Inspection·August 31, 2023

F 0925 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's care plan, last revised 07/27/23, did not indicate an environment free of pests. During an observation on 08/30/2023 at 11:10 AM, food crumbs and particles were observed on the dining table and on the floor beneath the table. Residents Affected - Some During an observation on 08/30/2023 at 11:20 AM, two medium sized roaches were observed on the floor and along baseboards of Resident #1's bathroom. During an observation on 08/30/2023 at 2:15 PM, two small sized roaches were observed on the floor in Resident #2's room. During an observation on 08/30/2023 at 2:18 PM, one large roach was observed crawling on the toilet tissue in Resident #1's bathroom. During an observation on 08/31/2023 at 10:35 AM, two small sized roaches were observed on the floor of Resident #1's bathroom. During an observation on 08/31/2023 at 10:50 AM, two medium sized roaches on brown crumbs were observed on the floor in Resident #2's room. During an observation on 8/31/2203 at 10:51 AM, one soda can with dead roaches and brown stains on the floor and wall behind the vending machines in the dining area. During an observation on 08/31/2023 at 11:01 AM, one large sized roach observed on the floor in Resident #2's room. During an interview on 08/30/2023 at 11:20 AM, Resident #1 said she often saw roaches in her bathroom, crawling on the floor around her dresser, and in the window seal. Resident #1 said she did not like the roaches, and it was disgusting. Resident #1 said the floors were dirty often with food crumbs, dust, and trash. During an interview on 08/30/2023 at 02:15 PM, Resident #2 said she always saw bugs crawling around on the floor in her room and in the dining area. Resident #2 said the bugs were big and little. Resident #2 said she did not like the bugs. During an interview on 08/30/2023 at 03:51 PM, the Exterminator said he saw roaches inside the facility. The Exterminator said he was treating mice and roaches at the facility. The Exterminator said roaches were bad inside the kitchen, dining area, and in resident rooms. The Exterminator said after every visit he left a summary report at the facility that included his recommendations. The Exterminator said he made recommendations verbally to the Maintenance Supervisor at the facility that the walls, cracks, and holes in the kitchen needed to be fixed. The Exterminator said he also recommended for the kitchen staff to pull the kitchen equipment away from the wall and clean the area monthly. The Exterminator said he verbally informed maintenance to keep the dining area clean of food debris. The Exterminator said the kitchen staff had not been compliant with his cleaning recommendations. The Exterminator said he saw food crumbs under the residents' beds and dressers. The Exterminator said he informed staff to clean after each meal to help get rid of the pests. The Exterminator said it was important to keep the environment free of pests because it was the residents' home and it needed to be clean and for them to have a safe environment. (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 08/31/2023 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 - Some During an interview on 08/30/23 at 04:27 PM, the Maintenance Supervisor said the exterminator made recommendations verbally to her regarding the walls, cracks, and holes in the kitchen needed to be fixed, the kitchen staff to pull the kitchen equipment away from the wall and clean the area monthly, and informed maintenance to keep the dining area clean of food debris. The Maintenance Supervisor said a lot of staff were off work related to COVID and she was picking up where they had left off on the cleaning. The Maintenance Supervisor said all the staff were responsible for making sure there was a clean, safe environment for everyone at the facility. During an interview on 08/31/2023 at 10:54 AM the Dietary Manager said she and the cooks were responsible for making sure the tables located in the dining room and the kitchen were cleaned and sanitized. The Dietary Manager said maintenance was responsible for covering the holes and caulking the cracks in the kitchen. The Dietary Manager said she was informed by Maintenance regarding the cleaning and repair recommendations from the exterminator. The Dietary Manager said she had been compliant with the recommendations from the exterminator. The Dietary Manager said she had weekly and daily cleaning schedules. The Dietary Manager said she physically checked the shelves, oven, stove, and fryers weekly. The Dietary Manager said food debris were checked after each shift. The Dietary Manager said she sanitized the kitchen and dining area daily. The Dietary Manager said she expected the kitchen and dining area to be free and clean of pests. The Dietary Manager said the facility should be free and clean of pests to maintain the residents' health and safety. During an interview on 08/31/2023 at 1:28 PM, the Administrator said she expected the Maintenance Supervisor to check the residents' rooms and dining area daily to ensure the facility was clean. The Administrator said the Dietary Manager was responsible for ensuring the kitchen and the dining tables were clean. The Administrator said she completed random spot checks to ensure the resident rooms were wiped down, the areas behind the furniture were cleaned, and the floors were swept. The Administrator said the facility should be free of pests to prevent infections and promote dignity for the residents. During an interview on 08/31/2023 at 02:07 PM, the ADON/Treatment Nurse said she saw roaches on the floor to the left side of the nurses' station on several occasions. The ADON/Treatment Nurse said the facility should be free of pests to prevent infections and environmental issues. The ADON/Treatment Nurse said she expected housekeeping to sweep and mop daily to prevent food and debris accumulation which attracted pest/rodents into the facility. She said it was everyone's job to pick up and take out trash from the residents' rooms to decrease bugs. The ADON/Treatment Nurse said food should be removed from rooms daily or wrapped tightly and securely to prevent cross contamination and infections caused by roaches. Record review of the exterminator service reports indicated visits on: 05/19/2023 - Recommendations: consider plastic or nylon seal tight containers for storage instead of cardboard boxes to remove potential harborages for cockroaches and mice in food storage/pantry area and patient rooms. 06/13/2023 - Recommendations: consider plastic or nylon seal tight containers for storage instead of cardboard boxes to remove potential harborages for cockroaches and mice in food storage/pantry area and patient rooms. 07/19/2023 - Recommendations: food and debris in corners need to be removed, clean and sanitize shelving and under booths to prevent pest and contamination, clean and sanitize under ovens/fryers. (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 08/31/2023 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 08/01/2023 - Recommendations: food and debris in corners need to be removed, clean and sanitize shelving and under booths to prevent pest and contamination, clean and sanitize under ovens/fryers. 08/18/2023 - Recommendations: food and debris in corners need to be removed, clean and sanitize shelving and under booths to prevent pest and contamination, clean and sanitize under ovens/fryers. Residents Affected - Some Record review of the Daily and Weekly Kitchen Check List dated 07/07/2023 - 08/27/2023, indicated the cleaning tasks had been completed. Record review of weekly Deep Cleaning List for Patient Rooms dated 07/25/2023 - 08/16/2023, indicated the cleaning tasks had been completed. Record review of the facility's revised policy, dated May 2008, titled, Pest Control, indicated, .Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 2. Pest control services are provided by . 3. Windows are screened at all times.4. Only approved FDA and EPA insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas. 5. Garbage and trash are not permitted to accumulate and are removed from the facility daily. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services not address maintaining an effective pest control program FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 4 of 4