Health inspection·July 24, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect and promote the resident's right to a dignified existence and self-determination for 1 of 6 residents (Resident #1) reviewed for resident rights, in that: The facility failed to allow Resident #1 to maintain her smoking privileges. This failure could place residents at risk of feelings of poor self-esteem, anxiety, decreased quality of life and loss of dignity.The findings were: Review of resident #1's face sheet dated 7/24/2025 revealed she is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Schizoaffective disorder, Bipolar type (mental health conditions involving mood disorders), Epilepsy (seizure disorder) Ulna Fracture (broken bone in forearm), Intellectual Disabilities (limitations in both intellectual functioning and adaptive behavior), Type 2 Diabetes (blood sugar disorder). Dementia with other behavioral disturbance (loss of memory) and Major Depressive Disorder. Face sheet further revealed that a family member was resident #1's Power of Attorney. The face sheet did not identify a responsible party. Review of resident #1's quarterly MDS dated [DATE], revealed a BIMs of 9, suggesting moderate cognitive impairment. In the behavior symptom section, resident #1 was noted to have verbal behaviors directed towards others occurring in 1 to 3 days in the last 7-day lookback period. There was no section in the MDS that addresses smoking. Review of resident #1's progress notes from 6/27/2025 to 7/23/2025 reflected no notes concerning removal of resident #1's smoking privileges. Review of resident #1's smoking assessment dated [DATE] reflected she was safe to smoke but needed supervision. This was the only smoking assessment found in resident #1's EMR Review of resident #1's Smoking Agreement dated 5/29/2025, reflected it was signed by resident #1 on 5/29/2025. In the agreement Resident #1 agreed to abide by the smoking rules which were centered around safe smoking habits. Specifically, #11 stated Failure to adhere to safe smoking practices may result in denial of smoking rights at [the facility]. Family and resident will be kept informed of issues that arise. Review of resident #1's untitled contract dated 6/27/2025 reflected I [resident] entering into this contract with [nursing facility] in the agreement. I will only smoke 3 cigarettes per day at 8:30 am, 1:30 pm and 6:30 pm. I understand if I break this agreement, I may have my smoking privileges taken away. Contract was signed by resident using her first name on 6/27/2025. Review of resident #1's care plan dated 7/24/2025 reflected [resident #1] is a smoker with goal of resident will smoke safely through next review and interventions: complete smoking assessment, if it is determined that resident is safe to smoke, staff will review and explain facility smoking policy and smoking agreement. During an interview on 7/24/2025 at 12:09 pm, the ADON stated on 7/23/2025 herself, the activities person and the ADM were having a meeting in her office and resident #1 came in and talked to the ADM about smoking. She stated resident #1 asked ADM if he would give her one more chance to smoke and ADM stated he didn't think it was a goo idea. She stated resident #1 started crying at that point which was not unusual for her - she would cry a lot when she didn't get her way. She stated the ADM Page 1 of 3 675141 675141 07/24/2025 Crestview Healthcare Residence 1400 Lake Shore Dr Waco, TX 76708

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had decided about 3 weeks ago for resident #1 to stop smoking. She stated she did not remember a meeting with resident, family member or IDT to discuss taking away resident #1's smoking privileges. During an interview on 7/24/2025 at 12:53 pm facility SW stated the facility cut out smoking for resident #1 because behaviors would happen around smoking times because resident #1 would get impatient. SW stated resident #1 has not verbalized any desire to smoke since the smoking privileges were taken away. He stated he did not recall their being an IDT meeting with the resident, a family member or the PASSAR case manager to discuss removing resident #1's smoking privileges. He stated resident #1's smoking privileges were taken away about a month ago. SW states smoking is a privilege, not a right. During an interview on 7/24/2025 at 1:30 pm ADM stated smoking at the facility was a resident privilege not a resident right. He stated resident #1's smoking privileges were taken away somewhere around 7/3/2025 because issues with smoking would lead to an escalation of behaviors with resident #1 with verbal and physical aggression incidents directed towards staff and other residents. ADM stated resident #1 did not have another smoking assessment completed when her smoking privileges were revoked because it was not a safe smoking issue, it was a behavior issue. ADM provided the facility policy on smoking, resident #1's smoking agreement and resident #1's cigarette contract for investigator review. During an interview on 7/24/2025 at 2:40 pm, PASARR Case Manger stated she was not aware of resident #1 having smoking restrictions or that her privileges had been revoked. She stated she attended resident #1's initial PASARR meeting on 7/3/2025 and resident #1 was still smoking at that time. She stated at that time no behavioral concerns around smoking were discussed in the meeting. She stated they did discuss resident #1's desire to continue smoking and what the expectations of resident #1 were - being patient, waiting for staff, only smoking when allowed - and resident #1 was in agreement with those expectations at that time. She stated she was not aware until yesterday 7/23/2025, that resident #1 was not allowed to smoke at the facility. When she asked staff why resident #1 was no longer allowed to smoke, she was informed it was because of increased behaviors around the time she was able to smoke, having access to cigarettes and refusing to come back in after smoke break. She could not remember which facility staff had informed her of these behaviors. During an interview on 7/24/2025 at 2:50 pm, resident #1 stated they took my cigarettes away and they wouldn't give them back She stated she didn't think it was right that other residents go out to smoke, and she isn't allowed to go out with them to smoke. She stated she wanted her cigarettes back and she wanted to go out and smoke. During an interview with the ADM on 7/24/2025 at 3:12 pm he stated he had a meeting with the resident regarding her smoking - he thought it had been on 6/30/2025 but it could have been the first or second of July. He staed he knows they had a conversation with her to tell her they were taking away her smoking privileges dur to her behaviors. He stated he could not find where it was documented anywhere in the EMR. He stated, we didn't document anything - how is that possible. During an interview on 7/24/2025 at 3:42 pm, the Medical Director stated he was not aware of resident #1's smoking privileges being revoked. He stated he doesn't necessarily get involved in day-to-day behavior issues and he is okay with not knowing about this issue. He stated resident #1 was being followed by psyche services and the last note on 6/29/2025 did not mention any behavior issues with smoking. MD was informed that resident #1's care plan had not been updated to reflect her smoking privileges being revoked and there being no progress notes or IDT meeting about the revocation. He stated the care plan should have been updated and documentation completed in the EMR. During an interview on 7/24/2025 at 4:12 pm, ADM stated it was his responsibility to follow up and ensure progress notes were completed when they had the conversation with resident #1 about revoking her smoking privileges. He stated he knew they had the conversation; it just wasn't documented. He stated the care 675141 Page 2 of 3 675141 07/24/2025 Crestview Healthcare Residence 1400 Lake Shore Dr Waco, TX 76708

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few plan should have been updated by the MDS coordinator but the MDS coordinator would not have known about the conversation [with resident #1 about revoking smoking privileges] and he [ADM] didn't remember sharing details with the MDS coordinator. ADM was asked who is responsible for doing smoking assessments when there are changes and he stated a re-assessment was not applicable [with resident #1] because resident was able to smoke safely, she just had behaviors around not being able to smoke, when she didn't get her way. Review of undated facility policy Smoking Policy - Residents reflected the following: This facility has established and maintains safe resident smoking policies.8. A resident's ability to smoke safely is re-evaluated quarterly, upon significant change (physical or cognitive0 and as determined by staff. 9. Any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 10. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. 675141 Page 3 of 3