Marshall, TX

Marshall Manor Nursing & Rehabilitation Center

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

1007 S Washington Ave, Marshall, TX

(903) 935-7971

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

179

Certified beds

Average residents

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

Caring Healthcare Group

Operator or chain grouping

Approved since

1986-03-27

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

14 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

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

0.42

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.14

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.83

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

4.39

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.56

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.77

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.16

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.44

CMS adjusted RN staffing hours

Adjusted total hours

4.60

CMS adjusted total nurse staffing hours

Case-mix index

1.30

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

41%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,638

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

26.15

Composite VBP score used to determine payment impact.

Payment multiplier

0.9841

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 20.75% · Performance 24.20% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

0.37

Baseline 9.61% · Performance 9.21% · Measure score 0.37 · Achievement 0 · Improvement 0.37

Total nurse turnover

6.09

Baseline 40.18% · Performance 38.78% · Measure score 6.09 · Achievement 6.09 · Improvement 0.42

Adjusted total nurse staffing

3.99

Baseline 5.04 hours · Performance 4.21 hours · Measure score 3.99 · Achievement 3.99 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.27%	10.72% 0.5 pts worse	No Different than the National Rate · Eligible stays 97 · Observed rate 12.37% · Lower 95% interval 8.01%
Discharge to community	55.75%	50.57% 5.2 pts better	No Different than the National Rate · Eligible stays 73 · Observed rate 49.32% · Lower 95% interval 46.11%
Medicare spending per beneficiary	0.94	1.02 0.1 pts better
Drug regimen review with follow-up	98.96%	95.27% 3.7 pts better	Numerator 95 · Denominator 96
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 96
Discharge self-care score	62.96%	53.69% 9.3 pts better	Numerator 34 · Denominator 54
Discharge mobility score	35.19%	50.94% 15.8 pts worse	Numerator 19 · Denominator 54
Pressure ulcers or injuries, new or worsened	1.04%	2.29% 1.2 pts better	Numerator 1 · Denominator 96 · Adjusted rate 1.08%
Healthcare-associated infections requiring hospitalization	9.21%	7.12% 2.1 pts worse	No Different than the National Rate · Eligible stays 68 · Observed rate 13.24% · Lower 95% interval 6.01%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 160
Staff flu vaccination coverage	17.73%	42% 24.3 pts worse	Numerator 36 · Denominator 203
Discharge function score	46.3%	56.45% 10.2 pts worse	Numerator 25 · Denominator 54
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 41 · Denominator 41
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 26 · Denominator 26
Resident COVID-19 vaccinations up to date	94.83%	25.2% 69.6 pts better	Numerator 55 · Denominator 58

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 2.4 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.4	2.1 0.7 pts better	1.8 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · 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	0.0%	3.3% 3.3 pts better	3.3% 3.3 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 who have depressive symptoms	0.6%	2.7% 2.1 pts better	11.4% 10.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 1.2% · Q4 0.0% · 4Q avg 0.6%
Percentage of long-stay residents who lose too much weight	0.0%	3.3% 3.3 pts better	5.4% 5.4 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 who received an antianxiety or hypnotic medication	15.5%	18.9% 3.4 pts better	19.6% 4.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 14.7% · Q3 23.2% · Q4 10.8% · 4Q avg 15.5%
Percentage of long-stay residents who received an antipsychotic medication	8.8%	10.8% 2 pts better	16.7% 7.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 9.3% · Q3 10.7% · Q4 8.3% · 4Q avg 8.8% · 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	13.0%	15.4% 2.4 pts better	16.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 23.6% · Q3 13.5% · Q4 6.6% · 4Q avg 13.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	16.0%	16.1% 0.1 pts better	14.9% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 17.7% · Q3 11.3% · Q4 17.6% · 4Q avg 16.0% · 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	0.9%	0.8% 0.1 pts worse	1.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 0.0% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	3.9%	15.0% 11.1 pts better	19.8% 15.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 6.8% · Q3 3.7% · Q4 2.5% · 4Q avg 3.9%
Percentage of long-stay residents with pressure ulcers	1.6%	4.2% 2.6 pts better	5.1% 3.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.5% · Q3 0.9% · Q4 3.5% · 4Q avg 1.6% · 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	13.3%	12.0% 1.3 pts worse	12.0% 1.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 13.3% · Observed 14.9% · Expected 12.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.5%	1.5% 1 pts better	1.6% 1.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · 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	36.7%	25.9% 10.8 pts worse	23.9% 12.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 36.7% · Observed 44.8% · Expected 29.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-07 · Fire 2025-05-07

9 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

3 fire-safety deficiencies

Top issue: Services (2 deficiencies)

Cycle 2 Health 2024-04-10 · Fire 2024-04-10

7 health deficiencies

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

1 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 3 Health 2023-02-24 · Fire 2023-02-24

9 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-05-07

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-05-07

D · Potential for more than minimal harm 2025-05-07

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-05-07

C · Minimal harm 2025-05-07

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

C · Minimal harm 2024-04-10

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

E · Potential for more than minimal harm 2023-02-24

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-04-28

E · Potential for more than minimal harm 2023-02-24

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 2023-03-23

C · Minimal harm 2023-02-24

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-05-07

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 2025-05-08

E · Potential for more than minimal harm 2025-05-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-05-08

D · Potential for more than minimal harm 2025-05-07

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-05-08

D · Potential for more than minimal harm 2025-05-07

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-05-08

D · Potential for more than minimal harm 2025-05-07

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 2025-05-08

D · Potential for more than minimal harm 2025-05-07

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 2025-05-08

D · Potential for more than minimal harm 2025-05-07

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 2025-05-08

D · Potential for more than minimal harm 2025-05-07

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2025-05-08

D · Potential for more than minimal harm 2025-04-15

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 2025-04-06

E · Potential for more than minimal harm 2024-04-10

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 2024-04-11

E · Potential for more than minimal harm 2024-04-10

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 2024-04-11

D · Potential for more than minimal harm 2024-04-10

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2024-04-11

D · Potential for more than minimal harm 2024-04-10

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 2024-04-11

D · Potential for more than minimal harm 2024-04-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-04-11

D · Potential for more than minimal harm 2024-03-13

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2024-03-14

D · Potential for more than minimal harm 2024-03-13

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 2024-03-14

E · Potential for more than minimal harm 2023-02-24

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2023-03-23

E · Potential for more than minimal harm 2023-02-24