Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- TexasAbove only 23% of peers1,167 rated homes · average 2.8★
- Bastrop CountyLowest tier among peers5 rated homes · average 2.8★
- United StatesAbove only 20% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point2★−0.8 vs TX avg
- StaffingCan add or remove a star2★−0.1 vs TX avg
- Quality measuresCan add or remove a star3★−0.8 vs TX avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersTX avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 37% of peersTX avg2.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 15% of peersTX avg3.8★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff2.72hrsAbove only 5% of peersTX avg3.40Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.22hrsAbove only 10% of peersTX avg0.44Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better30%Top 5%TX avg51%RN turnover38%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$55,725Above only 27% of peersTX avg$55,368Fines · denials1 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthFeb 2023 – Dec 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Dec 4, 2025Cycle 1worst D · no actual harm
- F602Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 5, 2025
Apr 25, 2025Cycle 1worst K · immediate jeopardy$55,725
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Apr 28, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Apr 28, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Apr 28, 2025
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareK · patternCorrected Apr 28, 2025
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Apr 28, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Apr 28, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Apr 28, 2025
Apr 4, 2024Cycle 2worst D · no actual harm
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Apr 5, 2024
Mar 21, 2024Cycle 2worst D · no actual harm
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Apr 10, 2024
Mar 5, 2024Cycle 2worst E · no actual harm
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Mar 19, 2024
- F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Mar 19, 2024
- F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and CareD · isolatedCorrected Mar 19, 2024
- F699Provide care or services that was trauma informed and/or culturally competent.Quality of Life and CareE · patternCorrected Mar 19, 2024
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Mar 19, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Mar 19, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Mar 19, 2024
Oct 9, 2023Cycle 3worst D · no actual harm
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningD · isolatedCorrected Oct 30, 2023
Jul 12, 2023Cycle 3worst E · no actual harm
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Jul 28, 2023
Feb 14, 2023Cycle 3worst F · no actual harm
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsD · isolatedCorrected Mar 10, 2023
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Mar 10, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Mar 10, 2023
- F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Mar 10, 2023
- F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and CareE · patternCorrected Mar 10, 2023
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Mar 10, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Mar 10, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined2.72hrs
- Registered nursesRN hours only0.22hrs
- Licensed practical nursesLPN hours0.75hrs
- Nurse aidesCNA hours1.75hrs
- Weekend nursingAll staff on Saturdays and Sundays2.46hrs
- Texas average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better30%Top 5%TX avg 51%
- RN turnoverRegistered nurses only38%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy114 certified beds · ~99 residents a day87%Above 85% of peersTX avg 67%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $55,725In fines
- 1Fine
- 0Payment denials
- $55,368TX avg in fines
Actions on record
- Apr 25, 2025Civil money penalty$55,725
Ownership
As filed with CMSStructure
- Ownership type
- Non profit - Corporation
- Chain
- Wellsential Health67 facilities in the chain2.8★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Smithville Hospital Authority
- Csv Rhea Management Holdco, LLC
- Regency Ihs of Elgin, LLC
- Regency Integrated Health Services LLC
- Smithville Hospital Authority
- Donovan Dekowski
- Travis Wheat
- Brad Hurta
- Michael Kahanek
- Robert Schreiner
- James Trousdale
- Linda Wilson
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 676180 · 1373 NORTH AVENUE C, ELGIN, TX, 78621.
- Percentiles compare this facility with every rated nursing home in Texas and Bastrop County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
