Inspection Reports for Hidalgo Nursing and Rehabilitation Center

The facility failed to provide Resident #1 with a BIPAP machine as per doctor's orders on the night of 11/26/25 due to equipment malfunction and staff unawareness of backup equipment. Despite this, Resident #1 did not experience any immediate negative outcomes during the night. The deficiency was classified as minimal harm affecting a few residents.

The facility failed to develop and implement a comprehensive person-centered care plan for Resident #247 that included the use of a mechanical lift for transfers, and failed to maintain complete and accurate clinical records for Resident #11, specifically the failure to document an assessment after redness was noted on the resident's leg.

The facility failed to ensure that LVN P documented an assessment of Resident #11's leg redness on 01/29/25 after being informed by CNA O. This failure to document could lead to delayed treatment and decreased quality of life for residents.

The complaint involved an allegation that CNA A verbally abused resident R#1 on 05/20/24. The investigation included interviews, observations, and record reviews. The allegation was substantiated by witness statements and facility investigation. CNA A was terminated. The complaint was reported to the state. The facility's complaint follow-up report indicated the investigation was completed and the allegation was unfounded, but the facility took corrective actions including staff in-service and resident counseling.

The facility failed to ensure residents were free from verbal abuse when CNA A used obscene language toward R#1 while attempting to transfer him to a wheelchair. The incident was witnessed by LVN B who intervened immediately. The resident was assessed with no injuries or distress. CNA A was suspended and later terminated. The facility provided counseling to the resident and in-serviced staff on abuse and neglect.

The facility was found deficient in ensuring residents' rights to formulate advance directives, developing and implementing comprehensive care plans, revising care plans after assessments, providing activities that meet residents' preferences, ensuring the activities program was directed by a qualified professional, coordinating hospice services, maintaining infection control practices, and providing mandatory QAPI training to staff.

The visit was complaint-related, triggered by allegations of failure in resident care planning, advance directives, activity provision, hospice coordination, infection control, and staff training. Specific substantiation status is not explicitly stated.

The facility was found deficient in multiple areas including failure to conduct care plan meetings involving residents, improper execution of advance directives, incomplete and unimplemented care plans, failure to revise care plans after assessments, inadequate provision of activities especially for isolated residents, unqualified activities director, lack of hospice documentation and coordination, improper infection control practices, and lack of QAPI training for staff.

The complaint investigation revealed failures in timely reporting of abuse and neglect incidents to HHSC, inadequate supervision leading to resident elopement, and deficiencies in pharmaceutical services including medication reconciliation and documentation.

The facility failed to report findings from investigations of abuse, neglect, exploitation, or mistreatment to HHSC within 5 working days for 4 of 9 reviewed incidents. The facility also failed to ensure adequate supervision to prevent accidents, resulting in a resident elopement incident. Additionally, the facility failed to maintain accurate drug records and reconcile controlled substances for one resident, risking medication errors and drug diversion.

The investigation was complaint-related, focusing on documentation inaccuracies for Resident #3. The complaint was substantiated by interviews with LVN A and the Director of Nursing, confirming that enteral feeding was documented as given when it was not administered.

The facility failed to maintain clinical records in accordance with accepted professional standards for Resident #3, as the Medication Administration Record documented enteral feeding as administered when it was not given. Interviews with staff confirmed the inaccurate documentation, which could place residents at risk for errors in care and treatment.

The facility failed to ensure that Resident #9 received oxygen therapy with a valid physician's order since 02/07/22. Observations and interviews confirmed Resident #9 was on oxygen without current physician orders, posing potential risk for respiratory complications. The facility's policy requires physician orders for oxygen administration, which were not present for this resident.