Health inspection·May 7, 2025

F 0584 gritty. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/07/25 beginning at 1:00 PM, NA D stated linens should have been changed every shower day. NA D stated the CNAs were responsible for changing the linens. NA D stated Resident #33 received showers on Monday, Wednesday, and Friday. NA D stated she was unsure if Resident #33's linens were changed on Monday because she did not work. NA D stated if Resident #33's sheets had noticeable stains or crusty substances they should have been changed even if it wasn't her shower day. NA D stated she noticed clean bed sheets coming from laundry were not in the best condition and often had stains. NA D stated she had not reported the condition of the bed sheets. NA D stated it was important to ensure linens were changed and in good condition to maintain a homelike and comfortable environment and prevent the growth of bacteria. Residents Affected - Few During an interview on 05/07/25 beginning at 1:03 PM, the Housekeeping Supervisor stated the laundry staff were trained to look at the condition of the bed sheets. The Housekeeping Supervisor stated if she noticed a bedsheet was torn or stained, they placed them into a bag or threw them away. The Housekeeping Supervisor stated it was hard to miss sheets that were heavily stained. The Housekeeping Supervisor stated if the sheets became stained or needed to be changed the CNAs were responsible for completing that. The Housekeeping Supervisor stated it was important to ensure sheets were changed and in good condition to prevent infection. The Housekeeping Supervisor stated it was also important to maintain a homelike and comfortable environment. During an interview on 05/07/25 beginning at 1:06 PM, the CNA Supervisor stated bed sheets should have been changed as needed and every shower day. The CNA Supervisor stated Resident #33's sheets should have been changed on Monday, Wednesday, and Friday. The CNA Supervisor was unsure why Resident #33's bed sheets would not have been changed. The CNA Supervisor stated it was important to ensure bed sheets were changed and in good condition to maintain infection control and a homelike environment. During an interview on 05/07/25 beginning at 1:12 PM, the DON stated she expected bed sheets to have been changed on shower days and as needed. The DON stated the CNAs and charge nurses should have ensured the bed sheets were changed. The DON stated Resident #33 was non-complaint at times with certain things. The DON stated she was unsure if Resident #33 refused to have her bedsheets changed. The DON stated general rounds were completed but there was no system in place for monitoring bed linens. The DON stated it was important to ensure bedsheets were changed to maintain good skin integrity, to control odors, to ensure residents were bathed properly, to maintain a comfortable environment, and maintain pest control. During an interview on 05/07/25 beginning at 1:41 PM, the Administrator stated she expected the staff to change the bed linens on shower days and as needed. The Administrator stated Resident #33 refused care at times but was unsure if she refused this week. The Administrator stated she expected staff to at least attempt to change the bed linens. The Administrator stated it was important to ensure bedsheets were changed for hygiene purposes and to maintain a comfortable environment. Record review of the Quality of Life - Homelike Environment policy, revised May 2017, reflected the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics included: .clean bed and bath linens that are in good condition . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 2 of 20 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 05/07/2025 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 assessments accurately reflected the resident status for 1 of 16 residents (Resident #3) reviewed for MDS assessment accuracy. Residents Affected - Few The facility failed to accurately reflect Resident #3's active diagnoses to not include a diagnosis of schizophrenia (a disorder that affected a person's ability to think, feel, and behave clearly) on her 4/23/25 MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #3's face sheet, dated 5/06/25, indicated she was [AGE] years old and admitted to the facility on originally on 7/13/21 and re-admitted on [DATE]. Resident #3 had diagnoses which included dementia (progressive or persistent loss of intellectual functioning including impairment of memory, thinking, and personality changes due to disease of the brain) with psychotic disturbance (mental disorder characterized by a disconnection from reality with symptoms of delusions-false belief of reality; hallucinations-seen, heard, touched, tasted, or smelled something that was not really there; talking incoherently; and agitation), neurosyphilis (infection that can occur in people with syphilis-sexually transmitted disease, especially if left untreated, that affects the coverings of the brain, the brain itself, or the spinal cord), and depressive episodes (feelings of sadness, tearfulness, angry outbursts, irritability or frustration even over small matters). Record review of Resident #3's annual MDS assessment, dated 4/23/25, indicated Resident #3 had a BIMS of 3, which indicated she had severe cognitive impairment. The MDS indicated Resident #3 had an active diagnosis of schizophrenia. Record review of Resident #3's undated care plan indicated she received an antidepressant and antipsychotic medication related to anxiety, paranoid delusional thinking, and depression auditory (hearing) and visual hallucinations, paranoid that people were out to get her and that she was being poisoned. Resident #3 had memory problems related to dementia. Resident #3 had physical behavioral symptoms toward others had history of hitting other residents. Resident #3 had auditory and visual hallucinations, talking to people and animals that were not present with diagnosis of schizophrenia with primary diagnosis of dementia. Record review of Resident 3's Physician Order Report, dated 4/07/25 - 5/07/25, indicated Resident #3 did not have a diagnosis of schizophrenia. During an interview on 5/07/25 at 8:10 AM, the Regional Nurse said the MDS Coordinator investigated Resident #3's chart and concluded the schizophrenia diagnosis was marked in error or was marked on the wrong resident with the same last name because she was the MDS Coordinator for two buildings/facilities. During an interview on 5/07/25 at 10:21 AM, the MDS Coordinator said she was the MDS Coordinator for two buildings/facilities and she did not know what happened but Resident #3's MDS was just miscoded. The MDS Coordinator said she had been the MDS Coordinator since 1999. The MDS Coordinator said she had been doing both buildings/facilities for a couple of years. The MDS Coordinator said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 3 of 20 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 05/07/2025 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 - Few primarily did the MDSs remotely and received information from the DON, SW, therapy, and all other care areas. The MDS Coordinator said she was in the process of submitting MDS corrections in Resident #3's chart. The MDS Coordinator said there was no pertinent information to justify the diagnosis of schizophrenia being coded on Resident #3's MDS. The MDS Coordinator said the MDS should reflect an accurate picture of the resident to guide the resident's care. The MDS Coordinator said the resident was at risk of not receiving the services that they needed if the MDS was not coded accurately. The MDS Coordinator said she followed the RAI manual and looked things up if she had any questions. The MDS Coordinator said she saw Resident #3's MDS included schizophrenia was first coded in May of 2024 and apparently was carried over from assessment to assessment. The MDS Coordinator said she just really did not have a good answer for why it was coded. The MDS Coordinator said she was currently auditing all of the diagnoses and assessments in the facility. During an interview on 5/07/25 at 1:24 PM, the ADM said she would expect the MDS to be coded accurately. The ADM said the MDS was a medical record, it affected what care was provided and/or services the resident received. The ADM said if the MDS was not coded accurately, the resident may not get medications or services that they needed or they may get medications or services they did not need. The ADM said the MDS Coordinator, and the DON were responsible for ensuring the MDS was coded accurately. Record review of the facility's undated policy titled Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy indicated . 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 were familiar with his/her physical, mental, and psychosocial well-being . Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require . the assessment accurately reflect the resident's status FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 4 of 20 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 05/07/2025 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 0699 Provide care or services that was trauma informed and/or culturally competent. 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 that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 resident (Resident #28) reviewed for trauma-informed care. Residents Affected - Few The facility failed to ensure Resident #28 had a trauma screening completed upon admission to the facility that identified possible triggers when Resident #28 had a history of trauma. This failure could place residents at an increased risk for psychological distress due to re-traumatization. The findings included: Record review of the face sheet, dated 05/06/25, reflected Resident #28 was a [AGE] year-old male who initially admitted to the facility on [DATE] with a diagnosis of PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of the annual MDS assessment, dated 03/13/25, reflected Resident #28 had clear speech and was understood by others. The MDS reflected Resident #28 was able to understand others. The MDS reflected Resident #28 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS reflected Resident #28 had no behaviors or refusal of care. The MDS reflected Resident #28 had an active diagnosis of PTSD. Record review of the comprehensive care plan, dated 03/25/2024, reflected Resident #28 had a history of being fearful and easily annoyed related to PTSD. The goal was to use effective coping mechanisms to manage PTSD and have no fearful episodes during the next 90 days. Record review of Resident #28's initial social service history, dated 03/19/24, reflected no screening questions to indicate a history of trauma. Record review of the Resident #28's Make Me Feel Important form, undated, reflected the sections titled Five things to NEVER do with/around me: and Five things to ALWAYS do with/around me: were not filled out or answered. During an interview on 05/06/25 beginning at 3:49 PM, the Social Services Director stated she was responsible for completing the initial social history assessment on admission. The Social Services Director stated quarterly assessments and progress notes were completed each time a care plan meeting was conducted. The Social Services Director stated the initial social history assessment had no screening questions related to trauma. The Social Services Director stated she communicated with the DON for psychiatric referrals for residents who confided in her about their traumatic histories. The Social Services Director stated there was no trauma screening completed on admission that she was aware of. The Social Services Director stated if someone admitted to the facility with a diagnosis of PTSD, the facility attempted to obtained counseling services. The Social Services Director was unaware of any services being provided for Resident #28. The Social Services Director stated it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 5 of 20 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 05/07/2025 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 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few important to ensure residents were screened for a history of trauma and potential triggers were identified to maintain the correct environment to prevent triggers that could have caused re-traumatization. The Social Services Director stated it would have been important to know the potential triggers to prevent aggravation, frustration, or other behaviors. During an observation and interview on 05/06/25 beginning at 4:02 PM, Resident #28 was sitting up in the dining room watching videos on his laptop. Resident #28 did not want to leave the dining room, unable to complete the interview regarding his PTSD diagnosis. During an interview on 05/07/25 beginning at 1:12 PM, the DON stated the only part of trauma informed care that she participated in was during the new admission referral process. The DON stated she reviewed the clinical record for psychotropic medication and behaviors. The DON stated she reviewed the diagnosis to ensure the referral was appropriate for admission to the facility. During an interview on 05/07/25 beginning at 1:41 PM, the Administrator stated she reviewed the clinical documentation of new admission referrals to try and identify a possible history of trauma or any diagnosis related to trauma. The Administrator stated the Social Services Director was responsible for completing the initial social history assessment, which included trauma screening questions. The Administrator stated she was unaware the initial social services history assessment did not include the trauma screening questions. The Administrator stated the Activity Director, and the CNA Supervisor completed the Make Me Feel Important form, which was used to identify specific triggers and de-escalation interventions. The Administrator was unaware Resident #28's Make Me Feel Important form was not filled out. The Administrator stated she recently started working on developing a system for trauma informed care and had not completed it. The Administrator stated it was important to ensure residents were assessed for a history of trauma and potential triggers were identified to prevent re-traumatizing and maintain the safety of the residents and staff. Record review of the Trauma Informed Care policy, dated 2024, reflected .a tool for screening new residents for trauma will be developed and implemented as part of the admissions process if a resident demonstrations signs of past trauma (either one-time or on-going), additional screening will take place . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 6 of 20 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 05/07/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents (Resident #36) reviewed for medication administration. The facility failed to ensure Resident #36 rinsed and spit after administration of an inhalation medication (Budesonide) for a diagnosis of COPD. This failure could place residents at an risk for inaccurate drug administration and not receiving the care and services to meet their individual needs. The findings include: Record review of Resident #36's face sheet, dated 05/07/2025, revealed Resident #36 was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #36 had a diagnosis which included COPD - chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the order summary report, dated 05/07/2025, revealed Resident #36 had an order, which started on 02/14/2025, for Budesonide 0.5 milligram/2 milliliter suspension for nebulization, I ampule inhalation twice a day for a diagnosis of COPD with special instruction to rinse mouth and spit after each use. Record review of the MAR, dated 05/06/2025, indicated Resident #36 received Budesonide 0.5 milligram/2 milliliter suspension for nebulization, I ampule inhalation. Record review of the Annual MDS assessment, dated 04/14/2025, indicated Resident #36 had clear speech and was understood by staff. Resident #36 was able to understand others. Resident #36 had a BIMS of 15, which indicated intact cognition. Record review of the comprehensive care plan, initiated on 07/19/2024, indicated Resident #36 had a diagnosis of COPD and took medication. The interventions included: administer medication per orders. During an observation on 05/06/2025 at 8:45 AM, revealed LVN F prepared Resident #36's medication for administration. LVN F obtained a bottle of multivitamin with minerals and placed one, round, pale pink tablet in the cup. LVN F finished preparing the remainder of Resident #36's morning medication, which included the Budesonide 0.5 milligram/2 milliliter suspension for nebulization, I ampule inhalation. LVN F obtained a plastic glass of water and went into Resident #36's room. LVN F gave Resident #36's his medication cup, which included the multivitamin with minerals, and Resident #36 swallowed the medication. LVN F then administered Resident #36's Budesonide 0.5 milligram/2 milliliter suspension for nebulization, I ampule inhalation. LVN F gave Resident #36 a glass of water after administration of the medication but did not instruct Resident #36 to rinse and spit after the use of his nebulizer inhalation treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 7 of 20 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 05/07/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 05/06/2025 at 09:10 AM, LVN F stated medication should have been administered per the physician orders. LVN F stated special instructions should have been followed during medication administration. LVN F stated she should have instructed Resident #36 to rinse and spit after administration of his nebulizer inhalation treatment, but she did not think to look at the label on the box. LVN F stated she should have verified the order and the medication bottle prior to administering the medication to Resident #36. LVN F stated it was important to ensure medication was administered per the physician orders to prevent adverse effects such as cavities. During an interview on 05/07/2025 at 01:10 PM, the DON stated she expected medications to be given as ordered by the physician. The DON stated LVN F should have instructed Resident #36 to rinse and spit after administration of his nebulizer inhalation treatment. The DON stated the EMAR , and the medication label should be verified at least 3 times prior to medication administration. The DON stated it was important to ensure special instructions were followed and the correct medications were administered to prevent adverse reactions to the resident . The DON said the resident should rinse per the medication guidelines and orders to prevent any side effects from the nebulizer such as cavities. During an interview on 05/07/2025 at 01:30 PM, the Administrator stated she expected medication to be administered per the physician order. The Administrator stated nursing management was responsible for monitoring to ensure medications were administered correctly. The Administrator stated it was important to administer medications according to the physician order to ensure the safety and well-being of the residents. Record review of the Administering Medications policy, revised on 12/2012, indicated 3. Medications must be administered in accordance with the orders, and by manufactures guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 8 of 20 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 05/07/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (Cart 4) reviewed for drugs and biologicals. 1. The facility failed to ensure LVN E locked Cart 4 on the secured unit nurse medication cart, when it was not in use on 05/06/2025. 2. The facility failed to ensure two Albuterol Sulfate Inhalation Solution (inhalation solution used to open the airways for breathing) on Cart 4 was dated when opened. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion. Findings include: During an observation and interview on 05/06/2025 starting at 09:32 AM, revealed LVN E entered the resident's room and did not lock her medication cart. While in the room, LVN E was not able to visualize her medication cart because she had the privacy curtain pulled. The nurse had a conversation with the resident for approximately 10 minutes before returning to her medication cart. LVN E said she guessed she got distracted and did not realize she did not lock it. LVN E said the nurse should ensure the medication cart was locked when not in use. LVN E said it was important for the medication cart to be locked because they had dementia patients, and someone could go and inject themselves or someone could take stuff. LVN E said it was super dangerous for the medication cart to be left unlocke with narcotics on the cart During an observation and interview on 05/07/2025 at 08:35 AM, two Albuterol Sulfate Inhalation Solutions on Cart 4 were not dated when opened. LVN E said she did not know who opened them, so she did not know why they had not put an open date on them. LVN E said the person who opened a medication was responsible for putting the open date on it. LVN E said it was important to label and date the medications when opened to ensure the medications were effective and therapeutic for the residents. During an interview on 05/07/2025 at 1:11 PM, the DON said the medication cart needed to be locked at all times when not in use. The DON said she conducted rounds daily to check to ensure the medication carts were locked. The DON said the nurses were responsible for ensuring the medication carts were locked. The DON said if the medication cart was left unlocked somebody could access the medications or treatments in it. The DON said she did random weekly audits on the medication carts to ensure the medications were labeled and dated correctly. The DON said it was important for all breathing inhalations to have an open date to ensure the residents did not receive expired medications. The DON said all medications should be stored and labeled per the manufacturer's instructions. During an interview on 05/07/2025 at 1:30 PM, the Administrator said she expected for the medication carts to be locked anytime the nurses were not in front of them. The Administrator said if the medication cart was left unlocked a resident could get into the medication cart. The Administrator said the nurses should be making sure they dated medications when opened. The Administrator said there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 9 of 20 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 05/07/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was a system in place to check the medication carts. This system included the clinic staff and the pharmacy consult checking the medication carts to ensure everything was dated. The Administrator said it was important to date medications as opened to ensure efficiency of the medication. Record review of the facility's policy, titled, Security of Medication Cart, revised April 2007, indicated, 4. Medication carts must be securely locked at all times when out of the nurse's view. Record review of the facility's policy, titled Labeling of Medication Containers, revised on April 2007, indicated, 5. The date drug dispensed; The expiration date when applicable FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 10 of 20 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 05/07/2025 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 0791 Provide or obtain dental services for each resident. 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 assist residents in obtaining routine and 24-hour emergency dental services to meet the needs of 1 of 1 (Resident #33) residents reviewed for dental services. Residents Affected - Few The facility failed to ensure Resident #33 received dental services when she had a broken tooth that caused her discomfort. This failure could place residents at risk of not receiving needed dental care and a decreased quality of life. The findings included: Record review of the face sheet, dated 05/07/25, reflected Resident #33 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnosis of unspecified dementia without behaviors (memory loss) and Schizophrenia (chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges). Record review of the quarterly MDS assessment, dated 04/07/25, reflected Resident #33 had clear speech and was understood by others. The MDS reflected Resident #33 was able to understand others. The MDS reflected Resident #33 had a BIMS score of 15, which indicated no cognitive impairment. The MDS reflected Resident #33 had no behaviors or refusal of care during the look-back period. The MDS reflected Resident #33 required supervision or touching assistance with oral hygiene that included ability to use suitable items to clean teeth. The MDS reflected Resident #33 had no broken or loosely fitting full or partial denture or mouth or facial pain, discomfort, or difficulty with chewing. Record review of the comprehensive care plan, dated 03/15/25, reflected Resident #33 required supervision or touching assistance with most ADLs. The care plan reflected Resident #33 required one staff assistance with oral care two times a day and as needed. The care plan did not address any dental issues. During an observation and interview on 05/05/25 beginning at 9:14 AM, Resident #33 was lying in the bed with the sheets pulled up around her face. Resident #33 stated her tooth was broken and had been giving her problems and she felt that the facility staff had not addressed it. Resident #33 stated she was having a hard time eating but had not lost any weight. Resident #33 denied constant pain or hurting. Resident #33 stated she had slight discomfort only while eating. Resident #33 opened her mouth to show the state surveyor her teeth. Resident #33 had her natural teeth, and no obvious broken teeth were observed. During an interview on 05/07/25 beginning at 9:36 AM, the Social Services Director stated she was aware Resident #33 had a dental concern. The Social Services Director stated she had attempted to reach out to the mobile dentistry used by the facility, but they would not see Resident #33 because she had an outstanding balance at the facility. The Social Services Director stated she attempted to reach out to several places in the community, but they would not accept Resident #33's medical insurance plan. The Social Services Director provided the documentation from a soft file in her office. Record review of the social progress notes, signed and dated 04/23/25, reflected On today [Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 11 of 20 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 05/07/2025 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #33] told this [Social Services Director] that her tooth cracked and is causing her a little pain and discomfort. This [Social Services Director] checking on [mobile dentistry] for resident and encouraged her to tell her nurse when it bothers her and maybe she can give resident [over the counter] pain reliver. Resident stated that she would. Will continue to monitor Record review of the social progress notes, signed and dated 04/24/25, reflected Resident [#33] has a past due balance and [the mobile dentistry] will only see residents whose bill is up to date. This [Social Service Director] trying to find an alternative for Resident #33. Will continue to monitor . There were no further notes to address the Resident #33's dental pain or discomfort. During an interview on 05/07/25 beginning at 9:44 AM, the Social Services Director was unable to answer any questions about the specifics of Resident #33's outstanding balance. The Social Services Director stated the BOM was responsible for handling Resident #33's finances. The Social Services Director stated she was unsure if there were any community resources that could have helped Resident #33 with her outstanding balance or dental concerns. During an interview on 05/07/25 beginning at 9:48 AM, the BOM stated Resident #33 had an outstanding balance at the facility. The BOM stated she had attempted to reach out to Resident #33's family member on numerous occasions to attempt to collect the balance. The BOM stated Resident #33's family member did not answer the phone or return her phone calls to the facility. The BOM stated Resident #33 complained of dental issues since admitting to the facility. The BOM stated Resident #33's family member mentioned he would have taken Resident #33 to the dentist in the past. The BOM stated she told the Social Services Director to reach out to places in the community that would have seen her. The BOM stated the facility has had problems with the mobile dentistry services for other residents. During an interview on 05/07/25 beginning at 10:02 AM, the BOM stated she provided a couple of phone numbers to dentist offices in the area to the Social Services Director. The BOM stated she attempted to call Resident #33's family member with no response. During an attempted telephone interview on 05/07/25 beginning at 10:15 AM, Resident #33's family member did not answer the phone. A brief message was left with a call back number, but the call was not returned upon exit of the facility. During an interview on 05/07/25 beginning at 11:11 AM, the Corporate Clinical Nurse stated Resident #33 was currently at the dentist and the facility was going to cover the cost. During an interview on 05/07/25 beginning at 12:10 PM, the Social Services Director stated she was unsure if she spoke with Resident #33's family member about her dental concerns when he was contacted on 04/25/25. The Social Services Director stated Resident #33 had just returned from a dental appointment. The Social Services Director stated when she attempted to reach out to other dentists in the area it was not for Resident #33. The Social Services Director stated when a resident complained of dental concerns, she looked to see if they had any dental insurance. She said if the residents had no dental insurance, then she attempted to set them up with the mobile dentistry service that came to the facility. The Social Services Director stated if everything checked out with the mobile dentistry service then they were scheduled. If the mobile dentistry was unable to see the resident, then they would find a place in the community and the resident would have to pay for it out of pocket. The Social Services Director stated she should have notified the nursing staff about Resident #33's dental concerns but the only person she notified was the BOM. The Social Services Director stated Resident #33 should have been seen by the dentist sooner. The Social Services Director stated she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 12 of 20 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 05/07/2025 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fairly new to the position and was still learning the specifics of her job duties. The Social Services Director stated it was important to ensure dental services were provided to residents who had dental concerns to minimize pain, prevent infection, and prevent appetite changes. During an interview on 05/07/25 beginning at 1:12 PM, the DON stated she had not been informed of Resident #33's dental concerns or any pain or discomfort. The DON stated she expected to be notified if a resident had any dental issues or concerns. The DON stated the facility staff usually talked about things like that during the morning stand-up meetings. The DON stated Resident #33's teeth were not discussed that she was able to recall. The DON stated it was important to ensure dental issues were followed up on to make sure care was provided, pain was controlled, and no secondary illness developed as a result of untreated dental issues. During an interview on 05/07/25 beginning at 1:41 PM, the Administrator stated she expected a process to have been followed for residents with dental pain. The Administrator stated the process included notifying nursing staff and herself as soon as the dental concerns were discovered. The Administrator she was notified on 05/05/25 regarding Resident #33's dental concerns and was following up to see where they were at in the clinical process. The Administrator stated she should have been notified sooner. The Administrator stated it was important to ensure dental issues were addressed to prevent infections and pain. Record review of the Dental Services policy, revised December 2016, reflected Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care .routine dental services are provided to our resident through: a contract agreement .referral to the resident's personal dentist .referral to community dentists .referral to other health care organizations that provide dental services .residents have the right to select dentists of their choice when dental care or services are needed .social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 13 of 20 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 05/07/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. 1. The facility failed to ensure food items were not stored on the floor of the dry pantry. 2. The facility failed to ensure food items in the dry pantry were labeled and dated. 3. The facility failed to ensure plastic bags of what appeared to be hamburger patties, chicken tender strips, sausage patties, onions/green/red peppers, and French fries were labeled and dated in the large freezer. 4. The facility failed to ensure a plastic bag containing an unknown meat was labeled and dated in the white freezer. 5. The facility failed to ensure the white freezer did not have melted and refrozen substance in the bottom of freezer. 6. The facility failed to ensure a silver metal container in the refrigerator/cooler with what appeared to be chicken noodle soup covered with plastic wrap, was labeled and dated. 7. The facility failed to ensure a large plastic zippered bag of what appeared to be 1/2 sandwiches with resident names on individual plastic bags were labeled or dated. 8. The facility failed to ensure a partial bag of what appeared to be biscuits was not labeled or dated. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During initial tour observations and interviews of the kitchen on 5/05/25 beginning at 8:25 AM, and accompanied by [NAME] A, revealed: The dry Pantry had: * A box on the floor with 6 large cans of mixed greens and they were not dated. * A partial box (3 of 6) large cans of vegetables for stew were stored on top of the mixed greens and they were not dated. * A partial box of chips with 3 large clear bags of chips was on the floor and they were not dated. * An unopened box of individual bagged coffee was on the floor. * A box of large cans of tropical fruit salad was on the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 14 of 20 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 05/07/2025 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 0812 * A box of large cans of peas and diced carrots was on the floor and was not dated. Level of Harm - Minimal harm or potential for actual harm The large Freezer had: * A plastic bag of what appeared to be hamburger patties, and they were not labeled or dated. Residents Affected - Many * A plastic bag of what appeared to be chicken tender strips, and they were not labeled or dated. * Two partial plastic bags of what appeared to be chicken tender strips, and they were not labeled or dated and there was no opened date. * A partial bag of what appeared to be sausage patties, and they were not labeled or dated and there was no opened date. * A plastic zippered bag with what appeared to be chopped onion, red/green bell peppers and they were not labeled or dated. * Three bags of what appeared to be French fries and they were not labeled or dated. White freezer had: * Two plastic zippered bags with an unknown meat that was not labeled or dated. * The white freezer had what looked like it had defrosted something in the bottom of the freezer, and it refroze. The Refrigerator/Cooler had: * A silver metal container with what appeared to be chicken noodle soup covered with plastic wrap and it was not labeled or dated. * A large plastic zippered bag of what appeared to be 1/2 sandwiches with resident names on individual plastic bags and they were not labeled or dated. * A partial bag of what appeared to be biscuits, and they were not labeled or dated and there was no opened date. During an interview on 5/05/25 at 8:45 AM, [NAME] A said all food items should be labeled and dated when they were placed in the freezer or cooler. [NAME] A said food items should be labeled and dated to know when it was placed in there and to know if or when it would go bad. [NAME] A said if food that was not labeled or dated was served to the residents, it could be expired, and residents could get sick. [NAME] A said food should not be stored on the floor of the dry goods pantry because it could cause accidents. [NAME] A said they were short staffed in the kitchen and there were only two people on each shift, and they tried to get to things as they could and since the dishwasher had not been working and they had to handwash everything, it took extra time. [NAME] A said they had someone who came in on the days of the truck deliveries to put up the stock, she said she was not sure why the delivery items were not put up from Friday (5/02/25). [NAME] A said the DM had been in the hospital since Friday (5/02/25). [NAME] A said the sandwiches were probably made yesterday for evening shift snacks, but she just assumed and was not for sure, but they only made sandwiches daily and they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 15 of 20 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 05/07/2025 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 0812 were used daily for the residents' snacks. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/05/25 at 8:55 AM, Dishwasher B said the dishwasher had been out for about two weeks and they tried to repair it, but the machine was old, and they could not get parts, so they had a new one ordered. Dishwasher B said food items should be labeled and dated when placed in the freezers or cooler. Dishwasher B said if the item was not labeled or dated, it should be thrown away and not served to the residents because you would not know when it was made. Dishwasher B said she threw anything away that was not labeled or dated and would not serve it to residents because it could make them sick. Residents Affected - Many During an interview on 5/07/25 at 8:30 AM, the DM said she expected staff to put food delivery stock up and label and date everything when it was delivered on Tuesdays and Fridays. The DM said they had a specific person to put stock up when it came in, Dietary Stocker C. The DM said she did not know why the stock person did not put the stock up. The DM said food items should be labeled and dated when placed in the freezer and if the package had been opened then it should have an opened date on it. The DM said it was important to label and date the food items when placed in the freezer to know what it was, and to ensure the food item was still good to use. The DM said if the food item was out of date and was served to the residents it could make them sick. During an interview on 5/07/25 at 12:53 PM, Dietary Stocker C said she was a stocker and only worked on Tuesdays. Dietary Stocker C said she put up the food truck deliveries and rotates the groceries. Dietary Stocker C said she dated the dry goods and placed on the shelf. Dietary Stocker C said they got food delivery trucks every Tuesday and sometimes on Fridays depending on the menus. Dietary Stocker C said she did not think they got a truck on last Friday (5/02/25). Dietary Stocker C said if there was a box or a bag, everything should be labeled and dated. Dietary Stocker C said sometimes she used the sticky labels on items in the freezer and sometimes they would come off. Dietary Stocker C said she did not usually have anything to do with putting partial bags of items in the freezer. Dietary Stocker C said if there were boxes of food items on the floor, she would ensure they were stored properly before leaving. Dietary Stocker C said items should be put up so it could be rotated, so the oldest items were used first, and it helped her with the rotating stock. Dietary Stocker C said if they were not labeled or dated, it could spoil and make someone sick. Dietary Stocker C said everyone gave a helping hand in the kitchen and someone else would help put things up if they received a food truck delivery when she was not working. During an interview on 5/07/25 at 1:24 PM, the ADM said boxes of food items should not be left on the floor. The ADM said when food items were delivered, the staff should inspect the items for damage, date the item with date delivered and put up for proper storage. The ADM said leaving food items stored on the floor contributed to pests and could be a food contamination issue. The ADM said she would expect staff to follow the facility's policy of labeling, dating, and storing food, even when the DM was not there. The ADM said there could be an infection control issue, cross contamination, and food spoilage if the food items were not labeled or dated. The ADM said it could also potentially make the resident sick or could be something the resident was allergic to if an item was not labeled or dated. The ADM said the DM would be the first one responsible for ensuring food was labeled, dated, and stored appropriately and then the ADM would be ultimately responsible. Record review of the facility's policy titled Food Receiving and Storage, dated revised July 2024, indicated . foods shall be received and stored in a manner that complies with safe food handling practices . food services, or other designated staff, will maintain clean food storage areas at all times . food in designated dry storage areas shall be kept off the floor (at least 18 inches) . all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 16 of 20 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 05/07/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . all foods belonging to residents must be labeled with the resident's name, the item and the use by date . other opened containers must be dated and sealed or covered during storage Record review of the facility's policy titled Food Preparation and Service, dated revised July 2024, indicated . food service employees shall prepare and serve food in a manner that complies with safe food handling practices . food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness Event ID: Facility ID: 675603 If continuation sheet Page 17 of 20 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 05/07/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 staff (Laundry Aide G) reviewed for infection control practices. Residents Affected - Few The facility failed to ensure that Laundry Aide G covered the laundry cart while delivering the resident's clothing. This failure could place residents and staff at risk for cross-contamination and the spread of infection. Findings: During an observation and interview on 05/05/2025 at 09:10 am., Laundry Aide G was seen in hall 2 pushing an uncovered laundry cart that had clean clothes exposed. Laundry Aide G said she covered the laundry cart while she transported it from the laundry building outside, but once she entered the facility, she was not required to cover the laundry cart while she delivered to the residents. During an interview 05/07/2025 at 1:10 PM., the DON said dirty and soiled laundry should not be transported out in the open due to the risk of infection and cross contamination. The DON said she expected the clean linens and residents' clothing to be distributed per the proper protocol per housekeeping, which is covered in and outside the building. The DON said and she expected all staff to ensure infection preventives were utilized daily to protect the residents' health and wellbeing by proper handwashing, bagging and transporting soiled linen in closed containers, using PPE appropriately and properly. During an interview on 05/07/2025 at 1:15 PM, the Housekeeping Supervisor said she was responsible for and had educated the laundry aides and expected the staff to keep the clean laundry covered while transported it from the laundry building outside and required to cover the laundry cart of clean clothing while delivered to the residents to prevent cross contamination. During an interview on 05/07/2025 at 1:30 PM, the Administrator said she expected for all staff to be responsible for infection control precaution. The Administrator stated the facility had purchased a covered cart strictly for the delivery of clean linens and expected staff to utilize the cart for linen delivery to prevent cross contamination while inside and outside of the building. Record review of the facility's policy titled, Departmental (Environmental Services) - Laundry and Linen, updated January 2014, indicated, . 7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contaminations, such as covering clean linen carts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 18 of 20 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 05/07/2025 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow their own established smoking policy for the facility's only smoking area and 1 of 1 facility smoking area reviewed for smoking policies. Residents Affected - Few The facility failed to ensure the smoking area had no cigarette butts on the ground and the red metal can was free of trash on 05/05/25. This failure could place residents at risk of an unsafe smoking environment. The findings included: During an observation on 05/05/25 beginning at 10:57 AM, there were 2 red-tipped cigarette butts on the sidewalk near the door. There was a sign on the door that stated, Do not throw cigarette butts on the ground. There was a used white tissue in the red metal can. During an interview on 05/07/25 beginning at 12:49 PM, The Social Services Director stated she was the staff member responsible for the 11:00 AM smoke break. The Social Services Director stated she did not notice the used white tissues in the red metal can or the used, red-tipped cigarette butts on ground during the smoke break on 05/05/25. The Social Services Director stated the Maintenance Assistant and housekeeping staff were responsible for making sure the red metal can had no trash and cigarette butts were kept off the ground. The Social Services Director stated when she noticed trash in the red metal can or cigarette butts on the ground, she should have let someone know or fixed it herself. The Social Services Director stated it was important toe ensure cigarette butts were kept off the ground and trash was kept out of the red metal can to prevent fires. During an interview on 05/07/25 beginning at 12:53 PM, the Housekeeping Supervisor stated the Maintenance Assistant was responsible for picking up the cigarette butts every morning. The Housekeeping Supervisor stated if anyone noticed cigarette butts on the ground, they should have picked them up. The Housekeeping Supervisor stated she worked together with the Maintenance Assistant to keep trash out of the red metal trashcan and cigarette butts off the ground. The Housekeeping Supervisor stated she believed the residents throw trash in the red metal can without thinking about it. The Housekeeping Supervisor stated it was important to ensure trash was kept out of the red metal can and cigarette butts were kept off the ground to prevent fires. During an interview on 05/07/25 beginning at 1:24 PM, the Maintenance Assistant stated she was responsible for picking up the cigarette butts and making sure the trash was kept out of the red metal can. The Maintenance Assistant stated she kept sand in the red can and recently added more. The Maintenance Assistant stated she had educated the staff who take the residents out to smoke about making sure the residents did not throw their cigarette butts on the ground. The Maintenance Assistant stated the staff should have been checking the red metal can for trash. The Maintenance Assistant stated if it was noticed they should have notified her or removed it. The Maintenance Assistant stated it was important to ensure cigarette butts were kept off the ground and trash was kept out of the red metal can to prevent fires. During an interview on 05/07/25 beginning at 1:41 PM, the Administrator stated she expected the facility staff to ensure residents were putting their cigarettes butts in the red metal can or ashtrays. The Administrator stated the Maintenance Assistant or housekeeping staff were responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 19 of 20 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 05/07/2025 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 0926 Level of Harm - Minimal harm or potential for actual harm monitoring to ensure the cigarette butts were kept off the ground and trash was kept out of the red metal can. The Administrator stated it was important for fire safety. Record review of the Smoking Policy - Residents, revised July 2017, reflected .this facility shall establish and maintain safe resident smoking practices .ashtrays are emptied only into designated receptacles . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675603 If continuation sheet Page 20 of 20