Cycle 1
Health 2024-12-04 · Fire 2024-12-04
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Carrollton, TX
The Madison On Marsh
3-star overall rating with 3-star inspections with $8,473 in total fines with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
2245 Marsh Ln, Carrollton, TX
(972) 416-1764
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cantex Continuing Care
Operator or chain grouping
Approved since
2007-01-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
38 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 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
0.52
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.28
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.27
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,521
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9926
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.40
Baseline 21.98% · Performance 19.55% · Measure score 4.40 · Achievement 4.05 · Improvement 4.40
Healthcare-associated infections
7.71
Baseline 6.46% · Performance 5.53% · Measure score 7.71 · Achievement 7.71 · Improvement 5.84
Total nurse turnover
2.45
Performance 53.66% · Measure score 2.45 · Achievement 2.45 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.28
Baseline 3.02 hours · Performance 3.44 hours · Measure score 1.28 · Achievement 1.28 · Improvement 1.04
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.91% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 121 · Observed rate 8.26% · Lower 95% interval 6.7% |
| Discharge to community | 49.31% |
50.57%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 91 · Observed rate 42.86% · Lower 95% interval 38.17% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.9% |
95.27%
3.6 pts better
|
Numerator 90 · Denominator 91 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 91 |
| Discharge self-care score | 59.7% |
53.69%
6 pts better
|
Numerator 40 · Denominator 67 |
| Discharge mobility score | 46.27% |
50.94%
4.7 pts worse
|
Numerator 31 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 91 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.53% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 0% · Lower 95% interval 2.86% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 107 |
| Staff flu vaccination coverage | 17.11% |
42%
24.9 pts worse
|
Numerator 26 · Denominator 152 |
| Discharge function score | 58.21% |
56.45%
1.8 pts better
|
Numerator 39 · Denominator 67 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 33 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 18.87% |
25.2%
6.3 pts worse
|
Numerator 10 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.5 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.1 · Expected 1.9 · 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 | 2.5% |
3.3%
0.8 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.4% · Q3 0.0% · Q4 3.2% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.7% |
2.7%
1 pts better
|
11.4%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.8% · Q3 0.0% · Q4 1.6% · 4Q avg 1.7% |
| 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 | 12.9% |
18.9%
6 pts better
|
19.6%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 14.3% · Q3 14.0% · Q4 8.9% · 4Q avg 12.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.1% |
10.8%
2.7 pts better
|
16.7%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 9.7% · Q3 11.8% · Q4 7.1% · 4Q avg 8.1% · 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 | 5.8% |
15.4%
9.6 pts better
|
16.3%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.6% |
16.1%
11.5 pts better
|
14.9%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.8% · Q3 5.3% · Q4 5.0% · 4Q avg 4.6% · 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 | 4.6% |
15.0%
10.4 pts better
|
19.8%
15.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.3% · Q3 0.0% · Q4 12.6% · 4Q avg 4.6% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.2%
0.7 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 6.3% · Q3 6.9% · Q4 1.2% · 4Q avg 4.9% · 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 | 8.3% |
12.0%
3.7 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 9.2% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.8% · Q3 0.8% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
88.0%
7.5 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.5% |
25.9%
9.4 pts better
|
23.9%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 17.1% · Expected 24.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-19 · Fire 2023-10-19
9 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-08-17 · Fire 2022-08-17
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-04
F · Potential for more than minimal harm
2024-12-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-12-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-12-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-04
E · Potential for more than minimal harm
2024-12-04
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-12-04
E · Potential for more than minimal harm
2024-12-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-12-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-10
F · Potential for more than minimal harm
2023-10-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-23
E · Potential for more than minimal harm
2023-10-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-20
D · Potential for more than minimal harm
2022-08-17
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2022-09-03
D · Potential for more than minimal harm
2022-08-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-09-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-03
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-12-04
D · Potential for more than minimal harm
2025-12-03
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 2025-12-04
J · Immediate jeopardy
2025-04-17
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 2025-03-01
E · Potential for more than minimal harm
2025-04-17
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 2025-04-23
D · Potential for more than minimal harm
2025-04-17
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 2025-04-23
E · Potential for more than minimal harm
2025-01-17
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-01-18
D · Potential for more than minimal harm
2025-01-17
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-01-18
D · Potential for more than minimal harm
2025-01-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-01-18
D · Potential for more than minimal harm
2025-01-17
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 2025-01-18
E · Potential for more than minimal harm
2024-12-04
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-12-04
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 2024-12-05
E · Potential for more than minimal harm
2024-12-04
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 2024-12-05
D · Potential for more than minimal harm
2023-10-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-10-19
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 2023-10-20
D · Potential for more than minimal harm
2023-10-19
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 2023-10-20
D · Potential for more than minimal harm
2023-10-19
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-10-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-08-16
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 2023-08-20
E · Potential for more than minimal harm
2022-08-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-14
D · Potential for more than minimal harm
2022-08-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-09-14
D · Potential for more than minimal harm
2022-08-17
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2022-09-14
Penalties and ownership
What sits behind the stars
$8,473
2025-04-17
Fine
Fine · fine $8,473
Fine
Ownership
Dallas County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Carrollton Health Care Center Ltd Co
Operational/Managerial Control · Organization
Castaneda, Edmundo
Corporate Officer · Individual
Cerise, Frederick
Corporate Officer · Individual
Patel, Ketan
Operational/Managerial Control · Individual
Sindatry, Maria
Operational/Managerial Control · Individual
Wallace, Roderick
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Heritage Gardens Rehabilitation and Healthcare
Carrollton, TX
1-star overall rating with 2-star inspections with abuse icon flag with $38,243 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Carrollton Health And Rehabilitation Center
Carrollton, TX
3-star overall rating with 3-star inspections with $19,185 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Signature Pointe
Dallas, TX
2-star overall rating with 2-star inspections with $38,436 in total fines with 21 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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