Inspection·December 10, 2025

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 13 ([DATE]th,10th, 23rd, 24th, and 31st, [DATE]th, 7th, and 21st, and [DATE]th, 18th, 19th, 25th, and 26th, 2025) of 90 days reviewed for RN hours, for the period from [DATE], through [DATE].The facility failed to have any RN coverage on weekends for [DATE]st, [DATE]th, 18th, 19th, 25th, and 26th, 2025.The facility failed to have less than 8 hours of RN coverage on weekends for [DATE]th,10th, 23rd, and 24th, and [DATE]th, 7th, and 21st, 2025.This failure could place residents at risk of harm by denying residents the advanced critical thinking skills a registered nurse could provide. The findings were: Record review of the facility's RN timesheets revealed no RN coverage on weekends for [DATE]st, and [DATE]th, 18th, 19th, 25th, and 26th, 2025.Record review of the facility's RN timesheets revealed less than 8 hours of RN coverage on weekends for [DATE]th,10th, 23rd, and 24th, [DATE]th, 7th, and 21st, 2025.In an interview with the DON and on [DATE] at 5:00 pm, she said there was not RN coverage every weekend. She said there were 4 RN's employed and only 1 worked weekends regularly. She said RN's assigned on weekends were not necessarily inside the building unless they were called. She said she was not aware of the rule about having RN's work 8 consecutive hours a day, 7 days a week. The DON said it was her responsibility to ensure the facility had RN coverage for 8 consecutive hours every day. She said if the scheduled RN were to call in, then it would be her and the ADON's responsibility to look for another RN, or she would have to cover the shift. The DON said the negative outcome of not having an RN in the facility for 8 consecutive hours could be that certain tasks only an RN could do (i.e., signing off on baseline care plans, removing midline/PICC (peripherally inserted central [intravenous] catheter) catheters, and/or pronouncing a resident deceased ) could not be performed. Policy(s) for Staffing/RN Coverage/Scheduling were requested, but not received prior to exit.In an interview with the ADM and RN A on [DATE] at 1:15 p.m., the ADM said that it was the DON's responsibility to ensure she scheduled an RN for 8 consecutive hours every day, but ultimately it was her responsibility as the Administrator. RN A said the negative outcome of not having an RN work 8 consecutive hours every day could be that the tasks that only an RN could perform, like pronouncing a death or being a resource in case of an emergency or a sudden illness. The Administrator said the facility had sufficient RNs to cover their 8 consecutive hours shift every day and did not know why it was not done. She said the facility followed Best Practices. Policy(s) for Staffing, RN Coverage, Scheduling, and best practices were requested but not received prior to exit. In an interview with the ADM and RN A on [DATE] at 3:30 pm, the ADM said she checked with another ADM at their sister facility, and they did not have the policies requested. She said the only policy she could find was a job description for the DON position. RN A said he was unaware of any specific policies the company had for scheduling or RN coverage.Record review of the facility's job description for the DON dated 10/2021 revealed under (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455672 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 12/10/2025 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)