Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Terrace Glen Village
Marion, IA · 40 certified beds · Last Life Safety survey November 19, 2025
CMS Certification Number 165625 · first certified January 2019
Also on this campus
The same campus holds a state-licensed assisted living facility, with its own state record on the Assisted Living Index: Terrace Glen Village (3400 Alburnett Road). Matched by the street address the two records share. The records are separate and are never added together.
Ownership
Operated by PIVOTAL HEALTH CARE · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IA
14 citations — more than 62% of the 387 certified nursing homes in IA. Compared within IA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys on file averaged 6. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: October 2026 to December 2026. This facility’s last Life Safety survey was November 2025. Facilities in IA are typically surveyed 11–13 months after the last one (median 12), measured over 692 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to about three years in Virginia. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 14 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in IA, and nationally. Surveyors differ markedly between states, so the IA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 14 |
| Median facility in IA | 12 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 29, 2023 | 6 |
| October 3, 2024 | 6 |
| November 19, 2025 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-10-03 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-10-03 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-11-19 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1 | 2024-10-03 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-11-19 |
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2023-06-29 |
| K-0133 | Install a two-hour-resistant firewall separation. | 1 | 2024-10-03 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2023-06-29 |
What the citations cover
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Smoke Deficiencies 4
- Miscellaneous Deficiencies 3
- Egress Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Smoke Deficiencies | 4 |
| Miscellaneous Deficiencies | 3 |
| Egress Deficiencies | 2 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 19, 2025 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 2, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 10, 2025) |
October 3, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (October 9, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 18, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 18, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 18, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 8, 2024) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (November 6, 2024) |
June 29, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (July 17, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 13, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 13, 2023) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.