6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Marshall, TX
2-star overall rating with 3-star inspections with $67,706 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
5915 Elysian Fields Road, Marshall, TX
(903) 935-6700
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
125
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Southwest Ltc
Operator or chain grouping
Approved since
2008-07-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 3 overall / 4 health / 2 staffing / 3 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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
RN hours / resident day
0.29
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.29
CMS adjusted RN staffing hours
Adjusted total hours
3.48
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Program rank
13,450
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
5.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0.17
Baseline 22.80% · Performance 22.41% · Measure score 0.17 · Achievement 0 · Improvement 0.17
Healthcare-associated infections
0
Baseline 8.39% · Performance 8.38% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
1.35
Baseline 3.97 hours · Performance 3.46 hours · Measure score 1.35 · Achievement 1.35 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.17% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 77 · Observed rate 9.09% · Lower 95% interval 6.28% |
| Discharge to community | 50.85% |
50.57%
0.3 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 46.77% · Lower 95% interval 38.67% |
| Medicare spending per beneficiary | 1.25 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 95.24% |
95.27%
About the same
|
Numerator 40 · Denominator 42 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 42 |
| Discharge self-care score | 39.29% |
53.69%
14.4 pts worse
|
Numerator 11 · Denominator 28 |
| Discharge mobility score | 32.14% |
50.94%
18.8 pts worse
|
Numerator 9 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 2.38% |
2.29%
0.1 pts worse
|
Numerator 1 · Denominator 42 · Adjusted rate 2.06% |
| Healthcare-associated infections requiring hospitalization | 8.38% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 12.24% · Lower 95% interval 5.17% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 114 |
| Staff flu vaccination coverage | 17.69% |
42%
24.3 pts worse
|
Numerator 23 · Denominator 130 |
| Discharge function score | 46.43% |
56.45%
10 pts worse
|
Numerator 13 · Denominator 28 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 48% |
25.2%
22.8 pts better
|
Numerator 12 · Denominator 25 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.1
0.6 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.7 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.5 · Expected 1.7 · 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 | 0.8% |
3.3%
2.5 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
2.7%
1.3 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.5% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
3.3%
0.1 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 6.4% · Q3 2.3% · Q4 2.0% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.8% |
18.9%
3.1 pts better
|
19.6%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 16.3% · Q3 15.6% · Q4 14.3% · 4Q avg 15.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.6% |
10.8%
6.8 pts worse
|
16.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 21.2% · Q3 18.8% · Q4 14.3% · 4Q avg 17.6% · 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 | 24.4% |
15.4%
9 pts worse
|
16.3%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.4% · Q3 18.4% · Q4 13.0% · 4Q avg 24.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.9% |
16.1%
8.8 pts worse
|
14.9%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 26.7% · Q3 14.0% · Q4 29.2% · 4Q avg 24.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.5%
0.1 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.5% |
15.0%
2.5 pts worse
|
19.8%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 28.2% · Q3 15.5% · Q4 13.1% · 4Q avg 17.5% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
4.2%
1.7 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 6.9% · Q3 4.2% · Q4 4.8% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.2% |
12.0%
7.2 pts worse
|
12.0%
7.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.2% · Observed 20.4% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.4% |
25.9%
4.5 pts better
|
23.9%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 22.2% · Expected 24.8% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Top issue: Resident Assessment and Care Planning (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-11
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-09-09
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-02
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-18
Inspection history
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-01-20
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-09-09
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-09-09
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-10
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-02-27
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-10
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-01-30
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-27
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-07-20
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-27
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-06-27
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-27
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-28
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-07-20
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-08-02
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-08-02
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-06-27
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-27
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-06-27
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-27
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 2024-06-28
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-06-28
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-06-27
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-27
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2024-06-30
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-06-27
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-06-13
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-13
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-13
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-28
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-06-23
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-23
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-23
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-06-23
Health
Implement a program that monitors antibiotic use.
Corrected 2023-06-23
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-23
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-06-23
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-06-23
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-23
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-06-23
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-06-23
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-06-23
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-06-23
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-06-23
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-06-23
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-06-23
Penalties and ownership
Fine · fine $67,706
Fine
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
W-2 Managing Employee · Individual
Nearby options
Marshall, TX
2-star overall rating with 2-star inspections with abuse icon flag with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Marshall, TX
3-star overall rating with 2-star inspections with $21,530 in total fines with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Jefferson, TX
1-star overall rating with 2-star inspections with $16,498 in total fines with 14 recent health deficiencies
Jump out