Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Terrace Glen Village during CMS and state inspections, most recent first.
MDS Medication Coding Errors: The facility inaccurately coded medications on the MDS for several residents. MARs showed daily clopidogrel use for multiple residents, but the MDS often coded anticoagulants instead of antiplatelets or omitted antiplatelet use, and one resident’s daily insulin injections were coded as 0 injections on the MDS despite MAR documentation. The MDS Coordinator acknowledged that Plavix is an antiplatelet, and the facility policy required MDS information to be complete, accurate, and supported by the medical record.
Incorrect portion sizes were served for modified diet breakfast items. Three residents on pureed diets received a #16 disher of pureed oatmeal even though their menu cards showed standing orders for more than a #8 scoop, and a resident on a mechanical soft diet received a #20 disher of sausage despite a 2-oz ordered serving. The chef prepared both items in unmeasured volumes, and staff confirmed the scoops used did not match the ordered serving sizes.
Food Storage Not Properly Labeled or Dated: Surveyors observed multiple food items in the kitchen that were opened, undated, or unlabeled, including vegetables, pizza crust, pizza topping sausage, dinner rolls, hamburger buns, sugar, chicken breasts, and pepperoni slices. The CDM stated stored food is typically labeled and dated before being placed in the refrigerator or freezer, and an ice machine scoop was found resting directly on the ice.
A facility failed to notify the ombudsman of a hospital transfer for a resident. The resident was hospitalized with tremors, elevated blood sugar, and a fever, and returned after treatment for CHF, UTI, and MI. The facility's documentation did not include the resident's hospital transfer for several months. An email from the DON confirmed the omission, and the Administrator noted a change in the reporting process led to the oversight.
MDS Medication Coding Errors
Penalty
Summary
The facility failed to accurately code medications on the MDS for 4 of 15 residents reviewed for MDS assessment accuracy. For Resident #2, the August 2025 MAR documented daily aspirin 81 mg and clopidogrel 75 mg, both antiplatelet medications, but the MDS dated 8/28/25 coded that the resident had received both anticoagulant and antiplatelet medication during the 7-day look-back period. For Resident #3, the MARs for February, April, July, and September 2025 documented daily clopidogrel 75 mg, but the MDS assessments dated 2/6/25, 4/21/25, 7/17/25, and 10/1/25 did not consistently code antiplatelet use and instead documented anticoagulant medication on several assessments. For Resident #12, the July and October 2025 MARs documented daily clopidogrel 75 mg, while the MDS assessments dated 7/24/25 and 10/8/25 coded anticoagulant medication and no antiplatelet medication during the look-back period. For Resident #34, the September 2025 MAR documented daily insulin injections, but the MDS dated 9/24/25 coded 0 insulin injections during the 7-day look-back period. The RAI Manual guidance cited in the report directs staff to review the MAR for the look-back period and determine whether insulin injections were received, and it also directs that antiplatelet medications be coded based on medications taken during the observation period. On 11/19/25, the MDS Coordinator stated she was aware that Plavix is an antiplatelet and not an anticoagulant and said she would make modifications to the affected assessments. The facility policy stated that MDS information must be complete, accurate, and supported by documentation in the medical record.
Incorrect Portion Sizes for Modified Diet Breakfast Items
Penalty
Summary
The facility failed to serve the appropriate portion of pureed oatmeal for 3 of 3 residents and mechanical soft sausage for 1 of 1 resident who were ordered modified diets. On 11/19/25 at 7:00 AM, Staff A, Chef, blended 12 sausage links with 1/3 cup of milk into mechanical soft consistency, poured the product into a pan, covered it with aluminum foil, and placed the unmeasured volume in the oven. At 7:25 AM, he placed an unmeasured amount of cooked oatmeal and five scoops of thickener into the blender, blended it into pureed consistency, poured it into a pan, covered it with aluminum foil, and placed the unmeasured volume in the oven. During meal service observation beginning at 7:50 AM, three residents on pureed diets received one #16 disher of pureed oatmeal, and one resident on a mechanical soft diet received one #20 disher of mechanical soft sausage. The Pureed Diet Portion Sizes/Dishers chart showed a #16 disher equaled 2 oz and a #20 disher equaled 1 5/8 oz, while the residents' menu cards showed the pureed oatmeal residents had standing orders for greater than a #8 scoop serving size and the mechanical soft sausage resident had a standing order for a full 2-oz serving. The Diet Spreadsheet indicated the mechanical soft ground sausage serving size was 2 ounces. At 8:56 AM, the CDM confirmed the serving size scoops used, and Staff B stated she did not prepare the pureed or mechanical soft diets or know which scoops would provide the ordered serving size. Staff A stated he used the menu to determine serving sizes but did not use the pureed serving size conversion chart to adjust the serving sizes based on the total volume.
Food Storage Not Properly Labeled or Dated
Penalty
Summary
The facility failed to properly label and date food stored in the refrigerator, freezer, and dry goods areas. During a kitchen tour, surveyors observed an undated, previously opened package of mixed vegetables, an unlabeled and undated opaque bag of disk-shaped tan items identified by the dietary manager as pizza crust, an unlabeled clear bag of brown meat-like items identified as pizza topping sausage, an undated previously opened bag of dinner rolls, an undated previously opened bag of hamburger buns, an ice machine with the serving scoop resting directly on the ice, and an undated previously opened bag of sugar in a white storage bin. The Certified Dietary Manager stated stored food is typically labeled and dated before being placed in the refrigerator or freezer and removed the ice machine scoop, stating it should not have been there. On a follow-up kitchen tour, surveyors again observed an opened bag of pizza crust, an opened box containing an opened, undated bag of boneless, skinless chicken breasts with rib meat, an opened box of pepperoni slices, and an unlabeled blue bin covered with aluminum foil and dated 11/19. The facility policy stated all foods stored in the refrigerator or freezer will be covered, labeled, and dated with a use-by date.
Failure to Notify Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to notify the ombudsman of a hospital transfer for a resident, which was identified during a review of clinical records, facility documentation, and staff interviews. The resident was admitted to the hospital with tremors, elevated blood sugar, and a fever, and returned to the facility after a stay for congestive heart failure, urinary tract infection, and myocardial infarction. The facility's documentation, specifically the Notice of Transfer Form to the Long Term Care Ombudsman, did not include the resident's hospital transfer for the month of July 2024, nor did it include any hospital transfers for June, July, or August 2024. An email from the Director of Nursing confirmed that the facility did not report the resident's hospitalization to the ombudsman. The Administrator explained that there was a change in the process for reporting, and when the task was handed off to the Admission's Coordinator, this step was lost. The facility was in the process of updating the procedure.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Winslow House Care Center | 1.3 mi | ★★★★★ | 10 | 0 |
| Hallmar Village | 1.3 mi | ★★★★★ | 11 | 0 |
| Oakview Nursing & Rehablitation - Marion | 1.3 mi | ★★★★★ | 5 | 0 |
| Northbrook Healthcare And Rehabilitation Center | 2.4 mi | ★★★★★ | 24 | 0 |
| Silver Oak Nursing And Rehabilitation Center Llc | 2.4 mi | ★★★★★ | 14 | 0 |
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