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Elgin Nursing and Rehabilitation Center
1373 North Avenue C, Elgin, TX 78621 · CMS Certification Number (CCN) 676180
At a glance
- CMS overall rating
- ★★☆☆☆ 2 of 5
- Health inspection citations
- 29 in the last 3 inspection cycles (1 immediate jeopardy, 0 actual harm, 6 from complaints)
- Fire safety citations
- 3
- Fines (last 3 years)
- 1 fine, total $36,221
- Payment denials
- 0
- Most recent standard inspection
- June 16, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★☆☆☆ 2 of 5 | 2.7 | 3 |
| Health inspections | ★★☆☆☆ 2 of 5 | 2.8 | 2.8 |
| Staffing | ★★☆☆☆ 2 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★★☆ 4 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
| Short-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | June 16, 2026 | 12 | 9 | 3 |
| Cycle 2 | April 25, 2025 | 10 | 7 | 3 |
CMS weighted health inspection score: 89.25 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
29 health citations across 9 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
July 28, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0699 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has plan of correction Corrected 07/30/2026 |
June 16, 2026: 9 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/10/2026 |
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/10/2026 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/10/2026 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/10/2026 |
| D | F-0656 | Develop 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 Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/10/2026 |
| D | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/10/2026 |
| E | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/10/2026 |
| D | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/10/2026 |
| D | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/10/2026 |
April 17, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0656 | Develop 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 Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 05/01/2026 |
December 4, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/05/2025 |
April 25, 2025: 7 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/28/2025 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/28/2025 |
| E | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/28/2025 |
| K | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/28/2025 |
| E | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/28/2025 |
| D | F-0656 | Develop 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 Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/28/2025 |
| E | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/28/2025 |
April 4, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/05/2024 |
March 21, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0690 | Provide 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 Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/10/2024 |
March 5, 2024: 7 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/19/2024 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/19/2024 |
| E | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/19/2024 |
| E | F-0699 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/19/2024 |
| D | F-0688 | 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. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/19/2024 |
| D | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/19/2024 |
| E | F-0656 | Develop 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 Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/19/2024 |
October 9, 2023: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 10/30/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
3 fire safety citations across 1 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 06/16/2026 | D | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies | Deficient, Provider has date of correction Corrected 07/10/2026 |
| 06/16/2026 | D | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/10/2026 |
| 06/16/2026 | E | K-0161 | Use approved construction type or materials. Construction Deficiencies | Deficient, Provider has date of correction Corrected 07/10/2026 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| April 25, 2025 | Fine | $36,221 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.04 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.31 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 0.75 | Not published | Not published |
| Nurse aide hours per resident per day | 1.98 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 2.69 | Not published | Not published |
| RN hours per resident per day, weekends | 0.24 | Not published | Not published |
| Total nursing staff turnover (%) | 33.3 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 0 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Smithville Hospital Authority
- Ownership type
- Non profit - Corporation
- Chain
- Wellsential Health (67 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 114
- Average residents per day
- 95.1
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- Yes
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- February 14, 2008
- County/parish
- Bastrop
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
40 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| SMITHVILLE HOSPITAL AUTHORITY | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | undefined undefined, NaN |
| REGENCY IHS OF ELGIN, LLC | DIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| DWD TX HOLDINGS LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| JACK AND NANCY DWYER WORKFORCE DEVELOPMENT CENTER INC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| REG LEASED OPCO LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| REG OPERATOR HOLDCO LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| REGENCY INTEGRATED HEALTH SERVICES LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| REGENCY TEXAS HOLDINGS LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BAIRD, DANIEL | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BUNTE, MARK | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CARVAJAL, ANTONIO | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CLAPP, BARBARA | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CORTESE, DAREN | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FULCHER, ANN | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GIBSON, PATRICIA | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KAUFMAN, NICOLE | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MANDELBAUM, ELLIOT | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WILSON, LINDA | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HURTA, BRAD | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KAHANEK, MICHAEL | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SCHREINER, ROBERT | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| TROUSDALE, JAMES | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WILSON, LINDA | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CSV RHEA MANAGEMENT HOLDCO, LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| REGENCY IHS OF ELGIN, LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| REGENCY INTEGRATED HEALTH SERVICES LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| SMITHVILLE HOSPITAL AUTHORITY | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| DEKOWSKI, DONOVAN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WHEAT, TRAVIS | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| 1373 NORTH AVENUE C LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| REGENCY IHS CLINICAL CONSULTING, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| REGENCY IHS OF ELGIN, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| REGENCY IHS REHAB LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| REGENCY INTEGRATED HEALTH SERVICES LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| SMITHVILLE HOSPITAL AUTHORITY | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| DEKOWSKI, DONOVAN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MOMIN, ZAHIR | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| RINCON, LORETTA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WHEAT, TRAVIS | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| YATES, BRANDON | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Elgin Nursing and Rehabilitation Center. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.