Health inspection·June 19, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's, undated policy stated Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675141 If continuation sheet Page 2 of 12 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 06/19/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen and 3 (nourishment room [ROOM NUMBER], 2, and 3) of 3 nourishment rooms reviewed for food safety and sanitation. 1. The facility failed to conduct temperature checks and/or complete the temperature check logs for refrigerators and freezers in the facility's kitchen and nourishment rooms. 2. The facility failed to conduct temperature checks and/or complete the temperature check log form for the 3-compartment sink in the facility's kitchen. 3. The facility failed to ensure the refrigerators and freezers in the facility's nourishment rooms were cleaned, sanitized, and in proper working condition. 4. The facility failed to ensure food items stored in the nourishment room refrigerators/freezers were labeled and dated. 5. The facility failed to ensure items stored in the nourishment room refrigerators/freezers were restricted to residents' items only. These failures could place residents at risk for foodborne illnesses. Findings include: Observation of the facility's kitchen on 6/17/2025 at 8:37 AM revealed written directives posted on the door of the refrigerator that stated in part: PUT A DATE ON ALL ITEMS IN THE FRIDGE PERSONAL ITEMS ARE NOT ALLOWED IN THE FRIDGE, THERE'S A FRIDGE IN THE BREAKROOM. Observation of the facility's kitchen on 6/17/2025 at 8:48 AM revealed the REFRIGERATOR/FREEZER TEMPERATURE LOG for the month of June 2025 in which staff failed to conduct and/or log temperature checks for the kitchen refrigerators and freezers as follows: 6/13/2025-No morning temperature check logged for refrigerator #2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675141 If continuation sheet Page 3 of 12 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 06/19/2025 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 0812 6/14/2025-No morning temperature check logged for refrigerator #2. Level of Harm - Minimal harm or potential for actual harm 6/14/2025-No morning temperature check logged for freezer #1. 6/15/2025-No evening temperature check logged for refrigerator #1. Residents Affected - Some 6/15/2025-No evening temperature check logged for refrigerator #2. 6/15/2025-No evening temperature check logged for freezer #1. 6/16/2025-No evening temperature check logged for refrigerator #1. 6/16/2025-No evening temperature check logged for refrigerator #2. 6/16/2025-No evening temperature check logged for freezer #1. Observation of the facility's kitchen on 6/17/2025 at 8:48 AM revealed the 3 Compartment Sink Log for the month of June 2025 in which staff failed to conduct and/or log the water temperature checks and sanitation solution concentration levels following dinner service on 6/15/2025 and 6/16/2025. Observation of the facility's kitchen on 6/17/2025 at 8:49 AM revealed the DAILY/AFTER EACH USE CLEANING SCHEDULE FORM for each week in the month of June 2025. Each form listed all items and areas that required at least daily cleaning and the staff members responsible for completing each task. The items and areas listed included refrigerators, freezers, microwave, food carts, and the janitor's closet, but did not include items or areas with the facility's nourishment rooms. Observation of nourishment room [ROOM NUMBER] (center station) on 6/17/2025 at 8:52 AM, revealed a refrigerator/freezer combination unit operable and in use. Adhered to the front of the unit was a temperature log form for June 2025. The Refrigerator Temperature Log included instructions that stated the following: Monitor Temperatures Closely Record Temps twice each day. Initial after you record the temp. Take action if temp is out of range - above 46'F or below 36'F. The temperature log was observed to be mostly incomplete with temperature checks not conducted and/or logged on any morning shift for the month, and no evening temperature checks conducted or logged on 6/11/2025 and 6/12/2025. Also adhered to the front of the unit were typed signs with directives which read as follows: EMPLOYEE FOOD ITEMS THERE IS A NEW REFRIGERATOR IN THE BREAK ROOM FOR EMPLOYEE FOOD ITEMS. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675141 If continuation sheet Page 4 of 12 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 06/19/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some BEGINNING MARCH 16TH, ALL EMPLOYEE FOOD ITEMS THAT ARE STORED IN THE NURSES STATION REFRIGERATORS WILL BE DISPOSED OF EACH DAY. YOU ARE NOT ALLOWED TO COMMINGLE RESIDENT AND STAFF FOOD ITEMS INCLUDING WATER AND SODAS. PLEASE HELP US MEET THE STATE REQUIREMENTS FOR THESE REFRIGERATORS; and Resident Refrigerator Personal Snacks and Supplements No Employee Items Allowed!! Observation of the interior of nourishment room [ROOM NUMBER]'s freezer on 6/17/2025 at 8:52 AM revealed an opened and partially consumed bottle of water, a pint of ice cream wrapped and tied in a plastic grocery bag, evidence of spillage of a red liquid which pooled, dripped and dried within the bottom and sides of the freezer. Stored within the shelves of the freezer door was a large frozen bottle of water, instant ice packs, and various plastic ice packs. None of the items stored within the freezer were labeled with a name or date the products were obtained or stored. The items stored in the freezer door shelves were also soiled and stained red from the evident spillage. Observation of the interior of nourishment room [ROOM NUMBER]'s refrigerator on 6/17/2025 at 8:53 AM revealed evidence of spillage of a red liquid that had dripped down and under the storage compartment drawers. The seal around the refrigerator door was contained red liquid which caused the door to be sticky and hard to open. An opened and partially empty plastic bottle containing red soda was observed within the refrigerator along with an opened can of coffee with a napkin shoved into the opening of the can and opened and unopened beverage jugs, bottles and cans. None of which were labeled with a name or date the products were obtained or stored. Observation of nourishment room [ROOM NUMBER]'s (central east station) refrigerator on 6/17/2025 at 8:54 AM revealed the absence of a temperature check log or documentation which indicated if or when temperature checks were done. Inspection of the interior of the refrigerator revealed the absence of a thermometer, and storage of food and beverage items which were inconsistent with resident type meals or snacks. These items included several plastic grocery bags full of fresh vegetables that appeared to have been brought in from someone's personal garden, partially consumed bottles of water, a can of diet Coke, a bag of chips, leftovers covered and stored in a personal looking storage container, yogurt, and a box of leftover pizza. None of the items were labeled or dated. Observation of nourishment room [ROOM NUMBER]'s (secure unit) refrigerator/freezer unit on 6/17/2025 at 8:59 AM revealed a temperature log form adhered to the front of the freezer door and a temperature log adhered to the front of the refrigerator door. Both forms were dated June 2025. The Refrigerator Temperature Log forms included instructions that stated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675141 If continuation sheet Page 5 of 12 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 06/19/2025 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 0812 Monitor Temperatures Closely Level of Harm - Minimal harm or potential for actual harm Record Temps twice each day. Initial after you record the temp. Residents Affected - Some Take action if temp is out of range - above 46'F or below 36'F. The temperature log adhered to the freezer door had the word Freezer handwritten on it. The freezer temperature log was observed to be mostly incomplete with temperature checks not conducted and/or logged on any morning shift for the month of June 2025, and no evening temperature check conducted or logged on 6/14/2025. The temperature log adhered to the refrigerator door was observed to be mostly incomplete with temperature checks not conducted and/or logged on any morning shift for the month of June 2025, and no evening temperature checks conducted or logged on 6/13/2025 and 6/14/2025. Observation of the interior of nourishment room [ROOM NUMBER]'s (secured unit) freezer and refrigerator on 6/17/2025 at 8:59 AM revealed a thick layer of ice and frost build up around all sides of the freezer and the back of the refrigerator. The freezer and refrigerator were observed as not maintaining acceptable temperatures as evidenced by the lack of cold air coming from the unit, condensation droplets from the melting ice build-up, and observation of the refrigerator temperature reading was 60'F on the thermometer placed near the back of the unit. Contained within the freezer were frozen beverage bottles with ice buildup around each and a frozen Magic cup. None of which were labeled or dated. The refrigerator contained an opened gallon of whole milk, several opened containers of pre-thickened water, pudding cups, packets of jalapeno ranch, and a ham, cheddar, and cracker snack pack. In an interview on 6/17/2025 at 8:50 AM, DC A stated the kitchen staff were responsible for cleaning equipment, surfaces, and areas within the facility's kitchen according to the posted cleaning schedule. DC A stated kitchen staff were responsible for conducting and logging temperature checks within the kitchen according to the schedule listed on the various temperature log forms. DC A also stated kitchen staff were responsible for conducting temperature checks and sanitation solution concentration checks for the kitchen's 3-compartment sink and dishwasher and logging such on the forms provided. DC A stated there was a refrigerator/freezer unit in each of the facility's nourishment rooms, but she and the kitchen staff were not responsible for those. In an interview on 6/17/2025 at 8:52 AM, TD A stated each of the facility's nourishment rooms contained a refrigerator/freezer unit which was restricted to resident use only. In an interview on 6/17/2025 at 8:53 AM, TD A stated the nourishment room refrigerators/freezers were supposed to be used to store resident items only. TD A stated he was uncertain as to who was responsible for cleaning the nourishment room refrigerators, or who was responsible for completing and documenting temperature checks of the refrigerators/freezers in the nourishment rooms. In an interview on 6/17/2025 at 8:55 AM, TD A stated the refrigerator in nourishment room [ROOM NUMBER] likely contained staff members' personal food and beverage items because during the facility's recent remodel, that room and refrigerator were not in use for resident items because the residents on this unit were moved elsewhere while construction was going on. TD A stated the renovation was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675141 If continuation sheet Page 6 of 12 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 06/19/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some completed several months prior and staff were instructed to use the breakroom refrigerator for storage of personal items. In an interview on 6/19/2025 at 2:19 PM, the HKS stated the housekeeping staff were not typically responsible for the cleaning and upkeep of nourishment room refrigerators, but he stated housekeeping staff would assist if asked. The HKS stated these tasks were the responsibility of the nursing staff, along with conducting and logging refrigerator/freezer temperatures. In an interview on 6/19/2025 at 2:21 PM, the ADM stated the facility had no specific policy regarding refrigerator/freezer tasks, which included which staff were responsible for maintaining them. The ADM stated it was known and understood that nursing staff was responsible for cleaning nourishment room refrigerators/freezers, and logging refrigerator/freezer temperature checks. If the units or thermometers contained therein were not working or malfunctioning, nursing staff should create an electronic work order and route it to the maintenance department, or nursing staff could report the problem directly to the ADM and he would address the issue right away. In an interview on 6/19/2025 at 2:25 PM, CNA A stated she had been employed with the facility for 4 years. CNA A stated it was the responsibility of the nursing staff to log temperature checks for the nourishment room refrigerators. CNA A stated the temperature check logs should be maintained on the outside of each unit. CNA A stated facility staff should never store personal items in the nourishment room refrigerators. These were for resident items only. CNA A stated this was necessary to prevent cross contamination and to prevent the possibility of mistakenly serving a resident a product not intended for them. CNA A stated nursing staff was responsible for cleaning and maintaining the nourishment refrigerators/freezers. In an interview on 6/19/2025 at 2:38 PM, LVN A stated she was a charge nurse who typically worked the dayshift. She stated she had been employed with the facility for 5 years. LVN A stated she's not sure who was responsible for cleaning and maintaining the nourishment room refrigerators. LVN A said the night shift nurse was responsible for completing and logging temperature checks for the nourishment room refrigerators/freezers. LVN A said the ADON was responsible for making sure this got done. LVN A said she did not know who was responsible in the absence of the ADON. LVN A said the facility's policy on was unclear and she's not sure what the policy stated. LVN A said the refrigerator in nourishment room [ROOM NUMBER] (east center station) was reopened about 2 months ago after the remodel of that unit was completed. LVN A said the nourishment room [ROOM NUMBER] (east station) refrigerator had historically been used by staff to store personal items such as coffee creamer. LVN A said the center station nourishment room was used to store resident items because that was where the kitchen staff delivered resident snack items. In an interview on 6/19/2025 at 2:45 PM, the DON said nursing staff was responsible for maintaining the nourishment rooms. The DON said the unit manager was responsible for making sure temperature checks were completed and logged, and the unit was clean and in working order. In an interview on 6/19/2025 at 2:45 PM, the RNC stated the ADM received the policies request. The RNC stated the ADM provided the only policies they had regarding nourishment room temperature check logs and cleaning. Record review of the facility's policy regarding measuring unit refrigerators for safe temperatures, updated January 2023, revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675141 If continuation sheet Page 7 of 12 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 06/19/2025 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 0812 Refrigerators: Level of Harm - Minimal harm or potential for actual harm All facility refrigerators should have working thermometers to measure and monitor safe temperatures. Residents Affected - Some Freezers should be solid frozen at all times. Leakages in freezers must be reported to the maintenance team immediately. Refrigerator temperatures shall remain at 41 degrees and below at all times. Daily logs: The temperature will be checked and recorded by designated staff. When checking temperature, the doors should have been kept closed for at least 10 minutes prior to evaluation. The reading and time of the reading will be noted, along with the signature of the person checking. Maintain logs per the retention policy and procedure. If the refrigerator/freezer was not maintaining acceptable temperatures the contents will be removed and destroyed Daily record keeping of refrigerator temperature shall be kept near or on the actual refrigerator. Any temperature issues (if below 41 degrees) should be communicated with the maintenance team. De-frosting of the freezers is recommended to be done monthly. During the de-frosting process and while cleaning the refrigerator, all stored items shall be transferred to another refrigerator/freezer and not left out in the open. Review of the U.S. Food and Drug Administration Food Code dated 2022 revealed the following: 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; P 3-305.11 Food Storage. (B) (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (C) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675141 If continuation sheet Page 8 of 12 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 06/19/2025 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 0812 (1) In a clean, dry location; Level of Harm - Minimal harm or potential for actual harm (D) (2) Where it is not exposed to splash, dust, or other contamination Residents Affected - Some 3-307.11 Miscellaneous Sources of Contamination. (E) FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. 4-602.11 Equipment Food-Contact Surfaces and Utensils. (D) Surfaces of UTENSILS and EQUIPMENT contacting TIME/TEMPERATURE CONTROL FOR SAFETY FOOD may be cleaned less frequently than every 4 hours if: (5) EQUIPMENT is used for storage of PACKAGED or unpackaged FOOD such as a reach-in refrigerator and the EQUIPMENT is cleaned at a frequency necessary to preclude accumulation of soil residues. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675141 If continuation sheet Page 9 of 12 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 06/19/2025 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 0880 Provide and implement an infection prevention and control program. 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident #19 and Resident #88) reviewed for infection control. Residents Affected - Few 1. The facility failed to ensure hand hygiene was implemented appropriately when CNA-A provided perineal and catheter care for Resident #19. 2. The facility failed to ensure hand hygiene was implemented appropriately when LVN-B provided wound care to Resident #88. These deficient practices could place residents at-risk of the spread of infection. Findings include: Record review of Resident #19's face sheet, dated 01/06/2025, revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #19's primary diagnosis included Spinal Stenosis, Cervical Region (a condition where the spinal column narrows, putting pressure on the spinal cord or nerves in the neck area). Record review of Resident #19's Care Plan, last updated 01/16/2025, revealed a Problem which included Resident # 19 requires a foley catheter secondary to Neurogenic Bladder,. This problem area included the following interventions: Change foley catheter monthly with 18 .F, 10 .CC. foley catheter care Q shift Monitor for evidence of blockage, flush catheter per MD order, change catheter as indicated. Record review of Resident #19's Quarterly MDS assessment, dated 06/05/2025, revealed a BIMS score of 15, which indicated intact cognition. Resident #19 was assessed as having an indwelling catheter. Record review of Resident #19's Active Orders, dated 06/18/2025, revealed orders which included: Foley catheter care every shift start date 06/02/2024. Observation on 06/18/2025 at 01:06 PM revealed there was a sign which indicated Enhanced Barrier (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675141 If continuation sheet Page 10 of 12 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 06/19/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Precautions outside the door to Resident #19's room, and there was a supply of PPE available outside the door/room. CNA-B sanitized her hands and donned gloves and gown prior to performing perineal care and foley care for Resident #19. During the care, CNA-B failed to sanitize her hands two of five times she changed from dirty gloves to clean gloves. During these instances, she removed soiled gloves and donned clean gloves after removing a soiled brief and she removed soiled gloves and donned clean gloves after wiping the perineal area of stool. During an interview with CNA-B on 06/18/2025 at 1:30PM, she stated it was an expectation that hand sanitization be performed each time dirty gloves were removed. She stated she may have failed to sanitize her hands in between glove changes as she was nervous. 2. Record review of Resident #88's face sheet, dated 09/17/2024, revealed a [AGE] year-old male with a diagnosis which included Cerebral Infarction (a condition where brain tissue dies due to a lack of blood supply). Record review of Resident #88's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 00, which indicated severe cognitive impairment. Record review of Resident #88's Care Plan and Orders, of 06/18/2025, revealed Resident #88 was assessed as having a skin tear wound to the left anterior superior leg. The orders stated Cleanse with NS, pat dry, apply Alginate Calcium with silver daily. Observation on 06/18/2025 at 12:52 AM of wound care treatment to Resident #88 by LVN B revealed LVN B changed gloves multiple times while care was provided which included after moving from dirty to clean areas and after touching the outside environmental object but did not sanitize her hands in between one glove change after LVN B removed the soiled dressing and donned clean gloves to cleanse the wound. During an interview with LVN B on 06/18/2025 at 1:10 PM, LVN B stated she did not sanitize her hands after each glove change while providing wound care to Resident #88 because she was nervous, but also stated she should have. During an interview with the DON on 06/19/2025 at 8:57 AM, she stated it was the policy to perform hand sanitization before donning gloves and when there was a change from dirty to clean gloves, and then when the procedure was completed. The DON stated staff were trained on hand hygiene expectations during their three-day orientation period and frequently thereafter. The DON reported the Infection Control Practitioner and herself performed random rounds and observations to ensure compliance with hand hygiene. The DON stated failure to perform hand hygiene could result in the spread of bacteria. During an interview with the Infection Control Practitioner on 06/19/2025 at 9:34 AM, she stated staff were expected to perform hand hygiene anytime there was a transition from dirty to clean. She stated staff were educated during their three-day orientation period and periodically during the year on the hand hygiene policy. The Infection Control Practitioner stated she performed monitoring of six instances of hand hygiene every two weeks. During an interview with the Administrator on 06/18/2025 at 10:10 AM, he stated it was his expectation that hand hygiene be performed each time soiled gloves were discarded and before clean gloves were donned. The Administrator stated a possible outcome of the failure to perform hand hygiene could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675141 If continuation sheet Page 11 of 12 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 06/19/2025 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 0880 result in the spread of infection. Level of Harm - Minimal harm or potential for actual harm During a record review of the hand hygiene policy revealed the following: Residents Affected - Few Purpose: Hand washing with either soap and water or hand sanitizer is one of the best ways to stop the spread of infection. Handling soiled or used linens, dressing, bedpans, catheters, and urinals. Removing gloves or aprons. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675141 If continuation sheet Page 12 of 12