Golden Palms Rehabilitation and Retirement
2101 Treasure Hills Boulevard, Harlingen, TX 78550 · Cameron County · 60 certified beds · avg 47 residents/day · certified since Nov 10, 1986
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jan 25, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 3, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Jun 25, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 26, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (23)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 13, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| May 13, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Apr 15, 2026 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Apr 15, 2026 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Apr 11, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Feb 20, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Dec 10, 2025 | E · Potential for harm, repeated | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint |
| May 15, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| May 8, 2025 | E · Potential for harm, repeated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| May 8, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| May 8, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Apr 15, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Jan 25, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 25, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jan 25, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jan 25, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jun 25, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 25, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Feb 23, 2024 | D · Potential for harm, one-off | The facility did not let a resident return after a hospital stay or approved leave that lasted longer than the facility's bed-hold policy allowed. Residents generally have the right to come back to the next available bed. · from a complaint |
| Nov 9, 2023 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Nov 9, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Oct 19, 2023 | D · Potential for harm, one-off | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (4 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 3 | 0 | E |
| 2024 | 4 | 1 | G ▲ |
| 2025 | 10 | 1 | J ▲ |
| 2026 | 6 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $15,997.
| Date | Type | Amount / length |
|---|---|---|
| Jan 25, 2025 | Fine | $9,113 |
| Jun 25, 2024 | Fine | $2,867 |
| Feb 23, 2024 | Fine | $4,017 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.19 | 3.46 | 3.95 | bottom 38% in Texas; bottom 21% in the U.S. |
| Registered Nurse hours | 0.65 | 0.44 | 0.69 | top 12% in Texas; top 43% in the U.S. |
| Weekend total nurse staffing | 2.69 | 3.04 | 3.50 | bottom 28% in Texas; bottom 16% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.32 | 0.34 | 0.48 | top 41% in Texas; bottom 36% in the U.S. |
| Total nursing staff turnover (%) | 47.8 | 55.3 | 45.8 | top 40% in Texas; bottom 42% in the U.S. |
| RN turnover (%) | 28.6 | 54.6 | 42.9 | top 15% in Texas; top 26% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.44, RN 0.70, weekend 2.90. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ashton, Andrew | Individual | Corporate Officer | NOT APPLICABLE | 04/16/2019 |
| Burnam, Soon | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/16/2019 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 04/16/2019 |
| Burton, Spencer | Individual | Corporate Officer | NOT APPLICABLE | 05/30/2015 |
| Christensen, Christopher | Individual | Corporate Officer | NOT APPLICABLE | 11/01/2014 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2019 |
| Guzman, Nefi | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2019 |
| Guzman, Nefi | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/01/2019 |
| Guzman, Nefi | Individual | ADP of the SNF | NOT APPLICABLE | 04/14/2025 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 06/01/2019 |
| Port, Barry | Individual | Corporate Officer | NOT APPLICABLE | 06/01/2019 |
| Snapper, Suzanne | Individual | Corporate Officer | NOT APPLICABLE | 08/01/2009 |
| Standard Bearer Healthcare Op, LP | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
| The Ensign Group INC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
| Treasure Hills Health Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
| Wittekind, Beverly | Individual | Corporate Officer | NOT APPLICABLE | 09/29/2008 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "How many hours a day is a registered nurse physically in the building, including weekends?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Treasure Hills Healthcare and Rehabilitation Cente | 0.3 mi | Harlingen, TX | ★★★☆☆ | 3/5 | |
| Sun Valley Rehabilitation and Healthcare Center | 0.7 mi | Harlingen, TX | ★★★★★ | 5/5 | |
| Windsor Nursing and Rehabilitation Center of Harli | 1.0 mi | Harlingen, TX | ★★★★★ | 4/5 | |
| Harlingen Nursing and Rehabilitation Center | 1.0 mi | Harlingen, TX | ★★★☆☆ | 2/5 | |
| Windsor Atrium | 1.9 mi | Harlingen, TX | ★★☆☆☆ | 2/5 | |
| Veranda Rehabilitation and Healthcare | 11.8 mi | Harlingen, TX | ★★★★★ | 4/5 | |
| Mid Valley Nursing & Rehabilitation | 13.1 mi | Mercedes, TX | ★★☆☆☆ | 2/5 | |
| Brownsville Nursing and Rehabilitation Center | 17.0 mi | Brownsville, TX | ★☆☆☆☆ | 2/5 | |
| Fox Hollow Post Acute | 19.0 mi | Brownsville, TX | ★☆☆☆☆ | 1/5 | |
| Mesa Hills Post Acute | 19.0 mi | Brownsville, TX | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 455672.