Inspection·March 15, 2023

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #32 later stated he slipped while attempting to transfer from his bed to wheelchair .Resident #32 has BIMS of 7 with severe cognitive deficit .staff were in-serviced on fall prevention, injury of unknown origin, and abuse, neglect, and exploitation . Record review of an incident report for Resident #32, dated 02/08/23, by LVN X at 5:00 a.m., revealed reported by LVN X .location in room .nature of incident unwitnessed fall with primary injury of laceration/skin tear . treatment of first aid in facility provided .Resident #22 noted by CNA A during rounds a small skin tear with scant blood along the left eyebrow .Resident #22 was in wheelchair .when asked, 'if he had a fall?' Resident #22 responded 'no' then 'I do not know' . Record review of CNA A's witness and/or person (s) involved statement for Resident #32, dated 02/08/23 at 5:00 a.m., revealed I [CNA A] was going down the hallway doing my rounds when I saw Resident #32 coming up the hallway and noticed blood on his eyebrow, reported to LVN X . Record review of an Abuse and Neglect in-service training report, given by the DON, for all departments, dated 02/08/23, revealed signatures of MA D, MR E, CNA F, Laundry G, HSPK H, CNA J, CNA B, RN K, CNA L, FD C, LVN M, WCN N. Summary of abuse/neglect in-service training report revealed Any suspicion of Abuse must be reported to the ADM/Abuse Coordinator ASAP!! The in-service training report did not reveal signatures for CNA A or LVN X the two staff members who worked the morning of Resident #32's incident. Record review of an Injury unknown in-service training report, given by the DON, for all departments, dated 02/08/23, revealed signatures of MA D, MR E, CNA F, Laundry G, HSPK H, CNA J, CNA B, RN K, CNA L, FD C, LVN M, WCN N. Summary of injury unknown in-service training report revealed Any skin tear, bruising, etc. That was not witness is considered injury unknown. The in-service training report did not reveal signatures for CNA A or LVN X the two staff members who worked the morning of Resident #32's incident. 2. Record review of an undated face sheet revealed Resident #22 was a [AGE] year-old female admitted on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and Alzheimer's (a progressive disease that destroys memory and other important mental functions). Record review of Resident #22's MDS assessment, dated 12/13/22, revealed Resident #22 was understood and understood others. The MDS revealed Resident #22 had BIMS 06 which indicated severe cognitive impairment and continuously presence of inattention (easily distractible or having difficulty keeping track of what is being said), disorganized thought (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject), and altered level of consciousness (a state of reduced alertness or inability to arouse due to low awareness of the environment). The MDS revealed Resident #22 required limited assistance with one person assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. Record review of Resident #22's care plan, dated 03/04/2020, revealed limited assistance required x1 person for ADLs: bed mobility, transfers, dressing, toileting, adjusting clothing and transfer on/off toilet (continent), bathing, personal hygiene. Resident #22 can feed self with set up. Intervention included adapt my environment to maximize independence as allowed. Record review of Resident #22's care plan, dated 03/04/20, revealed a memory/recall problem related to Alzheimer's disease. Intervention ensure area is free of hazards. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 2 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of an incident report for Resident #22, dated 03/02/23, by DON at 9:10 a.m., revealed .reported by hospice nurse .location the dining room .nature of incident skin tear/laceration and bruise/abrasion, treatment of first aid in facility provided . [DON]called to the dining room by hospice nurse, Resident #22 states 'I bumped my leg on the table' .1 cm long skin tear with surrounding discoloration . Record review of Resident #22's provider investigation report, dated 03/03/23 at 12:25 p.m., revealed .incident category: injury of unknow origin .03/02/23 at 9:10 a.m. not independently ambulatory .not interview able .no capacity to make informed decisions . history of similar allegations .no presence of witness .no statement attached .description of allegation: Resident #22's hospice nurse informed the DON of a large area of discoloration on her shin with 1 cm skin tear .staff were in-serviced on injury of unknown origin and abuse, neglect, and exploitation . Record review of the daily census, dated 03/02/23, revealed Resident #22 resided in 32A. Record review of the nursing assignment sheet, dated 03/01/23, revealed on the 10pm-6am shift: RN K (front hall), ADON O (back hall), CNA P (Front 1-13B rooms), CNA B (14-32A), CNA A (Back) Record review of the nursing assignment sheet, dated 03/02/23, revealed on the 6am-2pm shift: LVN V (front hall), WC N (back hall), CNA W (Front 1-7B rooms), CNA R (Front 9A-24B), CNA Q (Front 25B-32A), CNA L (back). Record review of the employee list last, updated on 03/03/23, revealed 71 employees including department heads and administrative staff. Record review of an Abuse and Neglect in-service training report, given by the DON, for all departments, dated 03/03/23, revealed signatures of CNA A, CNA B, and FD C. Summary of abuse/neglect in-service training report revealed Any suspicion of Abuse must be reported to the ADM/Abuse Coordinator ASAP!! The in-service training report did not reveal signatures for LVN V, WCN N, CNA W, CNA R, CNA Q, CNA L, RN K, CNA P the staff members who worked the night before and morning of Resident #22's incident. Record review of an Injury unknown in-service training report, given by the DON, for all departments, dated 03/03/23, revealed signatures of CNA A, CNA B, and FD C. Summary of injury unknown in-service training report revealed Any skin tear, bruising, etc. That was not witness is considered injury unknown. The in-service training report did not reveal signatures for LVN V, WCN N, CNA W, CNA R, CNA Q, CNA L, RN K, CNA P the staff members who worked the night before and morning of Resident #22's incident. Record review of the 2023 facility In-service binder did not reveal another copy of the Abuse/neglect or Injury unknown training reports dated 02/08/23 or 03/03/23 with more signatures. During an interview on 03/15/23 at 11:14 a.m., CNA Q said she was assigned to Resident #22 on 03/02/23 and worked the 6am-2pm shift. She said she could not remember if Resident #22 was already up and ready when she started her shift. CNA Q said she did not notice any bruises on Resident #22 at the start of her shift nor did she complain of discomfort. CNA Q said Resident #22 required assistance x1 for ADLs but did self-propel herself in the wheelchair. She said nothing in Resident #22's room or at her favorite table in the dining room could had caused the purple/red bruise in the middle of her leg. She said she did not remember doing an in-service on abuse/neglect or injury unknown after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 3 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the incident. CNA Q said she did not remember being interviewed about the incident and did not write a statement. During an interview on 03/15/23 at 11:31 a.m., CNA R said she worked 03/02/23 but did not take care of Resident #22. She said Resident #22 was scheduled for the 10pm-6am shift to get up but sometimes day shift had to get her dressed and in the wheelchair. CNA R said Resident #22 required assistance x1 for ADLs and could self-propel herself in the wheelchair. She said in Resident #22's room and her preferred table in the dining room did not have objects low enough to bump her leg. CNA R said she did not get interviewed about the incident involving Resident #22 or asked to make statement. CNA R said she remembered signing an in-service about abuse/neglect but did not recall if it was after Resident #22's incident. During an interview on 03/15/23 at 1:11 p.m., Resident #22's hospice nurse said she arrived at the facility around 8:50 a.m. on 03/02/23 and found her in the dining room. The hospice nurse said she wheeled Resident #22 to her room to do her assessment and found an abrasion and large dark purple, blackish bruise. She said the abrasion on Resident #22's leg looked like a half circle from a nail. The hospice nurse said when she arrived at the facility no staff member mentioned an incident to explain the abrasion and bruise and Resident #22 did not know what happened. She said Resident #22 had 2 special tables but mostly sat at the one with the window and the tables do not have regular chairs at them to cause a bruise. The hospice nurse said she did not write an involvement statement or was interviewed for Resident #22's incident. On 03/15/23 at 1:23 p.m., attempted to reach CNA A for phone interview, message left with no return call before exit. On 03/15/23 at 1:25 p.m., attempted to reach LVN X for phone interview, unable to leave message with no return call before exit. During an interview on 03/15/23 at 3:00 p.m., LVN V said she worked the day of Resident #22's incident. She said she did not think she was assigned to her but to the nurse assigned to the back hall. LVN V said she did not give a statement to the DON or ADM about not knowing or being involved in Resident #22's injury of unknown origin. During an interview on 03/15/23 at 4:14 p.m. the DON with the Regional Nurse in attendance, said when an incident happened, she reviewed the resident's medication, created, updated, or revised interventions, reviewed incidents report, and created in-services for the staff member such as fall prevention, abuse/neglect, and injury unknown. The DON said she also met with the interdisciplinary teams to help develop intervention for the resident. She said during an investigation of an incident, she interviewed the resident and obtained witness statements. The Regional Nurse said the DON was responsible for internal investigations and the ADM did external investigations like a hospice nurse. The DON said she did not know who got Resident #22 out of bed the morning of her incident or if the hospice aide had visited. The DON said after the incident happened, Resident #22 said she bumped something, so they removed the chair from her preferred table. The Regional Nurse said the facility decided to report it to the State later due to Resident #22's low BIMS. The DON said she talked to some staff members about Resident #22's injury of unknow origin incident but did not document who she spoke with or what they said. The DON said she did not get witness statements for Resident #22's incidents because it was not witnessed. She said she did not interview or get a statement from the hospice nurse because she did not work for the facility. The DON said the facility thought a chair at Resident #22's preferred dining room table may have caused the injury, but they were unsure. The DON said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 4 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #32's unwitnessed incident probably was from a fall but she had obtained statements from staff so Resident #22 should have had documented statements from staff members who worked the last 24-48 hours from the time of the incident. She said it was important to fully investigate incidents to provide a paper trail, rule out abuse and neglect, and to make sure the facility really knew what happened. The DON said the in-services after Resident #32 and #22's incidents, on abuse/neglect and injury unknown, should have been signed by all department staff members. The DON said she did not know the in-services only had 3-6 signatures. The DON said the in-services were for educational purposes. The Regional Nurse said the in-services were also to ensure staff knew what, when, and who to report abuse/neglect and prevention. The DON said all department heads were responsible for making sure their staff signed the in-services. During an interview on 03/15/23 at 4:56 p.m., the ADM said she was the abuse coordinator for the facility. She said her responsibilities involved interviewing staff and resident about the incidents, reviewed the incidents and accidents reports, and put intervention into place. The ADM said it was good to get witness statements or statements from staff members working the day of the incident to make sure the facility had all pieces to the puzzle. She said whoever filled out the incident report was responsible for statements. The ADM said she did not normally get external statements like Resident #22's hospice company employees. She said the in-services made after the incidents were left out for several days, so all staff had an opportunity to read and sign. The ADM said 3 signatures on an abuse/neglect or injury unknown in-service was not sufficient. Record review of an undated Facility Investigation Policy/Procedure revealed .to gather all the accurate and pertinent information when an allegation of abuse, neglect .has been lodged .facility internal investigation .includes resident interview, staff interview, and staff member's statement . make sure to interview all staff members and residents involved .have all staff members write a statement, make sure to include the date and time .after gathering as much information as possible .take appropriate actions as needed .this includes additional in-service Record review of an undated facility injury of unknown source Inservice policy interpretation and implementation policy revealed statements should be taken from all personnel who have contact with resident in the past 48 hours to determine if anyone has observed any incidents that could have contributed to the injury of unknow origin FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 5 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure an accurate MDS was completed for 4 of 24 reviewed for MDS accuracy. (#23 #05 #32, and #40) Residents Affected - Some The facility failed to accurately document Resident #23's antipsychotic and opioid usage. The facility failed to accurately document Resident #05's height, weight, and antidepressant usage. The facility failed to accurately document Resident #32's height and weight. The facility failed to accurately document Resident # 40's fall with injury, weight, height, and opioid usage. These failures could place residents at risk for not receiving needed care and services. Findings included: 1. Record review of an undated face sheet revealed Resident #23 was an 87- year-old- female, admitted on [DATE] with the diagnoses of Alzheimer's disease (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anemia (a condition in which the body does not have enough healthy red blood cells) and malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). Record review of an MDS dated [DATE] for Resident #23 revealed a BIMS of 05, which indicated a severe memory impairment. The MDS also revealed Resident #23 required extensive assistance bed mobility, eating, transfer, and toileting. The MDS revealed Resident #23 had not taken any antipsychotic medications in the look back period (the time period over which the resident's condition or status is captured by the MDS assessment). The MDS revealed Resident #23 had taken 7 days of opioid medication in the look back period. Record review of January 2023 consolidated physician orders revealed Resident #23 had an order for olanzapine (antipsychotic medication) 5mg twice daily and an order for hydrocodone (opioid) 7/325 mg one tablet every 6 hours as needed for pain. Record review of Resident # 23's MAR dated 01/01/2023 to 01/31/2023 indicated Resident #23 had taken olanzapine 5mg twice daily for the entire month of January 2023. The MAR also indicated that zero doses of hydrocodone 7/325 mg had been administered in the month of January 2023. During an interview on 03/15/2023, the MDS nurse revealed Resident #23 should have been coded for antipsychotic use and not coded for opioid use. The MDS nurse stated this was coded in error. The MDS nurse stated miscoding the MDS can affect things like the facility's quality measures and the residents care plan. The MDS nurse stated the residents care plan was used to guide that individualized resident care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 6 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0641 2. Level of Harm - Minimal harm or potential for actual harm Record review of an undated face sheet revealed Resident #05 was a [AGE] year-old- male, admitted on [DATE] with the diagnoses of anemia (a condition in which the body does not have enough healthy red blood cells), COPD (a group of lung diseases that make it hard to breathe and get worse over time), and TIA (transient ischemic attack - is a temporary period of symptoms similar to those of a stroke.) Residents Affected - Some Record review of the MDS dated [DATE] revealed Resident #05 had a BIMS of 07, which indicated a moderate cognitive impairment. The MDS also indicated Resident #05 was limited assistance of one staff member with ADLs including bed mobility, transfer, and toileting. The MDS indicated Resident #05 had a height of 0 inches and a weight of 0 pounds. The MDS indicated Resident #05 received 0 days of antidepressant medication. Record review of consolidated physician's orders dated December 2022 revealed an order for duloxetine (antidepressant) 60mg once daily. Record review of a MAR dated 12/01/2023-12/31/2023 revealed duloxetine 60 mg was administered daily from 12/15/2023 to 12/31/2023. During an interview on 03/15/2023 at 1:00 p.m., the MDS nurse stated Resident #05 was not coded with a height and weight because one was not recorded in the chart. The MDS nurse stated she did not ask for anyone to obtain the height and weight to complete the MDS assessment accurately. The MDS nurse explained that she was the MDS nurse for a sister facility full time and did MDS's for this facility as needed. The MDS nurse stated she came to the facility on occasion, or the facility sent her the information she needed to complete the MDS. The MDS nurse stated no data was available for her to put in the height and weight section of the MDS for Resident #05 sent to her. The MDS nurse stated she overlooked the antidepressant usage. 3. Record review of an undated face sheet revealed Resident #32 was a [AGE] year-old-male, admitted to the facility on [DATE] with diagnoses of anemia (a condition in which the body does not have enough healthy red blood cells), diabetes mellitus (an impairment in the way the body regulates and uses sugar (glucose) as a fuel), and viral hepatitis (an infection that causes liver inflammation and damage). Record review of an MDS dated [DATE] revealed Resident #32 had a BIMS of 08, which indicated a moderate cognitive impairment. Resident #32 required supervision only for all ADLs. The MDS indicated a height of 0 and a weight of 0. Record review of facility weight log 2023 indicated Resident #32 had an admission weight of 157.6 pounds on 02/04/2023. During an interview on 03/15/2023 at 12:00 p.m., Resident #32 stated he was 5 feet 6 inches tall when standing up. During an interview on 03/15/2023 at 1:00 p.m., the MDS nurse stated Resident #32 should have been coded to be 65 inches tall and weigh 158 pounds on the 02/10/2023 admission MDS. The MDS nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 7 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated that information was not available to her when she did the MDS. The MDS nurse stated it was important to know and include residents' weight to track weight loss and gain for each resident. 4. Record review of an undated face sheet revealed Resident #40 was an [AGE] year-old-male admitted to the facility on [DATE] with the diagnoses of heart failure ( a condition that develops when your heart doesn't pump enough blood for your body's needs), pulmonary fibrosis (a lung disease that occurs when lung tissue becomes damaged and scarred), and malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). Record review of an MDS dated [DATE] revealed Resident #40 had a BIMS of 07, which indicated a moderate memory impairment. Resident #40 required extensive assistance with bed mobility and extensive assistance with transfer and toileting. The MDS for Resident #40 indicated two falls with no injury occurred. The MDS was coded with a height of 0 inches and a weight of 0 pounds. The MDS was coded with 0 days of opioid use. Record review of an incident report dated 01/18/2023 revealed Resident #40 fell out of bed onto a fall mat at his bedside and obtained a skin tear. An incident report dated 01/24/2023 revealed Resident #40 fell out of bed onto a fall mat beside his bed no injuries noted. Record review of the weight report revealed no weight for Resident #40 in January 2023. The first recorded weight for Resident #40 was 120.6 pounds in February of 2023. Record review of Resident #40's admission orders dated January 2023 revealed an order for tramadol 50mg one tablet every 8 hours as needed for pain. Record review of Resident #40's MAR dated January 2023 revealed Resident #40 received tramadol 50mg one tablet on 01/20/2023. During an interview on 03/15/2023 at 1:00 p.m., the MDS nurse stated Resident #40 had several errors on his 01/24/2023 MDS after review. The MDS nurse stated Resident #40 should have been coded for 1 fall with no injury and 1 fall with injury. The MDS nurse stated there was no recorded weight for the resident made available to her when doing the MDS but according to the RAI manual she should have put a (-) for the unknown weight. Review of the RAI (Resident Assessment Instrument) manual 2022 version, .If a resident cannot be weighed, for example because of extreme pain, immobility, or risk of pathological fractures, use the standard no-information code (-) and document rationale on the resident's medical record. During an interview on 03/15/2023 at 1:15 p.m., the DON stated it was the responsibility of the MDS nurse to ensure accurate MDS's were produced and transmitted to CMS. The DON stated there was currently no system check in place to audit the MDS accuracy but ultimately the DON or corporate RN signed the MDS for completion and the MDS nurses signed it for accuracy. During an interview on 03/03/2023 at 2:00 p.m., the Administrator stated it was the responsibility of the MDS Nurse to produce accurate MDSs and care plans. The Administrator stated accuracy was important for revenue as well as to ensure the facility was reporting the correct information to CMS on the quality measures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 8 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0641 Level of Harm - Minimal harm or potential for actual harm During a record review of the facility's Minimum Data Set Policy for MDS assessment Data Accuracy, undated, revealed the purpose of the MDS policy was to ensure each resident received an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being. The assessment should accurately reflect the resident's status. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 9 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 2 residents (Resident #20) reviewed for PASRR Level I screenings. Residents Affected - Few The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #20. The PASRR 1 Level screening did not accurately reflect Resident #20 had an indicator or evidence of mental illness, although he had received medical attention for suicidal ideations 9 days prior to his admission to the facility. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of the consolidated physician orders for Resident #20 dated 2/23/23, indicated he was [AGE] years old, admitted to the facility on [DATE] with diagnoses including delusional disorders, major depressive disorder severe with psychotic symptoms, anxiety disorder, history of methamphetamine dependance, and suicidal ideations. Record review of the MDS assessment dated [DATE] indicated Resident #20 had moderate cognitive impairment (BIMS of 9). The MDS indicated Resident #20 had no evidence of a change in mental status from his base line. The MDS indicated he had no behaviors of inattention, disorganized thinking, or altered level of consciousness. The MDS indicated he had moderately severe depression (PHQ-9 [patient health questionnaire for the presence and severity of depression] score of 15). The MDS indicated he had no potential indicators of psychosis. The MDS indicated he had active diagnoses of anxiety and depression. Record review of the MDS assessment dated [DATE] indicated Resident #20 was cognitively intact (BIMS of 13). The MDS indicated Resident #20 had no evidence of a change in mental status from his base line. The MDS indicated he had no behaviors of inattention, disorganized thinking, or altered level of consciousness. The MDS indicated he had no symptoms of depression (PHQ-9 [patient health questionnaire for the presence and severity of depression] score of 0). The MDS indicated he had no potential indicators of psychosis. The MDS indicated he had active diagnoses of anxiety, depression and psychotic disorder other than schizophrenia. Record review of the care plan dated 6/9/23 indicated Resident #20 was being treated for depression, history of suicidal ideation, history of substance abuse, history of delusional disorder and anxiety. The care plan interventions included assess Resident #20's behavioral symptoms to determine if his behaviors present a danger to himself and/or others; intervene as necessary. The care plan was revised on 3/6/23 and indicated Resident #20 had a history of delusional disorder. The revised care plan interventions included do not confront, argue against or deny Resident #20's belief system; keep distance between Resident #20 and others during periods of delusional periods; reinforce and focus on reality . Record review of the transition record from the hospital dated 5/24/22 indicated Resident #20's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 10 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reason for admission to the hospital was Patient suicide ideation states he has no reason to live states he is going to jump off a bridge or cut his wrist. Record review of the hospital psych (psychiatry) consult note dated 6/1/22 indicated Resident #20 had a diagnosis of Major depressive disorder, recurrent, severe with psychotic symptoms. The psych note indicated Resident #20 had suicidal ideation with a plan to cut his wrist and indicated Resident #20 reported he had nothing to live for and indicated he was hearing voices. Record review of the discharge summary from the hospital dated 6/2/23 indicated his discharge diagnosis was major depressive disorder, recurrent, severe with psychotic symptoms. The discharge summary indicated Resident # 20 had been admitted for major depression and underwent psychiatric evaluation and was started on a program of group therapy, recreational therapies, individual therapy/counseling and psychiatric nursing interventions. The discharge summary stated, his medications were gradually adjusted as well and indicated his Seroquel (an antipsychotic drug) was increased to 225 mg (from 150 mg) daily. Record review of the PASRR level 1 screening for Resident #20 dated 6/2/22(prior to his admission to the facility) completed by the hospital social worker, indicated Resident #20 had no evidence or an indicator of mental illness. Record review of the PASRR level 1 screening for Resident #20 dated 6/2/22 (prior to his admission to the facility) entered by LVN Y, indicated Resident #20 had no evidence or an indicator of mental illness. During an interview on 3/15/23 at 1:18 p.m., LVN Y said she worked at the facility as the MDS coordinator and was also responsible for PASRR coordination. LVN Y said with regards to a new admission she entered the screening results from the referring entity (i.e., hospital) into the LTC online portal. LVN Y said she had worked with PASRR coordination since May of 2022. LVN Y said she would have been the one to enter Resident #20's screening information from the hospital into the LTC online portal. LVN Y indicated when she received a negative PASRR screening, she would review the hospital discharge documentation/hospital record to confirm the accuracy of the negative screen. LVN Y said she remembered talking to someone with local health authority regarding Resident #20 and believed it was decided his screen was negative because suicidal ideation was not a qualifying diagnosis for a positive PASRR screen. LVN Y said she could not remember who she had spoken with regarding Resident #20 at the local health authority. During an interview on 3/15/23 at 1:44 p.m., the DON said when the facility received a new admission from the hospital, she would send the PASRR to LVN Y and she (LVN Y) would take it from there. The DON clarified, LVN Y received PASRR screens, reviewed hospital records for screening accuracy and entered the information into the LTC online portal. The DON said she felt Resident #20 having been admitted to the hospital days before his admission to the facility with suicidal ideations would be an indicator of mental illness. The DON said there was no system in place to review or check the accuracy of the nursing facilities current practices in regard to PASRR screenings. During an interview on 3/15/23 at 2:06 p.m., the Licensed Mental Health Authority said it was the responsibility of the facility to review the PASSR screening from the hospital and the medical records from the hospital to ensure accurate PASRR screening completion. The Licensed Mental Health Authority said if the hospital record reflected the Resident had an indication of mental illness, it was the responsibility of the facility to redo the PASRR screening and enter the corrected information (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 11 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0645 Level of Harm - Minimal harm or potential for actual harm into the LTC online portal. The Licensed Mental Health Authority said once the facility entered the PASRR screening information to reflect an indication of mental illness, the local mental health authority would be prompted to come and complete and evaluation. The Licensed Mental Health Authority said it was not up to the facility to determine PASRR eligibility for a resident or to determine what diagnoses would qualify a resident to have been PASRR eligible. Residents Affected - Few During an interview on 3/15/23 at 3:47 p.m., the Administrator said Resident #20's PASRR screening should have been corrected by LVN Y to reflect and indicator of mental illness as he had been admitted to the hospital days before his admission to the facility because of suicidal ideation. The Administrator said there was no system in place to review or check the accuracy of the nursing facility's current practices in regard to PASRR screenings. Record review of the facility policy and procedure titled, Resident Assessment Coordination of PASRR and Assessments, dated 11/28/20 stated, .Coordination. The facility will coordinate assessments with eh pre-admission screening and resident review (PASRR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicate testing and effort . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 12 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 15 residents (Resident #32) reviewed for comprehensive person-centered care plans. The facility failed to implement Resident #32's fall management care plan interventions to inspect room for sharp objects and leave bathroom light on. The facility failed to implement fall prevention program due to not having therapy screen Resident #32's new wheelchair before use. The facility failed to ensure Resident #32 had an anti-pressure cushion for pressure reduction while out of bed in chair. These failures could place residents at risk of not having their individualized needs met, falls and a decline in their quality of care and life. Findings included: Record review of a face sheet dated 02/08/23 revealed Resident #32 was a [AGE] year-old male admitted on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), acquired absence of left leg below knee (amputation), rheumatoid arthritis (a type of arthritis where your immune system attacks the tissue lining the joints on both sides of your body), diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and hepatitis C (a viral infection that causes liver inflammation, sometimes leading to serious liver damage). Record review of Resident #32's admission MDS assessment, dated 02/10/23, revealed Resident #32 was understood and understood others. The MDS reveled Resident #32 had BIMS of 08 which indicated moderate cognitive impairment and required supervision for ADLs. The MDS revealed Resident #32 had falls in the last month prior to admission. The MDS revealed Resident #32 had falls in last 2-6 months prior to admission. The MDS revealed Resident #32 had falls since admission/entry with 2 or more had no injury and 1 had injury (except major; skin tears, abrasions, lacerations, superficial bruises, etc.). Record review of Resident #32's undated fall management care plan revealed potential for falls and injuries related to above the knee amputation left leg, rheumatoid arthritis, diabetes, and hepatitis C. Date of actual falls: 02/05/23 (unwitnessed), 02/06/23 (unwitnessed), 02/07/23 (unwitnessed), and 03/05/23 (unwitnessed). Goals: Remain fall free for 30 days. Remain free of injury related to falls for 30 days. Interventions: 02/05/23-Therapy evaluation, call light education. 02/06/23- Therapy evaluation today, medication review. 02/07/23- Neurological checks, safety education, anti-slip socks, and room change. 02/08/23- Nail care, room inspected for sharp objects. 03/05/23- Leave bathroom light on. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 13 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0656 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #32's care plan dated 03/08/23 revealed at risk for falling related to cognitive impairment with poor decision making and poor safety awareness will not call for assistance in transfers had has multiple falls, has potential to fatigue easily due to anemia and diabetes, left below knee amputation causing balance issues, has episodes of pain, phantom pain, rheumatoid arthritis and takes antidepressant medication. Intervention included place in a fall prevention program. Residents Affected - Few Record review of Resident #32's care plan dated 03/07/23 revealed at risk for skin breakdown related to cognitive impairment, incontinence episodes and refuses care at times, diabetes, left below knee amputation, fatigues easily due to anemia related to rheumatoid arthritis. Intervention included use an anti-pressure cushion for pressure reduction while out of bed in chair. Record review of Resident #32's incident report by LVN V dated 02/05/23 revealed resident room .unwitnessed fall .resident #32 on floor by wheelchair upon entering room resident noted back against wheelchair .Resident #32 stated 'I was gonna try and get over there in that wheelchair and slid down on the floor . Record review of Resident #32's incident report by LVN M dated 02/06/23 revealed .resident room .unwitnessed fall .Resident #32 laying supine between wheelchair and bed .try to get in the bed . Record review of Resident #32's incident report by WCN N dated 02/07/23 revealed . resident room .unwitnessed fall .confused .Resident #32 observed sitting upright in floor on buttocks bedside bed .Resident #32 reported he slid out of bed onto floor trying to get into wheelchair . Record review of an incident report for Resident #32, dated 02/08/23, by LVN X at 5:00 a.m., revealed reported by LVN X .location in room .nature of incident unwitnessed fall with primary injury of laceration/skin tear . treatment of first aid in facility provided .Resident #22 noted by CNA A during rounds a small skin tear with scant blood along the left eyebrow .Resident #22 was in wheelchair .when asked, 'if he had a fall?' Resident #22 responded 'no' then 'I do not know' . Record review of Resident #32's incident report by LVN X dated 03/05/23 revealed .resident bathroom .unwitnessed .during med pass I heard a loud thud and ran to attend to Resident #32 .noted Resident #32 sitting in floor in front of wheelchair on bottom .Resident #32 had scant bleeding from two skin tears lateral of left knee and skin tears lateral of right knee .Resident #32 stated going to the toilet . During an observation and interview on 03/13/23 at 11:27 a.m., Resident #32 was on the secured unit dining room. Resident #32 was sitting in a wheelchair labeled with another resident name on both sides and no wheelchair cushion. Resident #32 wheeled to his room with some difficulty in how he propelled himself. Resident #32's room was noted to have a nightstand by the head of his bed. The nightstand had four pointed, sharp edges. Resident #32's room was noted to have a dresser at the foot of his bed with a television on top of it. The dresser had four pointed, sharp edges. Resident #32 said the bathroom in his room had been broken for a week and he had to go to other resident's bathrooms. During an observation on 03/14/23 at 9:29 a.m., Resident #32 was on the secured unit going up and down the hall. Resident #32 was sitting in a wheelchair labeled with another resident name on both sides and no wheelchair cushion. Resident #32 wheeled to his room with some difficulty in how he propelled himself. During an observation and interview on 03/15/23 at 9:11 a.m., the Maintenance Assistant said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 14 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was responsible for putting padding around resident's furniture for fall interventions. She said Resident #32's nightstand and dresser had sharp edges, but no one had instructed her to wrap his furniture. During an interview on 03/15/23 at 9:15 a.m., CNA L said Resident #32 normally used a bathroom two doors down. CNA L said the residents kept the light on in the bathroom and CNAs had to always turn it off. CNA L said she did not know staff were supposed to keep the bathroom light on for Resident #32 for his falls. During an interview on 03/15/23 at 11:31 a.m., CNA R said she considered Resident #32's nightstand and dresser to have sharp edges. She said Resident #32 went to the bathroom by himself and was never told to keep the bathroom light on to help prevent his falls. During an interview on 03/15/23 at 2:33 p.m., LVN T said she did not know the facility's fall prevention intervention for Resident #32, but she sent a CNA with him to the bathroom. She said Resident #32's room still had sharp objects in his room. LVN T said she heard about keeping Resident #32's bathroom light on but it had been broken since Saturday (03/11/23). LVN T said about a week ago she asked a CNA, she could not recall who, why Resident #32 was in another resident's wheelchair. LVN T said the resident had given Resident #32 her wheelchair because his brakes did not work. During an interview on 03/15/23 at 4:14 p.m., the DON with the Regional Nurse in attendance, said when an incident happened, she reviewed the resident's medication, created, updated, or revised interventions. The DON said she also met with the interdisciplinary teams to help develop interventions for residents. She said after Resident #32's falls the facility provided nail care, therapy, safe education, no sharp objects, and because he fell a lot at night, a light was left on in the bathroom. The DON said she did not think Resident #32's nightstand and dresser had sharp edges. She said Resident #32 moved rooms but if he had sharp edges in his current rooms then his nightstand needed to be padded. The DON said the padding would cushion if he fell and prevented lacerations. She said all nursing staff can see the acute fall management care plan so should have been aware of Resident #32's fall interventions. The DON said nurses were responsible for implementing care plan interventions such as wheelchair cushions if the resident was not on therapy services. The DON said a therapy screen should have been placed for Resident #32 before he was given a new wheelchair. She said no one admitted to giving Resident #32 a new wheelchair. During an interview on 03/15/23 at 1:44 p.m., the DOR said she worked with Resident #32 on 02/10/23, she noticed his wheelchair brake was broken and replaced it with another wheelchair. The DOR said the wheelchair she gave Resident #32 did not have another resident's name on it. She said it would be important for Resident #32 to have the right sized wheelchair so he would not have difficulty propelling himself, reduced pressure, or skin issues, and ensure it had the right equipment in or on it, such as pressure reduction cushion. The DOR said Resident #32's previous wheelchair arm rest was removeable for easier transfers. She said Resident #32 was discharged for rehab services because he had reached maximum potential with skilled services. The DOR said if Resident #32 had more falls or injuries since 02/10/23, he needed to be reevaluated. She said the DON notified her of residents with increased falls who needed to be screened, evaluated, or reevaluated. The DOR said at daily morning meeting she got a report of incidents and accidents and only knew about Resident #32's incidents on 02/13/23 and 03/12/23. She said she would have wanted to see Resident #32 by now. The DOR said Resident #32 could have benefited from toilet modifications, support rails in the bathroom, or sliding board for transfers. She said Resident #32 receiving rehab services would have given him better quality of life, maintain his independence, and safety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 15 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of a facility Care Plans, Comprehensive Person-centered policy, dated 12/16 revealed .a comprehensive, person-centered care plan .to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .the interdisciplinary team, in conjunction with the resident and his/her family .develops and implements a comprehensive, person-centered care plan . Record review of an undated facility Fall Prevention and Management Program revealed .to systematically assess fall risk factors .provide guidelines for fall and repeat fall preventative .manipulation of the environment to prevent falls .and appropriate management of those who experience a fall .DON or designee is responsible .oversight of this policy .assuring implementation of this policy, for providing a safe environment, and maintaining appropriate equipment experts to aid in fall prevention .implementation and oversight of individualized resident fall prevention care . rehabilitation staff will provide assessment for assistive devices and need for gait training .environmental management service and maintenance staff will assure environment is safe .all high fall risk residents .falling star identification program .fall frequently .refer to rehabilitation therapy for further evaluation .gait/mobility problems .have occupational therapy assess the environment and implement their recommendations .often OT will recommend aids like transfer bars or raised toilet seats .place a bedside commode next to bed if the resident has difficulty walking to the bathroom at night . cognitive /memory problems .nursing staff ensure .the resident's bed in low position .toilet seat is at a height that allows easy transfer .assistive devices are working properly and repaired in timely manner .conducting environmental and equipment assessments . Event ID: Facility ID: 675603 If continuation sheet Page 16 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene were provided for 1 of 16 residents (Residents #15) reviewed for ADL care. Residents Affected - Few The facility failed to ensure Resident #15's facial hairs were removed. These failures could place residents at risk of not receiving care/services, decreased quality of life impacting their loss of dignity. Findings included: Record review of the Physician order report dated 3/1/2023-3/31/2023, indicated Resident #15 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including constipation, osteoarthritis (type of arthritis), chronic kidney disease, dementia (impairment of brain function such as memory loss and judgement), anxiety, high blood pressure and heart failure. Record review of the comprehensive MDS dated [DATE], indicated Resident #15 made herself understood and understood others. The MDS indicated Resident #15 had a BIMS score of 7(severe impairment). The MDS indicated Resident #15 required supervision with bed mobility, transfers, dressing, toileting, and personal hygiene. Record review of the care plan dated 2/10/2023, indicated Resident #15 required assistance with personal hygiene. The care plan indicated Resident #15 required encouragement and assistance of one staff member for set-up and supervision with showers. Interventions included assist with ADL's as needed, set-up, assist, give shower, shave, oral, hair, nail care per schedule and as needed. During an observation and interview on 3/13/2023 at 10:43 a.m., Resident #15 said she was to receive a shower three days a week on Monday, Wednesday, and Fridays. Resident #15 had multiple long (approx. 0.5 cm) hairs on her chin. Resident #15 said she would like them shaved or plucked but the staff did not do that regularly. During an observation and interview on 3/14/2023 at 2:00 p.m., Resident #15 had multiple long chin hairs. Resident #15 said she would really like to get rid of the chin hairs. During an observation on 3/15/2023 at 9:35 a.m., Resident #15 had multiple long chin hairs. During an interview on 3/15/2023 at 9:44 a.m., CNA B said she assisted residents on the unit with bathing and personal care. CNA B said Resident #15 would allow staff to assist her with removing chin hairs. CNA B said the facility did not have any razors at times, so she was unable to shave residents at each shower. During an interview on 3/15/2023 at 9:49 a.m., LVN A said chin hairs on women should be removed on scheduled shower days. During an interview on 3/15/2023 at 2:53 p.m., the DON said facial hairs should be removed on shower days and as needed. The DON said ADL's were documented in the electronic medical record and on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 17 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0677 shower sheets by the aides. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/15/2023 at 3:44 p.m., the Administrator said residents should have any facial hair trimmed or shaved during their scheduled shower times and as needed. Residents Affected - Few Record review of a policy dated 2001 titled Shaving the Resident, indicated the purpose of the procedure was to promote cleanliness and provide skin care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 18 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0692 Provide enough food/fluids to maintain a resident's health. 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 provide a therapeutic diet that took into account the residents clinical condition, and preferences for 1 of 1 resident receiving thickened liquids. (Resident #6) Residents Affected - Few The facility failed to serve Resident #6 thickened liquids during lunch per physician's orders. This failure could place residents at risk of coughing, aspiration, pneumonia and poor quality of life. Findings included: Record review of physician's orders dated 3/01/2023-3/31/2023, indicated Resident #6 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including cough, dementia (a general term for memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), depression, high blood pressure and dysphagia (difficulty swallowing foods or liquids). The orders indicated Resident #6 was on a regular diet with nectar thick liquids. Record review of the comprehensive MDS dated [DATE], indicated Resident #6 made herself understood and understood others. The MDS indicated Resident #6 had a BIMS score of 5 (severely impaired cognition). The MDS indicated Resident #6 required supervision for bed mobility, transfers, and toileting. The MDS indicated Resident #6 required extensive assistance with dressing, toileting, and personal hygiene. The MDS indicated Resident #6 was independent eating. Record review of the care plan updated 2/1/2023 indicated Resident #6 had a potential for malnutrition and ordered nectar thickened liquids. During an observation on 3/13/2023 at 12:10 p.m., Resident #6 was sitting in the dining room with a tray of food in front of her, a half of glass of tea with a straw and a cup of ice water. Resident #6 was sipping on the tea when she began to cough. The meal ticket next to the tray said nectar thick tea and water. The tea and water did not appear thickened. During an observation and interview on 3/12/2023 at 12:10 p.m., CNA B removed both the tea and the water from Resident #6 and said her liquids were supposed to have been thickened. During an interview on 3/12/2023 at 12:12 p.m., LVN C said Resident #6 should have had thickened liquids because she had dysphagia and drinking thin liquids could cause her to cough and liquid could go into her lungs. During an interview on 3/15/2023 at 9:10 a.m., ST D said coughing was a reflex when something was trying to enter the airway and the body was trying to clear it. She said if the cough was weak and did not clear the liquid from the airway there could be a risk of aspiration. The ST D said aspiration could lead to pneumonia. During an interview on 3/15/2023 at 9:15 a.m., The DOR said nursing staff was responsible for ensuring residents who were on thickened liquids received thickened liquids. The DOR said it was important Resident #6 received thickened liquids as ordered to prevent aspiration and pneumonia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 19 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0692 Level of Harm - Minimal harm or potential for actual harm During an interview on 3/15/2023 at 9:51 a.m ., LVN A said the kitchen thickened the liquids for Resident #6. LVN A said the meal card served with each resident's tray alerted staff that her liquids should be thickened, and the liquids were labeled as thickened. LVN A said Resident #6 had a hard time swallowing thin liquids after being admitted to the facility and the thickened liquids seemed to help. LVN A said Resident #6 could choke and aspirate the fluids if they were not thickened. Residents Affected - Few During an interview on 3/15/2022 at 11:15 a.m., Dietary aide E said the liquids were purchased pre-thickened for Resident #6. Dietary aide E said the dietary cards instructed the staff on what each resident was to be served. During an interview on 3/15/2023 at 11:20 a.m., the Dietary manager said any dietary orders were sent to her and she placed them on the resident's dietary card, so staff knew what food and drink to serve each resident. The Dietary manager said trays were to be checked by the nurses prior to being served by checking the card versus what was on the plate/tray. During an interview on 3/15/2023 at 2:53 p.m., the DON said Resident #6 got nectar thick liquids due to coughing when drinking thin liquids. The DON said Resident #6 went on hospice care and everyone involved in her care agreed with Resident #6's family member to not do a swallow study but to give Resident #6 nectar thick liquids. The DON said she had not seen or heard her have any issues since starting the thickened liquids. The DON said the danger of Resident #6 not receiving nectar thickened liquids as ordered was choking and aspiration. The DON said it was the responsibility of the dietary department and nursing to ensure Resident #6 received thickened liquids. The DON said staff should check each dietary card versus what was on the plate and tray prior to serving to the residents. During an interview on 3/15/2023 at 3:44 p.m., the Administrator said liquids were bought already thickened and she expected all diet orders to be followed by the kitchen and to be checked for accuracy by the staff passing trays. Record review of a policy dated 2001 titled Therapeutic diets indicated mechanically altered diets, as well as diets modified for medical or nutritional needs, will be considered therapeutic diets and examples include: d. altered consistency diets. The policy indicated the food services manager would establish and use a tray identification system to ensure each resident receives his or her diet as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 20 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Some Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 16 residents reviewed for palatable food. (Resident #37, Resident #20, and Resident #31) The facility failed to provide palatable food served at an appetizing temperature for Resident #37, Resident #20, and Resident #31. This failure could place residents who ate food from the kitchen at risk for weight loss, altered nutritional status, and diminished quality of life. Finding included: 1. Record review of an undated face sheet indicated Resident #37 was an [AGE] year-old female, admitted on [DATE] with diagnoses of dementia (a general term for memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), viral hepatitis (infection that causes liver inflammation and damage) and malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). Record review of an MDS dated [DATE] for Resident #37 revealed a BIMS of 07, which indicated a moderate memory impairment. The MDS also revealed Resident #37 required limited to extensive assistance for bed mobility, transfer, and toileting. Resident #37 was independent with eating. During an interview on 3/13/2023 at 10:15 a.m., Resident #37 stated her only complaint about the facility was that the food was always stone cold. Resident #37 stated she wanted her meals to be hot, but she would settle for warm. Resident #37 stated she refused to eat cold eggs or oatmeal and they were served every day. Resident #37 stated she just sent them back and did not bother trying to eat them. Resident #37 stated the kitchen often put gravy on meat to make them more appetizing, but the gravy was always congealed when she got her tray and she refused to eat that. Resident #37 stated she did not like microwaved meat or eggs, she would just as soon not eat. During an observation and interview on 03/14/2023 at 12:25 p.m., Resident #37 was noted to have a pork chop with gravy, cabbage, a roll, and sweet potatoes on her tray. Resident #37 ate the sweet potatoes, and half the roll. Resident #37 stated she wasn't eating that cold meat with the salty jelled gravy. 2. Record review of the consolidated physician orders for Resident #20 dated 2/23/23, indicated he was [AGE] years old, admitted to the facility on [DATE] with diagnoses including type II diabetes, chronic obstructive pulmonary disease (condition involving constriction of the airways and difficulty or discomfort in breathing), high blood pressure, vitamin b group deficiencies, morbid obesity, and hyperlipidemia (A condition in which there are high levels of fat particles [lipids such as cholesterol and triglycerides]in the blood). Record review of the MDS assessment dated [DATE] indicated Resident #20 was cognitively intact (BIMS of 13). The MDS indicated Resident #20 made himself understood and understood others. The MDS indicated he required no assistance or supervision with eating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 21 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the care plan revised on 3/6/23 indicated Resident #20 had diabetes. The care plan interventions included discourage excessive snacking, discourage family from bringing food for Resident #20 that does not adhere to dietary requirements; and monitor and record food intake. During an interview on 3/13/23 at 10:30 a.m., Resident #20 said the food at the facility was ok. He said the food tasted good but was often cold when he received it. Resident #20 said he could not remember if he had notified anyone about the cold food at the facility. 3. Record review of the consolidated physician orders for Resident #31 dated 2/25/23, indicated he was [AGE] years old, admitted to the facility on [DATE] with diagnoses including disturbances of salivary production, heart disease, diarrhea, nausea, hear failure, muscle wasting/atrophy (weakening, shrinking, and loss of muscle caused by disease or lack of use), GERD (Gastroesophageal reflux disease occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), and vitamin deficiency. Record review of the MDS assessment dated [DATE] indicated Resident #31 had moderate cognitive impairment (BIMS of 10). The MDS indicated Resident #31 made himself understood and understood others. The MDS indicated he required no assistance or supervision with eating. Record review of the care plan revised on 3/6/23 indicated Resident #31 had the potential for malnutrition. The care plan interventions included express to Resident #31 a willingness to adjust dietary regimen, explore alternative dietary options, provide a pleasant environment for eating and encourage family to bring food that Resident #31 will eat. During an interview on 3/13/23 at 10:50 a.m., Resident #31 said he preferred to eat in his room. Resident #31 said his food was often cold or just not warm enough to eat. Resident #31 said he had complained about the food many times to many people including the DON and Administrator, but it did not seem to do any good. During an observation and interview on 3/14/2023 at 1:00 p.m., a lunch tray was sampled by the dietary manager and four surveyors. The sample tray consisted of a pork chop with gravy, cabbage, yams, roll and cookie. The Dietary manager said the pork chop was a little dry and lukewarm in temperature. The Dietary manager said the facility did not have plate warmers to keep the food warm. The Dietary manager stated that the yams were room temperature and said they needed to be warmer. During an interview on 3/15/2023 at 3:44 p.m., the Administrator said residents needed to like what they were eating so they would eat and keep their weight at a healthy level. The Administrator said she expected hot foods to be served hot and cold foods to be served cold. A policy for food palatability was requested but not provided by the facility at the time of exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 22 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure all patient care equipment was in safe operating condition for 2 of 15 residents (Resident#32, Resident #35) reviewed for safe, functional equipment. Residents Affected - Few The facility failed to ensure Resident #32 had a functioning bed brake. The facility failed to ensure Resident #35 had appropriate armrest of his wheelchair. These failures could place residents at risk for skin issues, discomfort, and falls. Findings included: 1. Record review of a face sheet dated 02/08/23 revealed Resident #32 was a [AGE] year-old male admitted on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), acquired absence of left leg below knee (amputation), and rheumatoid arthritis (a type of arthritis where your immune system attacks the tissue lining the joints on both sides of your body). Record review of Resident #32's admission MDS assessment, dated 02/10/23, revealed Resident #32 was understood and understood others. The MDS reveled Resident #32 had BIMS of 08 which indicated moderate cognitive impairment and required supervision for ADLs. Record review of Resident #32's undated fall management care plan revealed potential for falls and injuries related to above the knee amputation left leg, rheumatoid arthritis, diabetes, and hepatitis C. Date of actual falls: 02/05/23 (unwitnessed), 02/06/23 (unwitnessed), 02/07/23 (unwitnessed), and 03/05/23 (unwitnessed). Goals: Remain fall free for 30 days. Remain free of injury related to falls for 30 days. Interventions: 02/05/23-Therapy evaluation, call light education. 02/06/23- Therapy evaluation today, medication review. 02/07/23- Neurological checks, safety education, anti-slip socks, and room change. 02/08/23- Nail care, room inspected for sharp objects. 03/05/23- Leave bathroom light on. During an observation and interview on 03/15/23 at 9:11 a.m., The Maintenance Assistant demonstrated Resident #32's bed mechanism with some difficult. The Maintenance Assistant called CNA L for assistance to work the handles. As the Maintenance Assistant and CNA L maneuvered Resident #32's bed, it would not stay in place. When asked to lock the bed, the Maintenance Assistant could not do it, then CNA L attempted with no success. CNA L said she did not know Resident #32 's bed did not lock because when she arrived for her morning shift, he was already in his wheelchair and out of his room. The Maintenance Assistant said she handled most of the repairs in the facility. She said the Maintenance Supervisor was primarily at their sister facility. The Maintenance Assistant said she made rounds on all the halls every morning looking for issues. She said she picked one random room a day and did a more thorough maintenance check. The Maintenance Assistant said she was responsible for fixing equipment, but she could only fix it if staff told her about it. CNA L said she knew to put repairs in the maintenance book. During an interview on 03/15/23 at 11:31 a.m., CNA R said she did not know Resident #32's bed brake (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 23 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was broken. She said she knew to put repairs in the maintenance book, but repairs took 2-3 months to get done. During an interview on 03/15/23 at 2:33 p.m., LVN T said she did not know Resident #32's bed brake was broken. She said nurse, CNAs, or housekeeping should have noticed Resident #32's bed brake not working. LVN T said Resident #32 had a lot of falls and did not call for assistance, so his furniture needed to be safe. 2. Record review of the undated face sheet revealed Resident #35 was a [AGE] year-old male admitted on [DATE] with diagnoses including cerebral infarction (stroke) with right sided weakness and age-related physical debility (a state of general weakness or feebleness). Record review of the annual MDS assessment dated [DATE] revealed Resident #35 was understood and understood others. The MDS revealed Resident #35 had a BIMS of 09 which indicated moderate cognitive impairment. The MDS revealed Resident #35 required supervision for bed mobility, transfer, dressing, toilet use, and personal hygiene but limited assistance for bathing. The MDS revealed Resident #35 was not steady but able to stabilize without staff assistance for moving from seated to standing position, walking, turning around, moving on and off toilet, and surface-to-surface transfer. The MDS revealed Resident #35 did not have functional limited range of motion. The MDS revealed Resident #35 used wheelchair. Record review of Resident #35's care plan dated 04 /27/19 revealed at risk for falls. Intervention included implement exercise program that targets strength, gait, and balance. Record review of Resident #35's care plan dated 10/30/2020 revealed required supervision/extensive assistance for ADLs. Interventions bed mobility assist x1 for supervision and transfer assist x1. I [Resident #35] am independent for locomotion once I am in my wheelchair. Record review of Resident #35's care plan dated 06/25/19 revealed complaint of chronic pain related to previous cerebrovascular accident (stroke), to my right arm. Intervention included offer positioning assistance for comfort. Record review of Resident #35's care plan dated 04/27/19 revealed at risk for injury/bruising related to anticoagulant (prevent or reduce coagulation of blood) medication and right sided hemiplegia (paralysis of one side of the body) related to cerebrovascular accident. Intervention encourage me to protect my right side from injury. During an interview and observation on 03/13/23 at 10:24 a.m., Resident #35 was in his room sitting in his wheelchair. Resident #35's wheelchair had gray, foam material with several strips of tape around the metal piece of the body of the wheelchair. On Resident #35's armrest was flattened gray foam with several strips and layers of tape of both sides. When the flattened gray foam was lifted, a thin piece of non-padded cardboard was exposed. Resident #35 said he had been using the wheelchair for about a year the way it was. He said about six months ago the facility was supposed to replace his armrest, but maintenance did not have the right size. Resident #35 said his current arm rests were not comfortable especially when he transferred or repositioned himself. During an interview on 03/15/23 at 9:40 a.m., the Maintenance assistant said she was responsible for the maintenance on resident's wheelchairs. The Maintenance assistant found Resident #35 in the hallway and looked at his wheelchair. She said Resident #35's wheelchair had always had the gray foam (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 24 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few around the metal frame. The maintenance assistant said she did not know why Resident #35 did not have proper armrest. She said the nurses should have told her Resident #35 needed new armrest or put it in the maintenance book. Resident #35 told the maintenance assistant, remember you were supposed to order some new armrest because the ones you had did not fit. She said, you are right, Mr. [Resident #35]. During an interview on 03/15/23 at 2:40 p.m., LVN V said when Resident #35 started using his current wheelchair, it was not in the shape it was currently in. She said Resident #35 used his wheelchair a lot and it had gone downhill. LVN V said she knew to let maintenance know or put in the logbook about repairs, but she honestly did not notice the condition of his armrest until it was brought to her attention. She Resident #35 needed a wheelchair in good repair because he used it a lot for his ADLs and did not want him to hurt himself when he transferred. During an interview on 03/15/23 at 4:14 p.m., the DON with the Regional Nurse in attendance said the CNAs and nurses should have noticed Resident #32's bed brake was broken and placed it in the maintenance book. She said maintenance was also responsible for the upkeep of resident wheelchairs. The DON said Resident #35 should have a good wheelchair for his safety and dignity. During an interview on 03/15/23 at 4:56 p.m., the ADM said maintenance was responsible for the upkeep of resident's equipment. She said staff should place issues in the maintenance binder and maintenance should check the binder daily. The ADM said maintenance completed a weekly maintenance checklist and she spot checked areas to ensure the checklist was accurate. She said properly working equipment or furniture was important for dignity and safety purposes. Record review of the maintenance binder dated 2022 did not reveal maintenance request for Resident #35's wheelchair arm rest replacements. Record review of the maintenance binder dated 2023 did not reveal maintenance request for Resident #35's wheelchair arm rest replacements or Resident #32 bed brake. Record review of the facility's weekly maintenance checklist x5 weeks, dated 01/23 revealed .Furniture not broken/damage in resident rooms . Record review of the facility's weekly maintenance checklist x4 weeks, dated 02/23 revealed .Furniture not broken/damage in resident rooms . Record review of a facility Assistive Devices and Equipment policy dated 07/17 revealed .our facility provides, maintains, trains, and supervise the use of assistive devices and equipment for residents .devices and equipment that assist with resident mobility, safety, and independence are provided for residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 25 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, 5 of 15 residents (Resident #5, Resident #21, Resident #18, Resident #28, Resident #32) reviewed for environment. The facility failed to ensure Resident #5, and Resident #32 had light cover over their light fixtures. The facility failed to ensure Resident #21's overhead light cover was not broken and unsecured. The facility failed to ensure Resident #28, Resident #18, and Resident #21 did not have objects on top of their overhead light fixtures. The facility failed to ensure Resident #32 did not have furniture with peeling particles and water damage. These failures could place residents at risk for diminished quality of life. Findings included: During an observation on 03/13/23 at 11:25 a.m., Resident #21 was lying in bed asleep on the secured unit. From the doorway, Resident #21's light fixture cover which was horizontal with her bed was leaning. On top of Resident #21's light fixture, a small teddy bear, cardboard Christmas ornament, and a teddy bear in a wooden box was observed. Resident #28, roommate of Resident #21, was not in the room. On top of Resident #28's light fixture which was above the head of her bed, were 3 objects. During an observation on 03/13/23 at 11:27 a.m., Resident #18 had 3 medium sized teddy bears and 4 paper cards on top of his light fixture which was horizontal to his bed on the secured unit. Resident #32, roommate of Resident #18, had exposed long fluorescent tube light bulb with no light cover directly over the head of his bed. The bulb was warm but not hot to touch. Next to Resident #32's bed was a nightstand with several area of missing particleboard and the bottom had a large strip of missing particleboard. During an observation on 03/13/23 at 2:00 p.m., Resident #21 was lying in bed asleep on the secured unit. From the doorway, Resident #21's light fixture cover which was horizontal with her bed was leaning. On top of Resident #21's light fixture, a small teddy bear, cardboard Christmas ornament, and a teddy bear in a wooden box was observed. Resident #28 was not in the room. On top of Resident #28's light fixture which was above the head of her bed, was 3 objects. During an observation on 03/14/23 at 9:20 a.m., Resident #21 was lying in bed asleep on the secured unit. From the doorway, Resident #21's light fixture cover which was horizontal with her bed was leaning. On top of Resident #21's light fixture, a small teddy bear, cardboard Christmas ornament, and a teddy bear in a wooden box was observed. Resident #28 was not in the room. On top of Resident #28's light fixture which was above the head of her bed, were 3 objects. During an observation on 03/13/23 at 09:29 a.m., Resident #18 had 3 medium sized teddy bears and 4 paper cards on top of his light fixture which was horizontal to his bed on the secured unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 26 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #32 had exposed long fluorescent tube light bulb with no light cover directly over the head of his bed. The bulb was warm but not hot to touch. Next to Resident #32's bed was a nightstand with several area of missing particleboard and the bottom had a large strip of missing particleboard. During an interview and observation on 03/14/2023 at 10:30 a.m., Resident #5 stated he was concerned about the light fixtures in his room. Resident #5 stated he shared a room with his family member, and she had dementia that was getting progressively worse. Resident #5 stated it was dangerous for himself and his family member to have exposed light bulbs in their light fixtures above their beds. Resident #5 stated he feared he or his family member would accidently bump the bulb or the fixture making the bulb fall out and shatter. During the observation it was noted that both beds were long way, up against the wall. It was also noted both beds had an exposed long fluorescent tube light bulb with no light cover directly above their body in the bed. The bulb was warm but not hot to touch. During an observation on 03/14/23 at 9:20 a.m., Resident #21 was in the dining room on the secured unit. From the doorway, Resident #21's light fixture cover which was horizontal with her bed was leaning. On top of Resident #21's light fixture, a small teddy bear, cardboard Christmas ornament, and a teddy bear in a wooden box was observed. Resident #28 was not in the room. On top of Resident #28's light fixture which was above the head of her bed, were 3 objects. During an observation and interview on 03/15/23 at 9:00 p.m. Resident #21 was in the dining room on the secured unit. From the doorway, Resident #21's light fixture cover which was horizontal with her bed was leaning. On top of Resident #21's light fixture, a small teddy bear, cardboard Christmas ornament, and a teddy bear in a wooden box was observed. Resident #28 was not in the room. On top of Resident #28's light fixture which was above the head of her bed, were 3 objects. the Maintenance Assistant said she handled most of the repairs in the facility. She said the Maintenance Supervisor was primarily at their sister facility. The Maintenance Assistant said she made rounds on all the halls every morning looking for issues. She said she picked one random room a day and did a more thorough maintenance check. She said she had not noticed Resident #21's leaning light fixture cover. The Maintenance assistant took the cover off the light fixture, and it was broken on one side. She said someone probably knocked it off, broke it and did not put in a work order. The Maintenance Assistant said she was responsible for fixing equipment, but she could only fix it if staff told her about it. The Maintenance assistant said nothing heavy should be on top of the light fixture covers. She said the facility's policy was nothing was allowed on top of the light fixture. She said nothing should be on top of the light fixture because of safety reasons and the objects could hit the residents. Resident #18 had 3 medium sized teddy bears and 4 paper cards on top of his light fixture which was horizontal to his bed on the secured unit. Resident #32 had exposed long fluorescent tube light bulb with no light cover directly over the head of his bed. The bulb was warm but not hot to touch. Next to Resident #32's bed was a nightstand with several area of missing particleboard and the bottom had a large strip of missing particleboard. The maintenance assistant said she had also missed Resident #32 not having a light fixture cover. She said no one and informed her Resident #32 did not have a cover. The Maintenance assistant said her, and the housekeeping supervisor had made a list of residents who needed new furniture on Monday (03/13/23). She said the facility did not have to order new furniture; they took furniture from empty rooms. She said Resident #32's nightstand should have been changed out because it had water damage. The maintenance assistant said Resident #32's nightstand was tacky. During an observation on 03/15/2023 at 10:45 a.m., the light bulbs in Resident #05's room were still directly above the residents in bed and had no cover leaving the bulbs exposed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 27 of 28 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 675603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Haven Retreat 200 Live Oak St Atlanta, TX 75551 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 03/15/23 at 11:31 a.m., CNA R said she knew to put repairs in the maintenance book, but repairs took 2-3 months to get done. During an interview on 03/15/23 at 12:43 p.m., the housekeeping supervisor said the building was an older building and she did the best she could to keep the place clean and tidy. She said she replaced furniture like overbed tables, dressers, and bedside tables, as it needed to be replaced. She said she rounded and looked for furniture that needed to be replaced once a week and replace what needed to be replaced or if the staff told her it needed to be replaced. During an interview on 03/15/23 at 2:33 p.m., LVN T said she had not noticed any furniture on the secure unit needing to be replaced. She said she did not notice Resident #32 had no light cover or Resident #21 light cover was leaning and if she did, she would have put it in the maintenance book. She said she did not recommend putting things on top of the light fixture because it was a fire hazard. During an interview on 03/15/23 at 4:14 p.m., the DON with the Regional Nurse in attendance said the CNAs and nurses should have noticed no light covers, broken light covers, and furniture was broken and placed it in the maintenance book. The DON said the maintenance assistant updated the ADM on furniture that need to be replaced. She said maintenance was responsible for the upkeep of the building. The DON said it was a safety and dignity issue. She said this was the resident's home and needed to suit their needs. She said maintenance should do inspection to ensure resident's items were not stored on top of the light fixtures. The DON said staff should also be make sure of that too. She said it was a fire hazard. During an interview on 03/15/23 at 4:56 p.m., the ADM said maintenance was responsible for the upkeep of resident's equipment. She said staff should place issues in the maintenance binder and maintenance should check the binder daily. The ADM said maintenance completed a weekly maintenance checklist and she spot checked areas to ensure the checklist was accurate. She said properly working equipment or furniture was important for dignity and safety purposes. The ADM said anyone can report broken or furniture that needed to be replaced to maintenance. Record review of the facility's weekly maintenance checklist x5 weeks, dated 01/23 revealed .Furniture not broken/damage in resident rooms . light bulbs/covers working Record review of the facility's weekly maintenance checklist x4 weeks, dated 02/23 revealed .Furniture not broken/damage in resident rooms . light bulbs/covers working Record review of a facility Fire Safety and Prevention policy dated 05/11 revealed .all personnel must learn methods of fire prevention and must report condition(s) that could result in a potential fire hazard . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 28 of 28