Health inspection·February 26, 2025

F 0600 Resident requires staff x 1 to choose simple comfortable clothing and for ability to dress self. Level of Harm - Minimal harm or potential for actual harm Resident requires staff xx1 for a sponge bath when a full bath or shower cannot be tolerated. Resident requires staff x 1 for reminding, prompting, cueing, for assistance with eating. Residents Affected - Few Resident requires setup help with meals but can feed self independently. Resident requires staff x 1 to set up or assist with oral care. Check nail length and trim and clean on bath day. Report any changes to the nurse. Praise all efforts at self-care. Record review of the facility's investigation report on 02/26/2025 at 12:21 PM reflected the facility was notified of this event by the outside representative on 02/13/2025 at 11:00 AM. According to the Facility's Investigation Report, RN D walked thru the Dining Room on 02/07/2025 after lunch and the outside representative notified him that Resident #3 needed to be changed as she had urinated on the floor. RN D notified CNA E that the resident needed to be changed. RN D placed Resident #3 in the Shower Room per CNA E's request. CNA E reported to RN D she would finish her round and attend to Resident #3. The outside representative later called Social Worker to report Resident #3 was alone in the shower for approximately 30 minutes unattended. Record review of the Facility follow up included the following: 02/13/2025 RND and CNA E are suspended pending further investigation. 02/13/2025 Ad Hoc QAPI 02/13/2025 and 02/14/2025 Notification of Medical Director 02/13/2025-02/14/2025 All staff inservicing to include Abuse and Neglect, Resident rights/Dignity-Bowel and Bladder, Communication-Clarification of Task Assignment, and Shower Room Monitoring. 02/14/2025 Attempted notification of responsible party. 02/17/2025 Education sent to outside providers regarding reporting of Abuse and Neglect. 02/18/2025 One on One communications with RN D and CNA E to include Communication and Clarification and Shower supervision. Record review of Resident #3's medical record on 02/26/2025 at 11:00 AM ,reflected the Social Worker completed an assessment for injury on 02/13/2026 at 4:45 PM. According to the note, Resident #3 did not demonstrate any signs of a negative outcome from this event. Skin Assessment completed on 02/14/2025 at 1:09 PM is negative for any physical injury. Interview with Resident #3 was conducted on 02/26/2025 at 11:33 AM. Resident #3 stated the staff are good to her and always help her. She has no recollection of being left in the Shower Room unattended. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675141 If continuation sheet Page 2 of 4 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 675141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestview Healthcare Residence 1400 Lake Shore Dr Waco, TX 76708 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with DON on 02/26/2025 was conducted at 10:26 AM. The DON stated it was her expectation that residents are not to be left alone in the Shower Room even if they can shower themselves. The DON stated the following interventions were implemented. RN D and CNA E were suspended on 02/12/2025 pending investigation. One on one communication with RN D and CNA E for training on staff-to-staff communication was completed on 02/18/2025. One on one training on Shower Supervision was completed with RN D and CNA E on 02/18/2025. The following in-service training was also implemented with direct care staff on 2/13/25 and 2/14/2025: Abuse and Neglect Resident Rights/Dignity related to Bowel and Bladder needs. Communication-Clarification of Task Assignment Shower Room Monitoring Interview conducted with CNA F was conducted on 02/26/2025 at 2:23 PM. She confirmed receiving training as listed above and described that a resident is never to left alone in the shower room. She also stated staff should always communicate clearly with coworkers and nurse to make sure everyone understands what is going on. Interview conducted with Activity Therapy staff G on 2/26/2025 at 2:35 PM. AT staff G confirms having received training as list above. She stated the main theme of the training was regarding monitoring residents in the shower and residents should never be left alone in the shower. Confirms receiving training on clear communication with coworker. Also reported having received training on reporting abuse and/or neglect the facility Administrator. Interview conducted with CNA H on 02/26/2025. CNA H confirms receipt of training as listed above. CNA stated she was trained on the types of abuse and neglect and to whom to report. CNA H verbalized receipt of training on rights and dignity. CNA H stated staff are to be in the shower room with any resident regardless of their mobility status. Interview with LVN I was conducted on 02/26/2025 at 2:51 PM. LVN, I confirmed receipt of training on abuse/neglect/exploitation and Resident Rights. LVN I stated residents are never to left unattended in the shower room for any reason. Interview with the Social Worker on 02/26/2025 at 1:27 PM revealed, he had received information about this event from the outside representative on 02/13/2025 at 11:00 AM. The outside representative reported she thought Resident #3 was in the shower room unattended for approximately 30 minutes. Interview with the outside representative by phone on 02/26/2025 at 2:07 PM was conducted. The outside representative stated she heard CNA E tell RN D to take Resident #3 to the shower and CNA E would be there in a little bit. The outside representative stated she did not know exactly how long Resident #3 was in the Shower Room, but she guessed it was about 30 minutes. The outside representative stated she did not realize Resident #3 was in the Shower Room alone until she heard her yell out. Interview with RN D on 02/26/2025 at 1:55 PM stated Resident #3 was taken to the Shower Room to await CNA E. He stated, I should have just done the hygiene care myself. RN D also reported he will change his practice by not ever leaving anyone in the Shower Room but, rather outside in the hallway. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675141 If continuation sheet Page 3 of 4 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 675141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestview Healthcare Residence 1400 Lake Shore Dr Waco, TX 76708 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 0600 RN D also stated he should have communicated better with CNA E. Level of Harm - Minimal harm or potential for actual harm Interview with CNA E was conducted at 02/26/2025 at 2:01 PM. CNA E stated she and RN D did not communicate regarding how long it was going to take CNA E to get to Resident #3. CNA E stated she should have let RN D know how long it was going to take her to get to Resident #3. Residents Affected - Few Interview with the Administrator was conducted 02/26/2025 at 4:54 PM. The Administrator stated every resident must be supervised while in the Shower Room. If the resident can shower independently, the CNA was to stand outside the door, knock and check on the resident frequently. Additionally, the Administrator was asked about the existence of documentation of notification of the physician and the resident representative regarding the event. The Administrator responded the physician was not notified because there was no injury, and the Resident Representative was not notified because Resident #3 was legally her own representative. A telephone interview was conducted with Resident #3's family member at 5:42 PM. He stated he was pleased with the care and treatment Resident #3 received from the facility and was thankful for the assistance. He stated: they're doing a great job and I'm thankful for that. Review of the facility's Abuse Prohibition policy, dated 12/2019, reflected: Each resident has the right to be free from verbal, sexual, physical and mental abuse, mistreatment, neglect, involuntary seclusion and misappropriate of property. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675141 If continuation sheet Page 4 of 4