Cycle 1
Health 2025-04-25 · Fire 2025-04-25
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Elgin, TX
Elgin Nursing And Rehabilitation Center
2-star overall rating with 2-star inspections with $36,221 in total fines with 8 recent health deficiencies
1373 North Avenue C, Elgin, TX
(512) 285-2457
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
114
Certified beds
Average residents
99
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Wellsential Health
Operator or chain grouping
Approved since
2008-02-14
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
0.22
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.75
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.72
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
0.97
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.46
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.24
CMS adjusted RN staffing hours
Adjusted total hours
2.97
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,723
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.66
Baseline 22.78% · Performance 21.54% · Measure score 1.66 · Achievement 0 · Improvement 1.66
Healthcare-associated infections
0
Baseline 6.21% · Performance 7.85% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.39
Baseline 55.56% · Performance 41.67% · Measure score 5.39 · Achievement 5.39 · Improvement 4.02
Adjusted total nurse staffing
0.69
Baseline 2.77 hours · Performance 3.13 hours · Measure score 0.69 · Achievement 0 · Improvement 0.69
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.79% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 16.39% · Lower 95% interval 8.5% |
| Discharge to community | 51.76% |
50.57%
1.2 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 45.9% · Lower 95% interval 40.1% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 54 · Denominator 54 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 54 |
| Discharge self-care score | 40% |
53.69%
13.7 pts worse
|
Numerator 16 · Denominator 40 |
| Discharge mobility score | 52.5% |
50.94%
1.6 pts better
|
Numerator 21 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 3.7% |
2.29%
1.4 pts worse
|
Numerator 2 · Denominator 54 · Adjusted rate 3.84% |
| Healthcare-associated infections requiring hospitalization | 7.85% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 11.11% · Lower 95% interval 3.84% |
| Staff COVID-19 vaccination coverage | 6.19% |
8.2%
2 pts worse
|
Numerator 6 · Denominator 97 |
| Staff flu vaccination coverage | 99.23% |
42%
57.2 pts better
|
Numerator 129 · Denominator 130 |
| Discharge function score | 52.5% |
56.45%
4 pts worse
|
Numerator 21 · Denominator 40 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 12.9% |
25.2%
12.3 pts worse
|
Numerator 4 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
2.1
0.7 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| 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 | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
3.3%
2.7 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 6.4% · Q3 5.1% · Q4 7.1% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.5% |
2.7%
1.8 pts worse
|
11.4%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.1% · Q3 4.4% · Q4 5.5% · 4Q avg 4.5% |
| Percentage of long-stay residents who lose too much weight | 0.7% |
3.3%
2.6 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 1.2% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.7% |
18.9%
1.2 pts better
|
19.6%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 17.8% · Q3 18.7% · Q4 17.3% · 4Q avg 17.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.9% |
10.8%
2.9 pts better
|
16.7%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 10.9% · Q3 4.9% · Q4 9.2% · 4Q avg 7.9% · 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 | 20.3% |
15.4%
4.9 pts worse
|
16.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 19.1% · Q3 28.1% · Q4 19.6% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.7% |
16.1%
6.6 pts worse
|
14.9%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 24.6% · Q3 23.3% · Q4 25.6% · 4Q avg 22.7% · 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 | 17.4% |
15.0%
2.4 pts worse
|
19.8%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 17.7% · Q3 15.3% · Q4 20.9% · 4Q avg 17.4% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
4.2%
0.4 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.2% · Q3 2.9% · Q4 5.6% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
89.7%
9.1 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 97.7% · Q3 98.8% · Q4 100.0% · 4Q avg 98.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.9% |
12.0%
0.9 pts worse
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 14.9% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.6% |
1.5%
2.1 pts worse
|
1.6%
2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.0% · Q3 4.4% · Q4 5.4% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.9% |
88.0%
10.9 pts better
|
79.7%
19.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.6% |
25.9%
5.3 pts better
|
23.9%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 25.5% · Expected 29.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-05 · Fire 2024-03-05
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-02-14 · Fire 2023-02-14
9 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-02-14
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-06-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-04
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-12-05
K · Immediate jeopardy
2025-04-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-04-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-04-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-04-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-04-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-04-25
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 2025-04-28
D · Potential for more than minimal harm
2025-04-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-28
D · Potential for more than minimal harm
2024-04-04
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-21
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-10
E · Potential for more than minimal harm
2024-03-05
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 2024-03-19
E · Potential for more than minimal harm
2024-03-05
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-03-19
E · Potential for more than minimal harm
2024-03-05
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-19
E · Potential for more than minimal harm
2024-03-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-19
D · Potential for more than minimal harm
2024-03-05
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-03-19
D · Potential for more than minimal harm
2024-03-05
F688 · Quality of Life and Care Deficiencies
Health
Provide 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.
Corrected 2024-03-19
D · Potential for more than minimal harm
2024-03-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-19
D · Potential for more than minimal harm
2023-10-09
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-10-30
E · Potential for more than minimal harm
2023-07-12
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 2023-07-28
F · Potential for more than minimal harm
2023-02-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-10
E · Potential for more than minimal harm
2023-02-14
F688 · Quality of Life and Care Deficiencies
Health
Provide 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.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-02-14
F584 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-02-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-02-14
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 2023-03-10
D · Potential for more than minimal harm
2023-02-14
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-02-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-10
Penalties and ownership
What sits behind the stars
$36,221
2025-04-25
Fine
Fine · fine $36,221
Fine
Ownership
Smithville Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Csv Rhea Management Holdco, LLC
Operational/Managerial Control · Organization
Dekowski, Donovan
Operational/Managerial Control · Individual
Hurta, Brad
Corporate Officer · Individual
Kahanek, Michael
Corporate Officer · Individual
Regency Ihs Of Elgin, LLC
Operational/Managerial Control · Organization
Regency Integrated Health Services LLC
Operational/Managerial Control · Organization
Schreiner, Robert
Corporate Officer · Individual
Smithville Hospital Authority
Operational/Managerial Control · Organization
Trousdale, James
Corporate Officer · Individual
Wheat, Travis
Operational/Managerial Control · Individual
Wilson, Linda
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Austin, TX
2-star overall rating with 2-star inspections with $31,959 in total fines with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Pflugerville Nursing And Rehabilitation Center
Pflugerville, TX
3-star overall rating with 3-star inspections with 10 recent health deficiencies
#3
Falcon Ridge Rehabilitation
Hutto, TX
2-star overall rating with 3-star inspections with $60,135 in total fines with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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