Marshall Manor West

Medicare Outcome Measures

• Potentially preventable hospital readmissions

  11.32% (lower is better)

  No Different than the National Rate

• Residents discharged back to the community

  38.80% (higher is better)

  No Different than the National Rate

• Infections acquired during the stay requiring hospitalization

  8.24% (lower is better)

  No Different than the National Rate

Source: CMS Skilled Nursing Facility Quality Reporting Program. Rates are risk-standardized by CMS; the comparison category is CMS's own, shown exactly as published.

Clinical Quality Measures

• Long-stay residents with a urinary tract infection

  0.0%

  national median 0.9%

  better than the national median

• Long-stay residents experiencing falls with major injury

  1.1%

  national median 2.8%

  better than the national median

• Short-stay residents who newly received an antipsychotic medication

  0.0%

  national median 1.0%

  better than the national median

• Long-stay residents whose ability to walk independently worsened

  3.9%

  national median 12.5%

  better than the national median

• Long-stay residents with pressure ulcers

  0.7%

  national median 4.2%

  better than the national median

• Long-stay residents who received an antipsychotic medication

  11.6%

  national median 13.4%

  near the national median

Source: CMS MDS quality measures (four-quarter average).

Nurse Staffing

Nurse staffing per resident per day

4.6 hours

TX average: 3.4 hours · National: 3.9 hours

All nursing staff combined: RNs, LPNs/LVNs, and nurse aides.

Registered nurse (RN) time per resident per day

0.3 hours

TX average: 0.4 hours · National: 0.7 hours

RN hours only — the most highly trained nursing staff.

Weekend nurse staffing per resident per day

3.5 hours

TX average: 3.0 hours · National: 3.4 hours

Total nurse staffing on Saturdays and Sundays, when staffing typically dips.

Nursing staff turnover in the past year

32.8%

TX average: 55.3% · National: 45.8%

Share of this facility’s nursing staff who stopped working there over 12 months.

Reported by facilities through CMS's Payroll-Based Journal system. Facility values and the state/national averages are shown exactly as CMS publishes them. More staffing hours are generally better; lower turnover is generally better.

Penalties & Enforcement

1 fine totaling $13,995 in the recent inspection window (most recent: October 22, 2025).

Federal enforcement actions from CMS's penalty file: civil money penalties (fines) and denials of Medicare payment tied to health-inspection deficiencies.

Ownership

Ownership type

Government - Hospital district

Chain

Caring Healthcare Group