Cycle 1
Health 2025-02-12 · Fire 2025-02-12
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Edinburg, TX
Hidalgo Nursing And Rehabilitation Center
2-star overall rating with 2-star inspections with abuse icon flag with $7,582 in total fines with 4 recent health deficiencies
4503 S Sugar Rd, Edinburg, TX
(956) 386-1112
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
126
Certified beds
Average residents
100
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Wellsential Health
Operator or chain grouping
Approved since
2013-11-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
67 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
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
0.43
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.39
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
2.69
CMS adjusted total nurse staffing hours
Case-mix index
1.73
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,101
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9847
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
6.33
Baseline 7.55% · Performance 5.94% · Measure score 6.33 · Achievement 6.33 · Improvement 5.78
Total nurse turnover
2.01
Baseline 24.29% · Performance 55.45% · Measure score 2.01 · Achievement 2.01 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.95 hours · Performance 3.01 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.32% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 13.25% · Lower 95% interval 8.19% |
| Discharge to community | 60.99% |
50.57%
10.4 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 53.62% · Lower 95% interval 49.5% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 88.68% |
95.27%
6.6 pts worse
|
Numerator 47 · Denominator 53 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 53 |
| Discharge self-care score | 65% |
53.69%
11.3 pts better
|
Numerator 26 · Denominator 40 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 20 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 3.77% |
2.29%
1.5 pts worse
|
Numerator 2 · Denominator 53 · Adjusted rate 2.46% |
| Healthcare-associated infections requiring hospitalization | 5.94% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 0% · Lower 95% interval 2.79% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 127 |
| Staff flu vaccination coverage | 97.32% |
42%
55.3 pts better
|
Numerator 145 · Denominator 149 |
| Discharge function score | 57.5% |
56.45%
1 pts better
|
Numerator 23 · Denominator 40 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 98.9% |
97.9%
1 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.3%
0.1 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.5% · Q3 2.6% · Q4 3.8% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
2.7%
2.3 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
3.3%
3.1 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 2.7% · Q3 9.9% · Q4 7.1% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.9% |
18.9%
9 pts better
|
19.6%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 9.2% · Q3 11.1% · Q4 11.0% · 4Q avg 9.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.5% |
10.8%
1.7 pts worse
|
16.7%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 12.1% · Q3 12.3% · Q4 13.4% · 4Q avg 12.5% · 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 | 19.0% |
15.4%
3.6 pts worse
|
16.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.5% |
16.1%
0.6 pts better
|
14.9%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 7.5% · Q3 15.1% · Q4 16.0% · 4Q avg 15.5% · 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 | 11.1% |
15.0%
3.9 pts better
|
19.8%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 7.0% · Q3 9.1% · Q4 16.5% · 4Q avg 11.1% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
4.2%
1.5 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.6% · Q3 1.7% · Q4 3.1% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
89.7%
8.4 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 99.1% · Q3 98.6% · Q4 97.2% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
12.0%
5.3 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 7.3% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.3% |
88.0%
10.3 pts better
|
79.7%
18.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
25.9%
1.7 pts better
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 29.3% · Expected 28.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-17 · Fire 2023-11-17
10 health deficiencies
Top issue: Administration (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-08-26 · Fire 2022-08-26
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-08-26
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2022-08-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-29
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2026-02-02
D · Potential for more than minimal harm
2025-11-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-02-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-02-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-20
E · Potential for more than minimal harm
2023-11-17
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-17
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-17
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-17
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-17
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-17
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-15
J · Immediate jeopardy
2023-11-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-11-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-11-03
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-10
D · Potential for more than minimal harm
2022-08-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-09-16
Penalties and ownership
What sits behind the stars
$7,582
2023-11-03
Fine
Fine · fine $7,582
Fine
Ownership
Uvalde County Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Apolinar, Adam
Corporate Officer · Individual
Contreras, Terri
Corporate Officer · Individual
Dekowski, Donovan
Operational/Managerial Control · Individual
Elliott, Benjamin
Corporate Officer · Individual
Faglie, Kelly
Corporate Officer · Individual
Garza, Senovio
Operational/Managerial Control · Individual
Gonzales, Hector
Corporate Officer · Individual
Regency Ihs Of Hidalgo LLC
Operational/Managerial Control · Organization
Regency Integrated Health Services LLC
Operational/Managerial Control · Organization
Uvalde County Hospital Authority
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Edinburg Nursing and Rehabilitation Center
Edinburg, TX
2-star overall rating with 3-star inspections with $21,472 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Colonial Manor Advanced Rehab & Healthcare
Pharr, TX
2-star overall rating with 2-star inspections with $71,122 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Windsor Nursing And Rehabilitation Center Of Edinb
Edinburg, TX
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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