Marshall, TX

Heritage House Of Marshall Health & Rehabilitation

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

Compare this facility

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

Facility snapshot

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

Hours and turnover

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

Value-based purchasing

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

How the VBP score is built

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

Medicare quality reporting measures

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

Resident outcomes and process scores

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

Recent inspection cycles

Cycle 1 Health 2025-07-29 · Fire 2025-07-29

6 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-06-26 · Fire 2024-06-26

25 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2023-05-11 · Fire 2023-05-11

16 health deficiencies

Top issue: Resident Assessment and Care Planning (4 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-07-29

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-09-11

E · Potential for more than minimal harm 2025-07-29

K321 · Smoke Deficiencies

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

F · Potential for more than minimal harm 2024-06-26

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-08-02

F · Potential for more than minimal harm 2023-05-11

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-08-18

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-02

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 2026-01-20

D · Potential for more than minimal harm 2025-07-29

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2025-09-09

D · Potential for more than minimal harm 2025-07-29

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2025-09-09

D · Potential for more than minimal harm 2025-04-09

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 2025-04-10

D · Potential for more than minimal harm 2025-04-09

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-04-09

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-04-10

E · Potential for more than minimal harm 2025-01-29

F755 · Pharmacy Service Deficiencies

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

J · Immediate jeopardy 2024-06-26

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-06-27

E · Potential for more than minimal harm 2024-06-26

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2024-07-20

E · Potential for more than minimal harm 2024-06-26

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-06-27

E · Potential for more than minimal harm 2024-06-26

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-06-27

E · Potential for more than minimal harm 2024-06-26

F755 · Pharmacy Service Deficiencies

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

E · Potential for more than minimal harm 2024-06-26

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-06-26

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-06-26

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 2024-08-02

D · Potential for more than minimal harm 2024-06-26

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2024-08-02

D · Potential for more than minimal harm 2024-06-26

F655 · Resident Assessment and Care Planning Deficiencies

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

D · Potential for more than minimal harm 2024-06-26

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 2024-06-27

D · Potential for more than minimal harm 2024-06-26

F661 · Resident Assessment and Care Planning Deficiencies

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

D · Potential for more than minimal harm 2024-06-26

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 2024-06-28

D · Potential for more than minimal harm 2024-06-26

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-06-27

D · Potential for more than minimal harm 2024-06-26

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 2024-06-28

D · Potential for more than minimal harm 2024-06-26

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-06-26

F758 · Pharmacy Service Deficiencies

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

D · Potential for more than minimal harm 2024-06-26

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-06-27

C · Minimal harm 2024-06-26

F680 · Quality of Life and Care Deficiencies

Health

Ensure the activities program is directed by a qualified professional.

Corrected 2024-06-30

B · Minimal harm 2024-06-26

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2024-06-27

D · Potential for more than minimal harm 2024-06-12

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-06-13

D · Potential for more than minimal harm 2024-06-12

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-06-13

D · Potential for more than minimal harm 2024-06-12

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-06-13

D · Potential for more than minimal harm 2024-05-26

F755 · Pharmacy Service Deficiencies

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

E · Potential for more than minimal harm 2023-05-11

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2023-06-23

E · Potential for more than minimal harm 2023-05-11

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 2023-06-23

E · Potential for more than minimal harm 2023-05-11

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-06-23

E · Potential for more than minimal harm 2023-05-11

F755 · Pharmacy Service Deficiencies

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

E · Potential for more than minimal harm 2023-05-11

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2023-06-23

D · Potential for more than minimal harm 2023-05-11

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 2023-06-23

D · Potential for more than minimal harm 2023-05-11

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2023-06-23

D · Potential for more than minimal harm 2023-05-11

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2023-06-23

D · Potential for more than minimal harm 2023-05-11

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

D · Potential for more than minimal harm 2023-05-11

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-06-23

D · Potential for more than minimal harm 2023-05-11

F638 · Resident Assessment and Care Planning Deficiencies

Health

Assure that each resident’s assessment is updated at least once every 3 months.

Corrected 2023-06-23

D · Potential for more than minimal harm 2023-05-11

F655 · Resident Assessment and Care Planning Deficiencies

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

D · Potential for more than minimal harm 2023-05-11

F756 · Pharmacy Service Deficiencies

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

D · Potential for more than minimal harm 2023-05-11

F758 · Pharmacy Service Deficiencies

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

D · Potential for more than minimal harm 2023-05-11

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2023-06-23

C · Minimal harm 2023-05-11

F640 · Resident Assessment and Care Planning Deficiencies

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

What sits behind the stars

$67,706 2024-06-26

Fine

Fine · fine $67,706

Fine

Ownership

Lindsey, Lynn

Operational/Managerial Control · Individual

0% 4 facilities 2022-01-01
Southwest Ltc Marshall Ltd

Operational/Managerial Control · Organization

0% 1 facilities 2017-04-01
Thurman, Linda

W-2 Managing Employee · Individual

0% 1 facilities 2022-09-01

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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

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Staffing
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#2

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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

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Fines
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#3

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1-star overall rating with 2-star inspections with $16,498 in total fines with 14 recent health deficiencies

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Fines
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