Cycle 1
Health 2021-08-26 · Fire 2021-08-26
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Russellville, AL
Terrace Manor Nursing & Rehabilitation Center, Inc
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
390 Underwood Road, Russellville, AL
(256) 332-3826
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
63
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Advanced Health Care Management
Operator or chain grouping
Approved since
1976-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 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
0.76
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.94
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.05
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
4.45
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,529
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9842
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.95
Baseline 19.61% · Performance 20.99% · Measure score 0.95 · Achievement 0.95 · Improvement 0
Healthcare-associated infections
0
Baseline 8.09% · Performance 8.35% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.21
Baseline 51.16% · Performance 42.37% · Measure score 5.21 · Achievement 5.21 · Improvement 2.84
Adjusted total nurse staffing
4.4
Baseline 3.59 hours · Performance 4.33 hours · Measure score 4.4 · Achievement 4.4 · Improvement 2.89
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.75% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 149 · Observed rate 10.07% · Lower 95% interval 7.4% |
| Discharge to community | 56.11% |
50.57%
5.5 pts better
|
No Different than the National Rate · Eligible stays 111 · Observed rate 50.45% · Lower 95% interval 44.41% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 79 · Denominator 79 |
| Falls with major injury | 1.27% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 79 |
| Discharge self-care score | 88.1% |
53.69%
34.4 pts better
|
Numerator 37 · Denominator 42 |
| Discharge mobility score | 83.33% |
50.94%
32.4 pts better
|
Numerator 35 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 7.59% |
2.29%
5.3 pts worse
|
Numerator 6 · Denominator 79 · Adjusted rate 8.83% |
| Healthcare-associated infections requiring hospitalization | 8.35% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 10.14% · Lower 95% interval 4.63% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 63 |
| Staff flu vaccination coverage | 3.08% |
42%
38.9 pts worse
|
Numerator 2 · Denominator 65 |
| Discharge function score | 88.1% |
56.45%
31.6 pts better
|
Numerator 37 · Denominator 42 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 58 · Denominator 58 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 2.44% |
25.2%
22.8 pts worse
|
Numerator 1 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.0
0.6 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.3%
8.7 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% |
94.8%
5.2 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 | 1.2% |
3.4%
2.2 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.4% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.3%
1.3 pts better
|
11.4%
11.4 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 lose too much weight | 5.5% |
5.3%
0.2 pts worse
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.6% · Q3 5.4% · Q4 5.4% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.9% |
24.9%
6 pts worse
|
19.6%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 32.4% · Q3 29.7% · Q4 32.4% · 4Q avg 30.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.5% |
22.8%
6.3 pts better
|
16.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 15.4% · Q3 19.4% · Q4 18.5% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.6%
0.6 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 | 13.6% |
14.8%
1.2 pts better
|
16.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 27.3% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.3% |
13.4%
6.9 pts worse
|
14.9%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 12.5% · Q3 12.5% · Q4 25.0% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.3%
1.3 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 | 1.8% |
2.6%
0.8 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.6% · Q3 0.0% · Q4 2.2% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.1% |
13.5%
9.6 pts worse
|
19.8%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 15.7% · Q3 22.9% · Q4 27.0% · 4Q avg 23.1% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
5.7%
1 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 8.7% · Q3 5.2% · Q4 7.8% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
84.3%
14.1 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 98.1% · Q3 100.0% · Q4 100.0% · 4Q avg 98.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.1% |
11.5%
1.6 pts worse
|
12.0%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 14.3% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
2.1%
0.3 pts better
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.3% |
80.3%
14 pts better
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.1% |
24.5%
2.4 pts better
|
23.9%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 21.4% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-07-11 · Fire 2019-07-11
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2018-06-08 · Fire 2018-06-08
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2021-08-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-09-10
F · Potential for more than minimal harm
2019-07-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2019-08-14
E · Potential for more than minimal harm
2019-07-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-08-14
C · Minimal harm
2019-07-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-08-14
F · Potential for more than minimal harm
2018-06-08
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2018-06-26
C · Minimal harm
2018-06-08
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2018-06-26
C · Minimal harm
2018-06-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2018-06-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2018-06-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2018-07-09
D · Potential for more than minimal harm
2018-06-08
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 2018-07-09
D · Potential for more than minimal harm
2018-06-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2018-07-09
D · Potential for more than minimal harm
2018-06-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-07-09
Penalties and ownership
What sits behind the stars
Ownership
Cain, Brian
5% Or Greater Direct Ownership Interest · Individual
Dt Investments LLC
5% Or Greater Direct Ownership Interest · Organization
Fembrooke Health Care, LLC
5% Or Greater Direct Ownership Interest · Organization
Griffin, Troy
5% Or Greater Indirect Ownership Interest · Individual
Providence Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Hubbard, Gene
5% Or Greater Indirect Ownership Interest · Individual
Cunningham, Joann
5% Or Greater Indirect Ownership Interest · Individual
Cunningham, Michael
5% Or Greater Indirect Ownership Interest · Individual
Hubbard, Brien
5% Or Greater Indirect Ownership Interest · Individual
Dt Investments LLC
Operational/Managerial Control · Organization
Griffin, Troy
Operational/Managerial Control · Individual
Griffin, Troy
Corporate Officer · Individual
Griffin, Troy
W-2 Managing Employee · Individual
Hubbard, Gene
Operational/Managerial Control · Individual
Hubbard, Gene
Corporate Officer · Individual
Hubbard, Gene
W-2 Managing Employee · Individual
Providence Holdings LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Arabella Health & Wellness Of Russellville
Russellville, AL
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Burns Nursing Home, Inc.
Russellville, AL
3-star overall rating with 2-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Cottage Of The Shoals
Tuscumbia, AL
3-star overall rating with 4-star inspections with 3 recent health deficiencies
Jump out