on
the use of safe handling/transfer practices to include use of mechanical liftdevices upon hire, annually and
as the need arises or changes in equipment occur.12. The staff must demonstrate competency in the use of
mechanical lifts prior to use and annually withdocumentation of that competency placed in their education
file.13. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure
tomaintain compliance may lead to disciplinary action up to and including termination of employment.14.
Resident lifting and transferring will be performed according to the resident's individual plan of care.15.
Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the
device. Review of facility's policy titled Accident and Supervision revised 05/16/2025 reflected: Policy:The
resident environment will remain as free of accident hazards as is possible. Each resident will receive
adequate supervision and assistive devices to prevent accidents. This includes:1. Identifying hazard(s) and
risk(s).2. Evaluating and analyzing hazard(s) and risk(s).3. Implementing interventions to reduce hazard(s)
and risk(s).4. Monitoring for effectiveness and modifying interventions when necessary. Definitions:Accident
refers to any unexpected or unintentional incident, which results in injury or illness to a resident.Hazards
refers to elements of the resident environment that have the potential to cause injury or
illness.Supervision/Adequate Supervision refers to intervention and means of mitigating risk of an accident.
Policy Explanation and Compliance Guidelines:The facility shall establish and utilize a systematic approach
to address resident risk and environmental hazards to minimize the likelihood of accidents. 5- SupervisionSupervision is an intervention and a means of mitigating accident risk. The facility will provide adequate
supervision to prevent accidents. Adequacy of supervision:a. Defined by type and frequencyb. Based on the
individual resident's assessed needs and identified hazards in the resident environment.
Event ID:
Facility ID:
455638
If continuation sheet
Page 7 of 9
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
455638
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/29/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Greenview Nursing and Rehabilitation
401 Owen LN
Waco, TX 76710
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 0919
Make sure that a working call system is available in each resident's bathroom and bathing area.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, interviews and record review, the facility failed to ensure resident rooms were
adequately equipped to allow residents to call for staff assistance through a communication system which
relays the call directly to a staff member or to a centralized staff work area for two (Resident #2 and
Resident #3) of six residents reviewed for resident call system in that: Resident #2 and Resident #3 did not
have a properly functioning call system in their room from 11/18/2025 to 01/29/2026. This failure placed
residents at risk of being unable to obtain assistance for activities of daily living or in the event of an
emergency.Findings included Observation on 01/29/2026 at about 09:40 am with the Maintenance Director,
in Resident #2 and Resident #3's room revealed their call light system was not functioning, and the entire
box was out of the wall. It was observed Resident #2's call button was placed on the bed within reach even
though it was non-functioning and a bell on top of Resident #2's nightstand was out of reach. Observation
also revealed Resident #3's call light was placed within reach even though it was non-functioning.During an
interview on 01/29/2026 at 09:43 am the Maintenance Director stated the call system in Resident #2 and
Resident #3's room broke sometimes last week and he had ordered a replacement part. The Maintenance
Director stated he gave both residents bells to use until the call system was replaced. The Maintenance
Director stated he verbally told staff of the broken call system. The Maintenance Director stated the nursing
staff put in maintenance requests in the facility's TELS system (Streamlines maintenance, housekeeping,
and repairs, allowing staff to track, manage, and complete tasks efficiently.). The Maintenance Director
stated he checked the TELS system daily in addition to his daily routines. The Maintenance Director stated
he tried to address concerns within a day or at most 72 hours based on the priority of the concern.During
an interview on 01/29/2026 at 09:47 am Resident #2 stated her call system had been broken for about 6
months. Resident #2 stated she was not able to reach the bell on the nightstand. Resident #2 stated
whenever she needed help, she would go to the restroom and use the call button in the restroom.During an
interview on 01/29/2026 at 1:05 pm the DON stated she was aware of the call system problem in Resident
#2 and Resident #3's room. The DON stated she was not sure how long the call system in their room had
been broken but the Maintenance Director was working on it. The DON stated the Maintenance Director
had given Resident #2 a bell to call for help.During an interview on 01/29/2026 at 1:49 pm the Administrator
stated he was aware Resident #2, and Resident #3‘s room call system was broken and they were given a
bell. The Administrator stated the call system had been broken for a couple of months, maybe 2 months.
The Administrator stated any damage to the facility should be fixed immediately.Review of facility's TELS
documentation reflected:Order # 2891-- Call light malfunctioning. Unscrewed and unplugged from
wall-undated -medium priority-room [Resident #2 and Resident #3's room number]Order # 3053- Call light
completely broken out of wall, separated from wiring-dated 12/12/2025-medium priority-room [Resident #2
and Resident #3's room number]. Review of facility's invoice completed by the Maintenance Director dated
11/18/2025 reflected: Patient Station, Bedside: 0.25 Dual 2-Jack 2-Gang Replacement Patient Station
Review of facility's policy titled Accommodation of Needs revised 06/06/2025 reflected: Policy:The facility
will treat each resident with respect and dignity and will evaluate and make reasonable accommodation for
the individual needs and preferences of a resident, except when the health and safety of the individual or
other resident would be endangered.Policy Explanation and Compliance Guidelines:1. The facility will make
reasonable accommodations to individualize the resident's physical environment including their personal
bathroom and bedroom and the common living areas within the facility.2.The facility will ensure that
common areas frequented by residents are accommodating physical limitations and enhance their abilities
to maintain
Residents Affected - Some
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455638
If continuation sheet
Page 8 of 9
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
455638
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/29/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Greenview Nursing and Rehabilitation
401 Owen LN
Waco, TX 76710
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 0919
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
independence.3.Facility staff shall make efforts to reasonably accommodate the needs and preference of
the resident as they make use of their physical environment.4.Based on individual needs and preferences,
the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and
wellbeing to the extent possible. Review of facility's policy titled Safe and Homelike Environment dated
06/15/2025 reflected: Policy:In accordance with residents' rights, the facility will provide a safe, clean,
comfortable and homelike environment, allowing the resident to use his or her personal belongings to the
extent possible. This includes ensuring that the resident can receive care and services safely and that the
physical layout of the facility, both inside and outside, maximizes resident independence and does not pose
a safety risk.Environment refers to any environment in the facility that is frequented by residents, including
(but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy
areas and activity areas.
Event ID:
Facility ID:
455638
If continuation sheet
Page 9 of 9