Atlanta, TX

Rose Haven Retreat

4-star overall rating with 3-star inspections with $8,281 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

200 Live Oak St, Atlanta, TX

(903) 796-4127

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

108

Certified beds

Average residents

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

Caring Healthcare Group

Operator or chain grouping

Approved since

1996-06-14

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

14 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.50

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.77

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

3.88

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

5.16

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.27

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

4.52

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.40

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.00

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.59

CMS adjusted RN staffing hours

Adjusted total hours

6.11

CMS adjusted total nurse staffing hours

Case-mix index

1.16

Higher values indicate more complex resident acuity

RN turnover

14%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

65%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,326

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

44.87

Composite VBP score used to determine payment impact.

Payment multiplier

0.9980

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

3.62

Baseline 55.77% · Performance 48.89% · Measure score 3.62 · Achievement 3.62 · Improvement 1.73

Adjusted total nurse staffing

5.36

Baseline 4.84 hours · Performance 4.60 hours · Measure score 5.36 · Achievement 5.36 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.81%	10.72% 0.1 pts worse	No Different than the National Rate · Eligible stays 28 · Observed rate 10.71% · Lower 95% interval 6.5%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.6	1.02 0.6 pts worse
Drug regimen review with follow-up	92.59%	95.27% 2.7 pts worse	Numerator 25 · Denominator 27
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 27
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 27 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 89
Staff flu vaccination coverage	31.33%	42% 10.7 pts worse	Numerator 26 · Denominator 83
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.7	2.1 0.6 pts worse	1.9 0.8 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 1.9 · Expected 1.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.2	2.1 0.1 pts worse	1.8 0.4 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.7 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	97.1% 2.9 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	97.9% 2.1 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	3.3% 3.3 pts better	3.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	2.7% 2.7 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	0.8%	3.3% 2.5 pts better	5.4% 4.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	23.6%	18.9% 4.7 pts worse	19.6% 4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 27.3% · Q3 29.0% · Q4 12.9% · 4Q avg 23.6%
Percentage of long-stay residents who received an antipsychotic medication	29.9%	10.8% 19.1 pts worse	16.7% 13.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 23.1% · Q3 31.8% · Q4 36.4% · 4Q avg 29.9% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	2.7%	15.4% 12.7 pts better	16.3% 13.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 5.4% · Q3 0.0% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	2.4%	16.1% 13.7 pts better	14.9% 12.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.3% · Q4 6.5% · 4Q avg 2.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	0.8% 0.8 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	1.9%	15.0% 13.1 pts better	19.8% 17.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 3.8% · Q4 1.9% · 4Q avg 1.9%
Percentage of long-stay residents with pressure ulcers	1.4%	4.2% 2.8 pts better	5.1% 3.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 1.9% · Q4 1.7% · 4Q avg 1.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	89.7% 10.3 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.5% 1.5 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	88.0% 12 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-07 · Fire 2025-05-07

9 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-04-17 · Fire 2024-04-17

11 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

1 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 3 Health 2023-03-15 · Fire 2023-03-15

14 health deficiencies

Top issue: Environmental (4 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-05-07

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-05-21

E · Potential for more than minimal harm 2025-05-07

K344 · Smoke Deficiencies

Fire Safety

Have an alternate power supply for its alarm system.

Corrected 2025-05-21

C · Minimal harm 2025-05-07

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

C · Minimal harm 2024-04-17

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

E · Potential for more than minimal harm 2023-03-15

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-05-17

C · Minimal harm 2023-03-15

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-05-07

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-05-08