Crestview Healthcare: Missed Medical Appointments - TX
The first appointment was cancelled when the Assistant Director of Nursing told a surgical center that no medically equipped staff would be available to handle the resident after the procedure. The surgical center called back the next day to say the resident couldn't use the facility's van transportation after his procedure.
The resident, identified only as Resident #1, had originally come from another town's hospital and scheduled his own MRI appointment with his own transportation. He attended that appointment but returned without any follow-up paperwork from the medical facility.
After the transportation issue cancelled his first appointment at the out-of-town surgical center, the resident received a referral to a local urologist instead. Staff scheduled the new appointment but never asked about preparation instructions, assuming he wouldn't need any special preparation for an MRI.
When the resident arrived for his local appointment, he couldn't be seen because he hadn't been properly prepared for the procedure.
The Assistant Director of Nursing admitted during the inspection that the facility had received orders from the doctor's office, but those orders were never entered into PCC, the facility's computer system. Without the orders in the system, staff couldn't prepare the resident properly.
"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 Assistant Director of Nursing told inspectors on August 14.
The Director of Nursing acknowledged that entering appointments and orders into PCC was the responsibility of either the Assistant Director of Nursing or the charge nurse, but ultimately fell under her oversight.
She explained that the first cancellation happened because the surgical center in the other town "did not communicate the instruction." For the second missed appointment, she said the problem was that orders "were not entered into PCC."
The Director of Nursing said she only learned about the missed orders when the Assistant Director of Nursing went on vacation. "She did not see the instruction," the Director of Nursing explained to inspectors.
After discovering the missing instructions, the Director of Nursing found them and reviewed the preparation requirements with the resident directly. She scheduled his procedure for August 15, 2025, and the resident agreed to the new date.
Both nursing supervisors insisted that the missed appointments were not life-threatening. The Administrator told inspectors during an interview that there had been "a mix up with the appointment" and that "it was not an appointment that was life threatening."
The Administrator explained the facility's usual transportation process: if residents had appointments scheduled at the same time, they used a ride share company. He said the Activity Director would normally transport residents to their appointments if informed about them.
The inspection revealed gaps in the facility's coordination of medical care. The resident had to navigate scheduling his own initial MRI appointment and arranging his own transportation to an out-of-town facility. When he returned from that appointment without follow-up documentation, staff had to rely on phone calls from surgical centers to learn about his medical needs.
The failure to enter doctor's orders into the computer system meant nursing staff couldn't access the preparation instructions needed for the resident's care. This basic administrative task, which the Director of Nursing acknowledged was part of standard procedures, fell through the cracks during a staff member's vacation.
Federal inspectors cited the facility for neglect under regulations requiring nursing homes to ensure residents receive necessary medical care. The facility's own policy defines neglect as "failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness," including "failure to provide medical care for physical and mental health needs."
The policy specifically states that each resident has the right to be free from neglect, which can 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."
The inspection found that while the missed appointments may not have been immediately life-threatening, they represented a pattern of communication breakdowns and system failures that prevented the resident from receiving timely medical care.
The resident's experience illustrates how administrative oversights can cascade into significant delays in medical treatment. What began as a transportation coordination issue evolved into a complete failure to prepare the resident for a rescheduled procedure, forcing him to wait additional weeks for needed urological care.
By the time of the inspection, facility staff had finally entered the doctor's orders into their computer system and begun the resident's pre-procedure preparation. The resident was scheduled to receive his delayed urological procedure the day after inspectors completed their investigation.
The case demonstrates how nursing home residents depend entirely on facility staff to coordinate their medical care, from transportation arrangements to following preparation instructions. When those systems break down, residents face delays in treatment that could affect their health outcomes and quality of life.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crestview Healthcare Residence from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Crestview Healthcare Residence in Waco, TX was cited for violations during a health inspection on August 14, 2025.
The surgical center called back the next day to say the resident couldn't use the facility's van transportation after his procedure.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.