Cycle 1
Health 2025-11-19 · Fire 2025-11-19
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Marion, IA
Terrace Glen Village
5-star overall rating with 4-star inspections with $12,248 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3400 Alburnett Road, Marion, IA
(319) 377-9000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
38
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pivotal Health Care
Operator or chain grouping
Approved since
2019-01-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 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
1.47
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.10
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.71
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.28
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.79
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.98
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.54
CMS adjusted RN staffing hours
Adjusted total hours
4.48
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
42%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,538
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.86
Composite VBP score used to determine payment impact.
Payment multiplier
0.9894
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.79
Baseline 17.58% · Performance 21.07% · Measure score 0.79 · Achievement 0.79 · Improvement 0
Healthcare-associated infections
2.95
Baseline 6.83% · Performance 6.95% · Measure score 2.95 · Achievement 2.95 · Improvement 0
Total nurse turnover
5.17
Baseline 47.37% · Performance 42.55% · Measure score 5.17 · Achievement 5.17 · Improvement 1.64
Adjusted total nurse staffing
5.44
Baseline 4.52 hours · Performance 4.63 hours · Measure score 5.44 · Achievement 5.44 · Improvement 0.32
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.01% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 8.11% · Lower 95% interval 6.97% |
| Discharge to community | 56.12% |
50.57%
5.5 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 49.28% · Lower 95% interval 43.78% |
| Medicare spending per beneficiary | 0.62 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 97.73% |
95.27%
2.5 pts better
|
Numerator 43 · Denominator 44 |
| Falls with major injury | 2.27% |
0.77%
1.5 pts worse
|
Numerator 1 · Denominator 44 |
| Discharge self-care score | 55.56% |
53.69%
1.9 pts better
|
Numerator 20 · Denominator 36 |
| Discharge mobility score | 38.89% |
50.94%
12 pts worse
|
Numerator 14 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 44 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.95% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 5.26% · Lower 95% interval 3.78% |
| Staff COVID-19 vaccination coverage | 39.89% |
8.2%
31.7 pts better
|
Numerator 73 · Denominator 183 |
| Staff flu vaccination coverage | 40.48% |
42%
1.5 pts worse
|
Numerator 68 · Denominator 168 |
| Discharge function score | 58.33% |
56.45%
1.9 pts better
|
Numerator 21 · Denominator 36 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 70.83% |
25.2%
45.6 pts better
|
Numerator 17 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.5
0.8 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 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 | 97.3% |
95.2%
2.1 pts better
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.7%
0.2 pts better
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.9% · Q3 0.0% · Q4 2.9% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.4% |
4.0%
0.4 pts worse
|
11.4%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 5.9% · Q3 2.6% · Q4 6.1% · 4Q avg 4.4% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
4.9%
1.7 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.3% · Q3 4.3% · Q4 0.0% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.6% |
20.6%
11 pts better
|
19.6%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 20.8% · Q3 4.3% · Q4 8.3% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.2% |
19.8%
8.6 pts better
|
16.7%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 10.0% · Q3 15.0% · Q4 15.0% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
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 | 18.9% |
18.5%
0.4 pts worse
|
16.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.2% |
18.3%
1.1 pts better
|
14.9%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 26.1% · Q3 17.4% · Q4 8.3% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
1.7%
0.2 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
2.5%
1.1 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 5.3% · Q4 5.7% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.2% |
26.0%
0.8 pts better
|
19.8%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.2% · Q2 32.7% · Q3 17.5% · Q4 19.0% · 4Q avg 25.2% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.3%
0.3 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 1.9% · Q3 5.1% · Q4 5.0% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
84.3%
15.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.4% |
13.1%
10.3 pts worse
|
12.0%
11.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 27.6% · Expected 13.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
1.9%
1 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.8% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.7% |
73.3%
12.4 pts better
|
79.7%
6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.8% |
21.3%
3.5 pts better
|
23.9%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.8% · Observed 20.7% · Expected 27.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-03 · Fire 2024-10-03
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2023-06-29 · Fire 2023-06-29
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-10
E · Potential for more than minimal harm
2025-11-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-02
F · Potential for more than minimal harm
2024-10-03
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-10-09
F · Potential for more than minimal harm
2024-10-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-10-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-10-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-10-03
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-06
E · Potential for more than minimal harm
2024-10-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-08
F · Potential for more than minimal harm
2023-06-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-06-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-06-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-13
F · Potential for more than minimal harm
2023-06-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-06-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-13
E · Potential for more than minimal harm
2023-06-29
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-07-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-11
E · Potential for more than minimal harm
2025-11-19
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-12-11
E · Potential for more than minimal harm
2025-11-19
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 2025-12-11
B · Minimal harm
2024-10-03
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-10
G · Actual harm
2023-06-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-19
G · Actual harm
2023-06-29
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 2023-07-19
G · Actual harm
2023-06-29
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 2023-07-19
D · Potential for more than minimal harm
2023-06-29
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 2023-07-19
D · Potential for more than minimal harm
2023-06-29
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 2023-07-19
D · Potential for more than minimal harm
2023-06-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-19
Penalties and ownership
What sits behind the stars
$12,248
2023-06-29
Fine
Fine · fine $12,248
Fine
Ownership
Anderson, Jordan
Operational/Managerial Control · Individual
Gulledge, Scott
Operational/Managerial Control · Individual
Gulledge, Travis
Operational/Managerial Control · Individual
Pivotal Health Care LLC
Operational/Managerial Control · Organization
Scenic Development LLC
Operational/Managerial Control · Organization
Taeger, Vincent
Operational/Managerial Control · Individual
Tressel, Stephen
Operational/Managerial Control · Individual
Wood, Gilbert
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Winslow House Care Center
Marion, IA
2-star overall rating with 1-star inspections with $43,778 in total fines with 11 recent health deficiencies
#2
Hallmar Village
Cedar Rapids, IA
2-star overall rating with 2-star inspections with $11,960 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Oakview Nursing & Rehablitation - Marion
Marion, IA
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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