Inspection·May 15, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (a group of thinking and social symptoms that interferes with daily functioning), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and sciatica- right side ( pain radiating along the sciatic nerve, which runs down one or both legs from the lower back). Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected that a brief interview for mental status should not be conducted due to resident rarely/never being understood. Further review reflected he had a functional limitation in range of motion due to upper and lower extremities and dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for roll left to right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). For the task of toilet transfer he was coded as not attempted due to medical condition or safety concerns. Record review of Resident #2's quarterly care plan dated 03/11/25 reflected he had a focus of ADL self-care performance deficit r/t weakness, sciatica to right side, dementia, and Alzheimer's disease. His interventions failed to indicate if he was a 1 or 2 person assist for toileting. Record review of Resident #2's [NAME] report dated 05/14/25 failed to reflect if he was a 1 or 2 person assist for toileting. An observation and interview on 05/14/25 at 9:17 a.m., CNA A said Resident #1 and Resident #2 were total bed bound residents who required a 2 person assist for toileting. CNA A said if a CNA needed to check if a resident required a 1 or 2 person assist on their ADLs, they would check the resident's [NAME] report. She was observed checking Resident #1 and Resident #2's [NAME] report and said it did not indicate if they were a 1 or 2 person assist for toileting. CNA A said she had cared for Resident #1 and Resident #2 since they had been admitted and knew they both were a 2 person assist for toileting. She was observed as she checked Resident #1's [NAME] report and stated his report did not have the ADL of toileting listed. CNA A said Resident #2's [NAME] report had his ADL of toileting listed but did not indicate if he was a 1 or 2 person assist for this specific task. CNA A said if a resident's [NAME] report failed to indicate the ADL of toileting and did not indicate if they were a 1 or 2 person assist, a CNA would not know how to provide the ADL of toileting. An interview with MDS-RN on 05/14/25 at 9:30 a.m. said the information listed on a resident's care plan was from what was listed on their MDS assessment. She said both Resident #1 and Resident #2 were considered dependent for all their ADLs which meant, both required a 2 person assist for toileting. She said their care plans did not reflect they were a were a 2 person assist for toileting and neither did their [NAME] report. She said a resident's [NAME] report reflected what was on their care plan. She said she had failed to care plan Resident #1 and Resident #2 were a two person assist for toileting. MDS-RN was not able to say if there were any negative outcomes to Resident #1 and/or Resident #2 not having their care plan indicate if they were a 1 or 2 person assist for toileting, she said that was a question for the DON. An interview on 05/14/25 at 10:03 am, the DON said Resident #1 and Resident #2 were both bed bound residents who required a 2 person assist for their ADL of toileting. The DON said the information listed on a resident's [NAME] report, was what was on their care plan. She said there were no negative outcome for Resident #1 and Resident #2 for not having their task of toileting on their care plans/[NAME] report because the CNAs assigned to their hall were tenured and had worked with both Resident #1 and Resident #2 since they had been admitted . The DON said a PRN or new CNA would check the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455672 If continuation sheet Page 2 of 3 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 455672 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Palms Rehabilitation and Retirement 2101 Treasure Hills Blvd Harlingen, TX 78550 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 0656 residents [NAME] report to guide them in performing their ADL tasks. She said if a specific ADL was not listed on a resident's [NAME] report, the CNA could always ask their charge nurse for assistance. Level of Harm - Minimal harm or potential for actual harm Record review of facility's Comprehensive Person-Centered Care Planning (no date) reflected: Residents Affected - Few Policy: It is the policy of this facility that the interdisciplinary team (IT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in a comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instruction needed to provide effective and person-centered care that meet professional standards of quality of care. Procedure: 4. The facility IDT will develop and implement a comprehensive person-centered care plan for each resident within 7 days of completion of the MDS and will include resident's needs identified in the comprehensive assessment, any specialized services as a result of PASRR recommendation, and resident's goal and desired outcomes, preferences for future discharge and discharge plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455672 If continuation sheet Page 3 of 3