Health inspection·May 8, 2025

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 interviews and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #1 and Resident #2) of 3 residents reviewed for accuracy of assessments. Residents Affected - Few The facility failed to ensure Resident #1 and Resident #2 were coded in the MDS for dialysis. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: Record review of Resident #1's face sheet dated 05/01/25 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (stroke), muscle weakness, type 2 diabetes (high levels of sugar in blood), unspecified protein-calorie malnutrition (does not consume enough protein or calories which can lead to weight loss or malnutrition), hypertension (high blood pressure), anemia (low iron levels), peripheral vascular disease (narrowing or blockage of blood vessels), end stage renal disease, and dependence on renal dialysis. Record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 8, indicating moderate cognitive impairment. Dialysis was not coded for section O: special treatments, procedures, and programs. Record review of Resident #1's care plan dated 05/01/25 reflected Resident #1 had renal failure related to end stage disease. Date initiated: 02/26/25. Resident #1 needed dialysis related to ESRD. Date initiated: 02/26/25. Record review of Resident #2's face sheet dated 05/01/25 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: chronic kidney disease (progressive loss of kidney function), muscle weakness, unspecified protein-calorie malnutrition (does not consume enough protein or calories which can lead to weight loss or malnutrition), hypertension (high blood pressure), end stage renal disease, and dependence on renal dialysis. Record review of Resident #2's MDS assessment dated [DATE] reflected Resident #2 had a BIMS score of 15, indicating intact cognition. Dialysis was not coded for section O: special treatments, procedures, and programs. Record review of Resident #2's care plan dated 05/01/25 reflected Resident #2 had renal failure Page 1 of 8 455672 455672 05/08/2025 Golden Palms Rehabilitation and Retirement 2101 Treasure Hills Blvd Harlingen, TX 78550

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few related to end stage disease. Date initiated: 06/17/24. Resident #2 needed dialysis related to ESRD. Date initiated: 06/17/24. On 05/07/25 at 4:00 PM, in an interview with MDS F, she said section O of the MDS assessment was completed by the MDS nurses. MDS F said she reviewed the MDS assessments for Resident #1 and Resident #2. MDS F said she agreed that dialysis was not coded correctly for the residents MDS assessments. MDS F said there was no negative outcome to the residents and they would not be at risk of a negative outcome as the MDS assessment section O was not used to care plan, but rather as a billing tool. MDS F said they would correct the assessments for payment and audit accuracies. On 05/07/25 at 4:30 PM, in an interview with the DON, she said for the MDS coding, section O did not trigger care areas to develop the care plans for dialysis. The DON said the care plans included dialysis for Resident #1 and Resident #2. The DON said they would modify the assessments for accuracy and for payment. The DON said there was no negative outcome or risk of injury for the residents as that section of the MDS assessments was used for billing. Record review of the facility's Resident Assessment and Associated Processes policy dated January 2022 reflected - Policy: It is the policy of this facility that resident's will be assessed and the findings documented in their clinical health record. The comprehensive assessment includes the completion of the MDS as well as the Care Area Assessment process. An accurate comprehensive assessment will include special treatments and procedures. Record review of CMS's RAI Version 3.0 Manual dated 10/2024 reflected section O: O0110: Special Treatments, Procedures, and Programs Coding instructions: Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the assessment period defined for each column (on admission, while a resident, and at discharge). 455672 Page 2 of 8 455672 05/08/2025 Golden Palms Rehabilitation and Retirement 2101 Treasure Hills Blvd Harlingen, TX 78550

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to offer a therapeutic diet when there was a nutritional problem and the health care provider ordered a therapeutic diet for 1 (Resident #1) of 3 residents reviewed for diets. Residents Affected - Some The facility failed to administer Resident #1 with liquid protein (on 02/28/25, 03/02/25, 03/03/25, 03/04/25, 03/08/25, 03/09/25, 03/10/25, 03/11/25, 03/12/25, 03/14/25, 03/16/25, 03/17/25, 03/19/25, 03/20/25, 03/21/25, and 03/24/25) and Nepro (on 02/28/25, 03/01/25, 03/03/25, 03/04/25, 03/06/25, 03/07/25, 03/09/25, 03/12/25, 03/13/25, 03/15/25, and 03/24/25) supplements as ordered by her physician. This failure could affect residents on therapeutic diets by placing them at increased risk for significant weight loss and malnutrition. Findings include: Record review of Resident #1's face sheet dated 05/01/25 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (stroke), muscle weakness, type 2 diabetes (high levels of sugar in blood), unspecified protein-calorie malnutrition (does not consume enough protein or calories which can lead to weight loss or malnutrition), hypertension (high blood pressure), anemia (low iron levels), peripheral vascular disease (narrowing or blockage of blood vessels), end stage renal disease, and dependence on renal dialysis. Record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 8, indicating moderate cognitive impairment. Resident #1 was noted to be at risk for malnutrition (protein or calorie). Nutritional approaches included a mechanically altered diet and a therapeutic diet. Record review of Resident #1's Mini Nutritional assessment dated [DATE] reflected Resident #1 was at risk of malnutrition with a score of 9. Resident #1's BMI was less than 19 (underweight). Record review of Resident #1's care plan dated 05/01/25 reflected Resident #1 had a nutritional problem or potential nutritional problem related to risk for malnutrition due to diagnoses of cerebral infarction, hypertension, diabetes, anemia, and ESRD with dialysis. Date initiated: 02/26/25. Interventions included: renal diet mechanical soft with thin liquids. Date initiated: 02/27/25. Liquid protein as ordered for 30 days. Date initiated: 02/27/25. Nepro. Date initiated: 02/28/25. Record review of Resident #1's order summary dated 05/01/25 reflected dietary supplements - Resident #1 was ordered liquid protein one time a day for risk for malnutrition. Give 30 ml for days. Start date: 02/28/25. Resident #1 was ordered Nepro (specialized nutritional product designed for individuals on dialysis) one time a day for supplement 118 ml. Start date: 02/28/25. Record review of Resident #1's MAR reflected Liquid protein was not administered on 02/28/25, 03/02/25, 03/03/25, 03/04/25, 03/08/25, 03/09/25, 03/10/25, 03/11/25, 03/12/25, 03/14/25, 03/16/25, 03/17/25, 03/19/25, 03/20/25, 03/21/25, and 455672 Page 3 of 8 455672 05/08/2025 Golden Palms Rehabilitation and Retirement 2101 Treasure Hills Blvd Harlingen, TX 78550

F 0692 03/24/25. Level of Harm - Minimal harm or potential for actual harm Nepro was not administered on 02/28/25, 03/01/25, 03/03/25, 03/04/25, 03/06/25, 03/07/25, 03/09/25, 03/12/25, 03/13/25, 03/15/25, and 03/24/25. Residents Affected - Some Record review of Resident #1's progress notes reflected On 02/28/25 at 4:40 PM - Medication Administration Note for Nepro, one time a day for supplement. Need clarification on supplement. Nurse notified. Documented by: CMA E On 03/03/25 at 4:30 PM - Medication Administration Note for Nepro, one time a day for supplement. Need clarification on supplement (quantity). Nurse notified. Documented by: CMA E On 03/04/25 at 8:18 AM - Medication Administration Note for liquid protein, one time a day for risk for malnutrition, give 30 ml for 30 days. Pending clarification in which protein to give. Nurse notified. Documented by: CMA E On 03/04/25 at 4:54 PM - Medication Administration Note for Nepro, one time a day for supplement. Need clarification on supplement. Documented by: CMA E On 03/06/25 at 3:11 PM - Medication Administration Note for Nepro, one time a day for supplement. Need clarification on supplement. Documented by: CMA D On 03/09/25 at 7:46 AM - Medication Administration Note for liquid protein, one time a day for risk for malnutrition, give 30 ml for 30 days. Pending clarification in which protein to give. Nurse notified. Documented by: CMA D On 03/09/25 at 4:50 PM - Medication Administration Note for Nepro, one time a day for supplement. Need clarification on supplement. Documented by: CMA D On 03/11/25 7:26 AM - Medication Administration Note for liquid protein, one time a day for risk for malnutrition, give 30 ml for 30 days. Pending clarification in which protein to give. Nurse notified. Documented by: CMA D 455672 Page 4 of 8 455672 05/08/2025 Golden Palms Rehabilitation and Retirement 2101 Treasure Hills Blvd Harlingen, TX 78550

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 03/12/25 at 3:25 PM - Medication Administration Note for Nepro, one time a day for supplement 118ml. Needs clarification on Nepro 118 ml. Nurse notified. Documented by: CMA E On 03/14/25 9:31 AM - Medication Administration Note for liquid protein, one time a day for risk for malnutrition, give 30 ml for 30 days. Pending clarification in which protein to give. Nurse notified. Documented by: CMA D On 03/15/25 4:49 PM - Medication Administration Note for Nepro, one time a day for supplement. Need clarification on supplement. Documented by: CMA E On 03/16/25 7:25 AM - Medication Administration Note for liquid protein, one time a day for risk for malnutrition, give 30 ml for 30 days. Pending clarification in which protein to give. Nurse notified. Documented by: CMA D On 03/19/25 11:12 AM - Medication Administration Note for liquid protein, one time a day for risk for malnutrition, give 30 ml for 30 days. Pending clarification in which protein to give. Nurse notified. Documented by: CMA D On 03/24/25 8:24 AM - Medication Administration Note for liquid protein, one time a day for risk for malnutrition, give 30 ml for 30 days. Pending clarification in which protein to give. Nurse notified. Documented by: CMA D Record review of Resident #1's weights dated 05/01/25 reflected Resident #1 weighed 117 pounds on 02/26/25 and 119 pounds on 03/04/25. Record review of Resident #1's meal percentage task dated 05/08/25 reflected from 03/11/25-03/24/25 Resident #1 ate between 51-100% for most meals. On 05/07/25 at 12:35 PM, in an interview with CMA D, she said there was a resident that she recalled she did not give the liquid protein and Nepro to because she needed clarification on the orders. CMA D said she did not remember the resident's name but she remembered that situation. CMA D said the order did not have the quantity or dosage, or she needed clarification on something, so she could not administer the supplements. CMA D said when that happened, she documented and notified the nurse. CMA D said she did not remember the specific nurse or date/time that she needed the clarification for but she remembered following those steps. CMA D said she did not remember if she ever got clarification on those orders. 455672 Page 5 of 8 455672 05/08/2025 Golden Palms Rehabilitation and Retirement 2101 Treasure Hills Blvd Harlingen, TX 78550

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 05/07/25 at 1:00 PM, in an interview with CMA E, he said he recalled asking the nurses for clarification on Resident #1's orders. CMA E said he needed clarification on the liquid protein as the order did not specify what kind of protein to use. CMA E said he also needed clarification for Nepro because the orders said to give 118 ml but the cups they use did not have show 118 ml, only showed 120, 130, 140 ml. CMA E said the nurses rotated so it was not one specific nurse he notified but he did his part in informing the nurse, and the nurse would have taken over from there and possibly called the doctor to get clarification. CMA E said he was unsure if he got clarification on those orders. On 05/08/25 at 11:15 AM, in an interview with the DON, she said Resident #1 had physician's orders for liquid protein and Nepro. The DON said she reviewed Resident #1's file and it appeared that the med aides needed clarification on these orders such as which kind or brand of liquid protein to use and the ml for the Nepro. The DON said the med aides did not receive clarification on these orders and Resident #1 was not administered the supplements. The DON said she was unsure of how many times or days were missed. The DON said the root cause of how they went many days without clarification was lack of follow up or miscommunication. The DON said the med aides administered those supplements but since they documented and signed off on the order, then the clarification was not obtained or followed up on. The DON said they identified this issue on 05/01/25 during a chart audit. The DON said she implemented a change for the med aides to not sign off on the MAR so that it stays red in the system and the nurses must follow up on those orders. The DON said Resident #1 had the orders for liquid protein and Nepro because she was at risk for malnutrition based on her assessments. The DON said Resident #1 did not have any weight loss and ate well. The DON said she informed the staff and this was an on-going in-service. The DON said Resident #1 was not at risk of any negative outcomes because the liquid protein and Nepro were for risk of malnutrition but Resident #1 still had a good appetite and good meal intake. The DON said there was no specific policy available for the process of how med aides inform the nurse when they need clarification on orders, then the nurse reaches out to the doctor. The DON said she was working on the in-service which would turn into a policy. 455672 Page 6 of 8 455672 05/08/2025 Golden Palms Rehabilitation and Retirement 2101 Treasure Hills Blvd Harlingen, TX 78550

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #1) of 3 residents reviewed for accuracy of records, in that: LVN A failed to document Resident #1's change of condition for nausea on 03/24/25. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care. The findings included: Record review of Resident #1's face sheet dated 05/01/25 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (stroke), muscle weakness, type 2 diabetes (high levels of sugar in blood), unspecified protein-calorie malnutrition (does not consume enough protein or calories which can lead to weight loss or malnutrition), hypertension (high blood pressure), anemia (low iron levels), peripheral vascular disease (narrowing or blockage of blood vessels), end stage renal disease, and dependence on renal dialysis. Record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 8, indicating moderate cognitive impairment. Record review of Resident #1's care plan dated 05/01/25 reflected Resident #1 had risk for acute/chronic pain related to diagnosis and disease processes. Date initiated: 02/26/25. Interventions included: Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs/symptoms or complaints of pain or discomfort. Date initiated: 02/26/25. Record review of Resident #1's stop and watch form dated 03/24/25 at 2:10 PM reflected Resident #1 seemed different than usual, ate less, was tired/weak/confused, and stated she felt nauseous. Form completed by SLP G and reported to LVN A. Nurse response: pending orders. Record review of Resident #1's chart on 05/01/25 reflected LVN A did not document a form or note regarding the change of condition when Resident #1 experienced nausea. On 05/07/25 at 12:50 PM, in an interview with LVN A, she said on 03/24/25 during the day shift, a therapy staff (did not remember who) informed her that Resident #1 was not feeling well. LVN A said she followed up with Resident #1 and she said she felt nauseous. LVN A said she notified the physician but did not recall if they gave any new orders or said to just monitor. LVN A said she did not recall if she documented a form or note for the change of condition. On 05/07/25 at 2:00 PM, in an interview with SLP G, she said on 03/24/25 at around 2 PM, Resident #1 looked different so she completed a stop and watch where she noted the change. SLP G said Resident 455672 Page 7 of 8 455672 05/08/2025 Golden Palms Rehabilitation and Retirement 2101 Treasure Hills Blvd Harlingen, TX 78550

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #1 told her she did not feel like eating as she felt nauseous. SLP G said she completed the form, reminded Resident #1 to use the call light, and informed Resident #1 she would notify the nurse. SLP G said she informed and gave the stop and watch form to LVN A. SLP G said LVN A said she would notify the physician and was pending orders from what she recalled. On 05/07/25 at 8:30 PM, in an interview with LVN B, she said on 03/24/25, LVN A informed her during shift change that Resident #1 had felt nauseous during the day shift and that she notified the physician. LVN B said she did not recall if the physician gave new orders or if Resident #1 was given any new medications. On 05/08/25 at 11:15 AM, in an interview with the DON, she said she did not recall if there was a change of condition for Resident #1 on 03/24/25. The DON said if a therapy staff did a stop and watch (form where they noted a change), and gave the form to the nurse, the nurse would have had to notify the physician, physician would have given an order or maybe just said to monitor. The DON said the nurse would have carried out orders or documented the result of the notification to the physician. The DON said she did not see any documentation on Resident #1's chart on 03/24/25 regarding a change such as her feeling nauseous. Record review of the facility's Daily Skilled Nursing Documentation policy dated 05/2023 reflected Policy statement: All skilled services provided to the resident receiving skilled level of care, or any changes in the resident's medical or mental condition shall be documented in the resident's medical record. 6. Documentation of direct skilled nursing services, procedures, and treatments shall include care-specific details and shall include at a minimum: a. date/time b. name and title of the licensed nurse c. the assessment/evaluation data or any unusual findings f. notification of family, physician, or other staff g. conversation with physician or other staff 455672 Page 8 of 8