Health inspection·April 17, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm During an interview on 4/14/23 at 12:20 p.m., Resident #4 indicated the way Sitter E spoke to him made him feel angry and embarrassed. 2.Record review of Resident #3's face sheet dated 6/24/22 indicated she was [AGE] years old, re-admitted to the facility on [DATE] with diagnoses including dementia, disorientation, and heart disease. Residents Affected - Few Record review of the MDS dated [DATE] indicated Resident #3 was understood and made herself understood. The MDS indicated Resident #3 had severe cognitive impairment (BIMS of 6). The MDS indicated she had no behavior of rejecting care and no physical or verbal behaviors towards others. The MDS indicated Resident #3 required limited assistance with dressing, personal hygiene, and bathing. The MDS indicated Resident #3 required supervision with all other ADLS except locomotion (for which no assistance/supervision was required). Record review of the care plan revised on 2/14/23 indicated Resident #3 had diagnoses of anxiety, delusional thinking, and depression. The care plan interventions included, monitor if Resident #3's behavior/mood symptoms present a danger to herself or other residents and intervene as needed. The care plan interventions also included to avoid over stimulation (such as noise, crowding, other physically aggressive residents) and maintain a calm environment for Resident #3, maintain a calm approach with Resident #3. During an observation on 4/14/23 at 12:10 p.m., Resident #3 sat beside Sitter E infront of the nursing station. Resident #4 sat infront of Sitter E. Resident #3 began to speak rudely to Resident #4. Sitter E attempted to intervene. Sitter E spoke in a rude tone of voice and yelled at Resident #3 Back off! Back off! Leave him alone! Be quiet! Leave him alone! I'm going to make you get up out my chair if you keep it up! Resident #3 continued to speak rudely and grew louder in response to Sitter E. During an interview on 4/14/23 at 12:35 p.m., Resident #3 indicated she did not recall Sitter E talking to her at the nursing station. During an interview on 4/14/23 at 12:45 p.m., Sitter E said she had worked at the facility for about 8-9 years. Sitter E said she worked from 6:30 a.m. to 2:30 p.m., Monday through Friday. Sitter E said until recently she also worked 4 days a week from 11:00 p.m. to 7:00 a.m. at another facility. Sitter E indicated she had known Resident #4 for a long time. Sitter E stated, He (Resident #4) does a lot of stuff to aggravate me. Sitter E said she did not intend to upset Resident #4. Sitter E said I might have been too much. I didn't mean to be. They just keep going and going. Sitter E indicated she thought when she yelled at Resident #3, she (Resident #3) would stop being mean to Resident #2. During an interview on 4/14/23 at 2:15 p.m., LVN A said Sitter E spoke loudly because she was hard of hearing. During an interview on 4/17/23 at 10:10 a.m., CNA C said residents should be treated with respect and dignity. CNA C said if a resident was being rude to another resident staff should intervene in a calm manner. During an interview on 4/17/23 at 10:15 a.m., CNA D indicated she did not usually work on the secured unit and just started working on the secured unit in the past 2 days. CNA D said she had not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 2 of 7 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 04/17/2023 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few heard anything bad about Sitter E. CNA D said all residents should always be treated with dignity and respect. CNA D said if a resident was being rude to another resident they should be separated. During an interview on 4/17/23 at 10:30 a.m., CNA B indicated he regularly worked on the secured unit and regularly worked with Sitter E. CNA B said if a resident was being rude to another resident staff should intervene in a calm manner in order not to escalate the situation. He said the residents should also be separated. During an interview on 4/17/23 at 11:10a.m., LVN G said she always worked on the secured unit. LVN G said if residents were involved in a verbal altercation they should be separated. LVN G indicated staff should speak calmly to deescalate the situation. During an interview on 4/17/23 at 11:55 a.m., the DON said Sitter E had worked at the facility a long time. The DON said Sitter E speaking rudely to Resident #4 was not appropriate and was a dignity/respect issue. The DON said while she supported intervention with a resident-to-resident verbal altercation, it should be handled in a calm and respectful manner. During an interview on 4/17/23 at 12:10 p.m., the Administrator said she knew Sitter E spoke loudly but had never witnessed nor had it been reported to her that Sitter E was disrespectful towards residents. The Administrator said all residents should be treated with respect and dignity. Record review of the facility policy and procedure titled, Dignity revised February 2021, stated .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being , level of satisfaction with life and feelings of self-worth and self-esteem .Residents are treated with dignity and respect at all times .Staff speak respectfully to residents at all times .Staff are expected to treat cognitively impaired residents with dignity and sensitivity . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 3 of 7 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 04/17/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident hazards for 2 of 5 residents reviewed for accident hazards (Resident #1 and Resident #2). The facility did not ensure Resident #1 had appropriate footwear on. The facility did not ensure Resident #2's bed had a locking mechanism in place. These failures could place dependent residents at risk for falls and injury. Findings included: 1.Record review of Resident #1's face sheet dated 12/21/22 indicated she was [AGE] years old, admitted to the facility on [DATE] with diagnoses including; history of hip fracture, dementia, osteoporosis (condition in which the bones become brittle and fragile from loss of tissue), and history of repeated falls. Record review of the MDS dated [DATE] indicated Resident #1 was understood and made herself understood. The MDS indicated Resident #1 had severe cognitive impairment (BIMS of 6). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #1 required extensive assistance with dressing and personal hygiene. The MDS indicated Resident #1 required supervision with bed mobility, transfers, walking, and toilet use. The MDS indicated Resident #1 had 2 or more falls since admission that resulted in no injuries. Record review of the care plan revised on 3/8/23 indicated Resident #1 was at risk for falls due to cognitive impairment with poor safety awareness. The care plan indicated Resident #1 had a history of repeated falls. The care plan interventions included Resident #1 was to be provided proper, well-maintained footwear. Record review of the facility Incident/Accident Tracking Log for the month March 2023, revealed Resident #1 had three unwitnessed falls on the following dates: 3/21/23; 3/24/23; and 3/31/23. The Incident Log indicated these falls did not result in any injuries. Record review of the Incident Report for Resident #1 dated 3/21/23 indicated she was found sitting on the floor in her room between her bed and her wheelchair. The incident report indicated Resident #1 was assessed and found with no injury. Record review of the Incident Report for Resident #1 dated 3/24/23 indicated she was found sitting on the floor in her room infront of her wheelchair. The incident report indicated Resident #1 was assessed and found with no injury. Resident #1's Incident Report for 3/31/23 was requested from the Administrator on 4/17/23 at 1:00 p.m. but not received . Record review of the facility Incident/Accident Tracking Log for the month April 2023, revealed Resident #1 had one unwitnessed fall on 4/8/23. The Incident Log indicated the fall resulted in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 4 of 7 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 04/17/2023 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 0689 swelling and discoloration to Resident #1's right eye. Level of Harm - Minimal harm or potential for actual harm Record review of the Incident Report for Resident #1 dated 4/8/23 indicated she was found on the floor in her room. The incident report indicated Resident #1 was assessed and was found with a 4 inches x 3 inches knot to the right side of her forehead with discoloration. Residents Affected - Some During an observation on 4/13/23 at 3:30 p.m., Resident #1 scooted herself around the secured unit dining room in her wheelchair. Resident #1 had two black eyes, the bridge of her nose was bruised and was light green in color. The right side of her face (from the top of her forehead to the base of her cheek) was bruised and was purple to black in color. Resident #1 had soft fuzzy socks that were pink and gray in color. The left sock was twisted and revealed the bottom surface of the sock at the ankle. There was no anti-skid gripping on the bottom of the sock. During an interview on 413/23 at 3:35 p.m., CNA H said all residents should have appropriate footwear on to prevent falls. CNA H indicated appropriate footwear included shoes with a sole that were not slick or socks with grips on the bottom . CNA H indicated the bruising to Resident #1's face was a result from her fall on 4/8/23. During an interview and observation on 4/13/23 at 3:40 p.m., LVN G said it was important for residents to have appropriate footwear on to prevent falls. She indicated this was especially true for residents on the secured unit such as Resident #1. LVN G said on the secured unit most of the residents do not have safety awareness and must be watched closely. LVN G indicated the bruising to Resident #1's face was a result from her fall on 4/8/23. During an interview on 4/13/23 at 4:30 p.m., Resident #1 sat in her wheelchair in the secured unit dining room. Resident #1 still had the soft fuzzy socks that were pink/gray in color and without grips on her feet. 2. Record review of Resident #2's face sheet dated 3/30/23 indicated she was [AGE] years old, admitted to the facility on [DATE] with diagnoses including; muscle weakness, dementia, malnutrition, dysphagia (difficulty or discomfort in swallowing), aphasia (disorder that effects communication). Record review of the MDS dated [DATE] indicated Resident #2 had severe cognitive impairment (BIMS of 3). The MDS indicated Resident #1 required extensive assistance with dressing and personal hygiene. The MDS indicated Resident #2 required limited assistance with dressing, personal hygiene, and toileting. The MDS indicated she required extensive assistance with bathing. The MDS indicated Resident #2 required supervision with all other ADLS except locomotion. The MDS indicated she had not had any falls since admission. Record review of the care plan dated 4/6/23 indicated Resident #2 was at risk for falls due to cognitive impairment. The care plan interventions included Resident #2's bed wheels were to be locked. Record review of the facility Incident/Accident Tracking Log for the month March 2023, indicated Resident #2 had no falls or incident in March (Resident #2 admitted to the facility 4/30/23). Record review of the facility Incident/Accident Tracking Log for the month April 2023, revealed Resident #2 was found with bruising to her arms on 4/5/23. Record review of the Incident Report dated 4/5/23 indicated Resident #2 was found with purple (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 5 of 7 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 04/17/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some discoloration to both of her upper arms (above the elbows and below the shoulder). The Incident Report indicated Resident #2 had been found sitting in the dining room floor on many occasions since her admission to the facility. The incident report indicated Resident #2 had no documented falls since her admission. During an observation 4/13/23 at 3:35 p.m., revealed Resident #2 sat in her wheelchair in the secured unit dining room. Resident #2 had bruising (black and purple in color) to both upper portions (above the elbows and below the shoulder) of her arms. During an interview and observation on 4/13/23 at 3:40 p.m., LVN G took the surveyor to Resident #2's empty room. LVN G said Resident #2's bed was changed because staff would find the bed swung to one side or the other and felt it was not safe. LVN G said the bed swung freely because there were no brakes on the bed. LVN G said the bed was replaced because of how freely it moved. LVN G grabbed the foot of Resident #2's bed (the new bed) and moved it to the left then right. While she moved the bed LVN G said, this bed moves too but not as bad as the other one did. There were no locking mechanisms on the bed (the new bed). LVN G then walked to the other bed in the room which was located on the far right with one side against the wall. LVN G grabbed the foot of that bed and moved it with one hand to left and indicated it was her old bed. The 'old' bed moved quickly and freely. Neither the 'old' bed nor the 'new' bed had locking mechanisms. LVN G indicated she had not notified the maintenance director about the bed but said she could not say if other staff had notified the maintenance director. LVN G said the night shift nurse had changed the beds out. LVN G indicated she did not know if another bed was available. During an interview on 4/14/23 at 2:15 p.m., LVN A said bed wheels should be locked to prevent residents from falls and injuries. LVN A indicated if a bed was missing a locking mechanism the bed should have been recorded in the maintenance book in order for it to be repaired. LVN A said residents should have appropriate footwear (non-slip shoes or socks) to prevent falls and injuries. During an interview on 4/17/23 at 10:10 a.m., CNA C said residents not having appropriate footwear on was a safety issue. CNA C said appropriate footwear included socks with slip proof gripping on the bottom or shoes with ant-slip sole. CNA C said beds should remain locked unless staff were in the room and needed to move the bed to provide care. CNA C said an unlocked bed was a safety issue and could cause a resident to fall. CNA C said if a bed was missing brakes, she would notify the nurse and the maintenance director so the bed could be replaced. During an interview on 4/17/23 at 10:15 a.m., CNA D indicated bed wheels should be locked to prevent resident falls and injuries. CNA D said if a bed was missing brakes and could not be locked, she would tell the nurse on duty. CNA D said residents should have appropriate footwear (non-slip shoes or socks) to prevent falls. During an interview on 4/17/23 at 10:30 a.m., CNA B indicated bed wheels should be locked to prevent residents from falls and injuries. CNA B indicated if a bed was missing a locking mechanism, he would notify the nurse right away because a bed without brakes posed a risk for injury to both the resident and the staff that provided care. CNA B said he would also log the bed in the maintenance book so it could be repaired. CNA B said residents should have appropriate footwear (non-slip shoes or socks) to prevent falls. Record review of the Maintenance Log for April 2023 indicated no bed missing brakes had been logged in the maintenance book. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 6 of 7 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 04/17/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/17/23 at 11:00 a.m., the Maintenance Director said no staff had notified her of a bed missing brakes or a bed that would not lock. She said there was not a system in place in which she routinely or systematically checked the facility beds for brakes. The Maintenance Director said she relied on staff to notify her of if a bed would not lock. During an interview on 4/17/23 at 11:55 a.m., the DON said beds without breaks and residents in inappropriate footwear were significant fall risks. The DON indicated she expected staff to ensure residents had appropriate footwear on especially on the secure unit as most residents had decreased safety awareness and decreased cognition. The DON said she expected nurses to check to ensure residents had appropriate footwear throughout their shifts when routine care was provided. The DON said Resident #1 should have had appropriate footwear on her feet. The DON said there was no system in place, that she was aware of, to ensure beds locked. The DON said she expected staff to notify the maintenance director if a bed was found that could not be locked. The DON said she expected staff to remove the bed from service until it could be repaired. The DON said neither of the beds that would not lock should have been in Resident #2's room. During an interview on 4/17/23 at 12:10 p.m., the Administrator said she expected staff to notify herself and the maintenance director if a bed would not lock. The Administrator said she expected staff to notify the maintenance director in person and record the bed in the maintenance log in order for it be repaired. She said the bed should have been removed from Resident #2's room and indicated the bed should have been replaced with a locking bed. The Administrator said she expected staff to ensure that all residents had appropriate footwear. The Administrator indicated beds without breaks and residents wearing inappropriate footwear posed a risk of injury. Record review of the undated facility policy and procedure titled, Fall Prevention and Management Program, stated Purpose: To establish policy, assign responsibility and provide procedure for residents at risk for falls; to systematically assess fall risk factors; provide guidelines for fall and repeat fall preventative interventions; and outline procedures for documentation and communication procedures . (3) the Director of Nursing, Designee, or Charge Nurses are responsible for implementation and oversight of individualized residents fall prevention care as follows: .( e) Supervising direct care personnel in delivering safe and personalized care .(5) Environmental Management Staff Service and Maintenance staff will ensure environment is safe. (8) Cognitive/Memory problems- this includes residents who forgot their limitations. For these residents there are a variety of interventions. (a) Nursing Staff ensure .Resident has appropriate footwear present (i.e., for tiled floors either treaded slipper socks or hard sole shoes) .(9) Conducting Environmental and Equipment Assessments . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 7 of 7