Health inspection·July 18, 2023

F 0925 Level of Harm - Minimal harm or potential for actual harm them. She said the Pest Control Company came out to the facility after that and treated the kitchen. She said she did not remember the date. She said the Maintenance Director went into the kitchen and followed up after the Pest Control Company had visited. She said she was not sure what the Maintenance Supervisor did to help prevent roaches, but she had not seen any roaches since then. The surveyor did not see any roaches in the kitchen. Residents Affected - Many During an interview and record review on 7/15/23 at 11:19 a.m., the Administrator provided the surveyor the last Pest Control Company visit dated 6/13/23. The [Name of Company] indicated on 6/13/23 they had inspected the facility. The public areas indicated German Roaches, inspected and applied treatment . The Administrator showed the surveyor the contract dated 10/16/13. The [Name of Company] indicated they had a Commercial Outside Pest Control contract monthly. During an interview on 7/15/23 at 11:27 a.m., RN C said she had seen roaches in the last few days in the Secured Unit but had not seen anyone come out to spray for the roaches. During an interview on 7/15/23 at 11:39 a.m., the DON said they were considering changing pest control company's because of the roaches. She said their current Pest Control Company was due to be at the facility Tuesday, (7/18/23). She said the Maintenance Director had put something out last week for roaches/bugs until the Pest Control Company came. She said she was not sure what he had done. During an interview on 7/15/23 at 12:04 p.m., CNA D said she always worked in the Secure Unit. She said she had seen roaches in the Secure Unit shower room this morning. She said when she turned the light on, they ran. She said they were the little type of roaches. She said she had seen the Pest Company spray for them, but it did not seem to be doing any good. She said she did not remember when they had sprayed for the roaches. During an interview on 7/15/23 at 12:24 p.m. the Administrator said she called another Pest Control Company and they were supposed to be at the facility today to spray for the roaches. During an interview and record review on 7/15/23 at 12:40 p.m., the DON showed the surveyor a sheet indicating the Maintenance Director had put out glue strips in the kitchen for the roaches on 7/6/23. The document was titled Maintenance Log and indicated: 7/6/23 Kitchen, put out glue strips. The Maintenance Director had signed the log. During an interview on 7/18/23 at 8:30 a.m., Resident #5 (room [ROOM NUMBER]) said she saw one roach on her floor yesterday. She said she had only seen one. During an observation and interview on 7/18/23 at 8:38 a.m., revealed Resident #6 (room [ROOM NUMBER]) was sitting on his bed that was on the floor. His bed side table was adjusted for his bed so he could eat his meals sitting on his bed. He said he saw a roach on his bed side table today at breakfast time and he killed it. During an interview on 7/18/23 at 8:43 a.m., the Administrator said a new Pest Control Company came out Monday (7/17/23) and they would be sending a quote for the building. She said she had not received the quote at this time. During an interview on 7/18/23 at 8:55 a.m., CNA E said there were roaches all over the building and it was horrible. She said she had seen roaches today on the floor on hall 100, behind the trash can on hall 100, and in room [ROOM NUMBER]. She said roaches had been a problem in the facility for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 2 of 4 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 07/18/2023 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many about 2 months. She said she had seen the Pest Control Company come to spray but did not remember when they were there. She said the treatment by the Pest Control Company did not seem to help get rid of the roaches. During a record review and interview on 7/18/23 at 9:14 a.m., the Administrator provided the [Name of Company] contract. The contract indicated Commercial Outside Pest Control. She said that was the only contract she had. She said they treated the inside and outside as needed. She indicated to the surveyor a section on the visit 6/13/23 that indicated the Pest Control Company had inspected and performed preventative treatment to the laundry/storage area. The document indicated German Roaches were found in public areas and were inspected with treatment applied. During an interview on 7/18/23 at 9:24 a.m., CNA F said she saw roaches in the Secure Unit today. She said she saw 3 or 4 in bathroom/shower room. She said they ran off when she turned on the light. She said she had seen roaches in the Secure Unit for months and everyone knew there was a roach problem. She said a Pest Control Company came out and sprayed but it did not do any good. During an interview on 7/18/23 at 10:00 a.m., LVN G said roaches had been a problem in the facility for months. She said they were in residents' rooms, halls, and medication rooms. She said she had told the Administrator, DON, and Maintenance Director. She said roaches were all over the building. During a phone interview on 7/18/23 at 10:27 a.m., the Maintenance Director said roaches in the kitchen was a newer, more recent thing. He said the rain lately had pushed the roaches in the facility. He said the roaches had been bad in the facility for the last 2 weeks. He said he put out bait trays and glue traps in the utility closets (mops and brooms) in the kitchen, the kitchen pantries, and different areas in the kitchen last Thursday (7/13/23). He said he had seen roaches in the utility closets and kitchen pantries. He said he did not know if there were roaches today. He said his Maintenance Log reflected he put out glue strips on 7/6/23 in the kitchen. He said he put out bait trays and glue strips on 7/13/23 but that was documented in his personal notes he carried with him. He said it was probably not documented on the Maintenance Log. He said he also worked at a sister facility. He said the last time he saw roaches in the facility was 7/13/23 in the kitchen pantry, and utility closets. He said the combination of the Pest Control Company and the things he was doing to prevent roaches was working, but the kitchen could be better. He said he was not aware staff and resident's were seeing roaches all over the building. He said roaches were not out of control in the facility. He said the kitchen needed to be cleaned a little better and they needed the Pest Control Company to come out when there were sightings of roaches. He said one of the maintenance crew had called the Pest Control Company about a roach sighting on Saturday (7/15/23). He said he thought the Pest Control Company came out on Saturday, but they may not have because they rescheduled for today (7/18/23). The Maintenance Director said he could not say that roaches were a problem. During an interview on 7/18/23 at 11:36 a.m., ADON H said roaches were a problem in the building, but they were not as bad now as they used to be. She said the last 2 weeks she worked in the Secured Unit she only killed 2 roaches. She said she could not speak for the front of the building, but the back (Secure Unit) was better. She said prior to the last 2 weeks she would kill 4-5 roaches per night. She said any roaches in the building was a problem. She said the risk of roaches in the building was they carried disease and could make someone sick. During an interview on 7/18/23 at 1:51 p.m., ADON J said roaches were a problem earlier this year and Pest Control came and sprayed. She said it was much better now. She said she still saw roaches but not as many. She said the last time she saw live roaches was 2 weeks ago and had not seen any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 3 of 4 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 07/18/2023 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many since. She said she saw a dead roach this morning in the short hall that led outside to the laundry. She said the risk of having roaches in the building was they could cause infections and spread disease. During an interview on 7/18/23 at 12:04 p.m., the DON said there were roaches in the building currently and they were being treated. She said it was not a problem. She said they were up against one (next door) of the nastiest apartment complexes there was, and that contributed to the fact that they had to stay on top of the roaches. She said she did not remember the last time Pest Control came out to spray. She said as wet as it had been from the rain, they needed to come out and spray again. She said she did not know if the Pest Control Company would come spray today or not. She said she did not see a risk or danger to anyone because roaches did not carry diseases. During an interview on 7/18/23 at 12:17 p.m., the Administrator said they had a problem with roaches and they were working on it. She said they had been doing deep cleans in resident rooms and in the kitchen. She said she did not have the documentation for the deep cleaning but would look for it. She said they had been doing deep cleans for a couple of months. She said Pest Control was coming to the facility today. She said she was looking at a new provider for Pest Control and was waiting on a new quote. She said the risk of having the roaches was infection and quality of life. At the time of exit on 7/18/23 at 12:50 p.m., the Administrator had not provided the documentation for deep cleaning the kitchen and resident rooms. A Record Review of an email, provided by the Administrator, from their Pest Control Company dated 7/18/23 that indicated the facility was on a monthly plan for Pest Control which auto renewed every month. A Record Review of a Pest Control Policy dated May 2008 indicated: Policy Statement. 1.This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . 6.Maintenance services assist, when appropriate and necessary, in providing pest control services. A Record Review of a Quality of Life - Homelike Environment Policy dated May 2017 indicated: Residents are provided with a safe, clean, comfortable and homelike environment . 2.The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary, and orderly environment FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 4 of 4