Inspection·December 17, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food according with professional standards for food service safety. Residents Affected - Many Dietary staff failed to ensure food was at a safe temperature prior to serving food to residents. This failure could place the census of 47 residents who ate food from the kitchen at risk for food borne illness. Findings included: During an observation on 12/16/23 at 11:05 a.m., food trays had been delivered to residents. Review of a cooking temperature log dated 12/16/23 showed the temperature of the food from the breakfast meal and lunch meal had not been entered. During an interview on 12/16/23 at 11:06 a.m., [NAME] A said she had not taken the temperature of the food for the noon meal prior to serving the food to residents. [NAME] A said she had taken the temperature of the food for breakfast but had not entered the temperatures in the cooking temperature logbook. She said she had the temperatures written down and would go get them. During an observation on 12/16/23 at 11:07 a.m. [NAME] A was observed walking to the dietary office which was out of sight. [NAME] A returned with a piece of paper with some numbers written on the paper. [NAME] A said the numbers were the temperatures of the food this morning for breakfast. [NAME] A said she had received training on taking food temperatures before sending out food to residents. During an interview on 12/16/23 at 11:08 a.m. DA D said the temperature of the food should be taken before serving. DA D said staff had been trained to take temperatures and record the temperatures in the logbook before residents were serviced. DA D said she was not aware that [NAME] A had not taken the temperatures before sending food out to the residents. During an interview on 12/16/23 at 11:10 a.m. DA C said the temperature of the food should be taken before serving. DA C said staff had been trained to take temperatures and record the temperatures in the logbook before residents are served. DA C said she was not aware that [NAME] A had not taken the temperatures before sending food out to the residents. During an interview on 12/16/23 at 12:35 p.m. DA B said [NAME] A had not taken the temperature of the food at breakfast or lunch before serving residents on 12/16/23. DA B said he witnessed [NAME] A (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675603 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 12/17/2023 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)