Health inspection·August 14, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** These failures could place residents at risk for unassessed changes in conditions that could lead to permanent impairment, including decreased quality of life. Based on interviews and record reviews the facility failed to ensure that residents received treatments and care in accordance with professional standards of practice and the residents' choices for 1 of 1 resident (Resident #1) reviewed for quality of care.Resident #1 had an appointment on or around 4/28/2025, for an MRI (a medical imaging technique that uses a magnetic field and computer-generated radio waves to create detailed images of the organs and tissues in your body) for his prostate, and the facility failed to schedule the appointment and failed to place the necessary preop instructions needed for the procedure in PCC; subsequently Resident #1 missed his appointment twice. There were no adverse reactions from him not attending his appointment. These failures could place residents at risk for unassessed changes in conditions that could lead to permanent impairment, including decreased quality of life. Record review of Resident #1's admission record, dated 8/14/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnosis which included major depressive disorder, recurrent severe without psychotic feature (s characterized by multiple episodes of major depressive disorder that are severe in nature but do not include psychotic symptoms), chronic embolism and thrombosis of unspecified vein (a blood clot in a deep vein that has lasted for at least a month. It can be difficult to treat and can lead to scarring and vein damage), overactive bladder (causes sudden urges to urinate that may be hard to control), and benign prostatic hyperplasia with lower urinary tract symptoms (is a noncancerous enlargement of the prostate gland that can lead to lower urinary tract symptoms, affecting urination and overall quality of life). Record review of Resident #1's quarterly MDS, dated [DATE] reflected a BIMs of 10, which indicated mild cognitive impairment. Record review of Resident #1's physicians order dated 10/31/2024 reflected Resident #1 had a referral to see the urologist upon admission. Original orders from the hospital dated 3/31/2025 revealed the resident had a cystoscopy on 3/26/2024 which identified large bladder capacity. The resident has an overflow incontinence. TRUS not performed. It was recommended a Urolift but the patient canceled. 12/3/24: the resident wen in there of complaints included severe urge incontinence. Overall, he is frustrated with his status. Patient report delayed ejaculation. During an interview on 8/14/2025 at 1:50 PM with Resident #1 revealed he had an MRI that was scheduled that he did not attend. Resident #1 stated he waited a month to get the appointment scheduled, he was advised the facility never received he prep instructions. He stated he gave the instructions to the ADON. He stated he has waited 3 months for the appointment, and it is finally scheduled for 8/15/2025. He stated the DON apologized and assured him it was rescheduled, and he will be prepped the night before and he will be transported to his appointment. He stated he was upset that once he saw the ADON, she did not apologize to hm for the mistake she made. During an interview on 8/14/2025 at 4:20 PM with ADM revealed there was a transportation driver that brings the Residents Affected - Few Page 1 of 2 675141 675141 08/14/2025 Crestview Healthcare Residence 1400 Lake Shore Dr Waco, TX 76708

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents to their appointments if she was informed. He stated if residents had appointments scheduled at the same time, they utilized a ride share company. He stated there was a mix up with the appointment with Resident #1. He stated it was missed once and it was rescheduled. He stated it was an MRI appointment for urology. He stated it was not an appointment that was life threatening. During an interview on 8/14/2025 at 5:08 PM with ADON revealed Resident #1 came from another town hospital and he scheduled his own MRI and set up his own transportation where he attended his appointment in the other town. She stated he came back with no follow-up paperwork. She stated she received a call from the surgical confirming his appointment on or about 3/30/2025. She advised the surgical representative that there will not have anyone medically equipped on the van to handle Resident #1 after the procedure. The next day they called from the same surgical center and stated he cannot get on the van after the procedure. The ADON stated that was why the first appointment was cancelled. She stated Resident #1 then received a referral from the doctor to a local urologist. The ADON stated the appointment was scheduled but never questioned anything regarding preop instructions because she figured he did not need anything for the MRI. Once he arrived at the appointment, he could not be seen because he had not been prepped. The ADON stated they received the orders from the doctors' office, but the orders were not put into PCC so Resident #1 missed that appointment. The ADON stated the orders was now placed into the system and Resident #1 appointment was scheduled and he has started his preop for the procedure that will take place on tomorrow. The ADON stated the was not a life-threatening procedural appointment he missed. During an interview on 8/14/2025 at 5:38 PM with DON revealed it was the ADON or the charge nurse job to make sure appointments and orders are placed in PCC but ultimately it was her responsibility. The DON stated the first time, the surgical center in [NAME] did not communicate the instruction. The second time, it was not entered into PCC. When she learned about it, she scheduled it. She stated the ADON went on vacation, and she did not see the instruction. It was revealed, the instructions were not placed in PCC. She found the instructions and she went over them with Resident #1. She advised him it was scheduled for 8/15/2025 and he was alright with that. A record review of the facility's Abuse Prohibition undated policy revealed, each resident has the right to be free from verbal, sexual, physical and mental abuse, mistreatment, neglect, involuntary seclusion and misappropriation of property. Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. It may include failure to assist in personal hygiene, or in provision of food, clothing, shelter; failure to provide medical care for physical and mental health needs or failure to protect from health and safety hazards. 675141 Page 2 of 2