Federal inspection record · CMS data as of October 1, 2026
Terrace At Bishop's Glen, The
900 LPga Blvd, Holly Hill, FL · (386) 226-9000
- Certified beds
- 60
- Residents per day
- 54
- Ownership
- For-Profit
- Chain
- Serenity Estates
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- February 25, 1986
1
How this home got 5 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Florida.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
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Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★5 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Florida homes
Terrace At Bishop's Glen, The carries 20 inspection points. That is fewer than 73% of Florida's 691 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Florida: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–8 pts
- 4★ 8–25 pts
- 3★ 25–46 pts
- 2★ 46–85 pts
- 1★ over 85 pts
Bars show every rated home in Florida by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
12 health citations on record since 2022. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
G
Ensure that residents are free from significant medication errors.
Everything else, by area of care
Quality of Life and Care5D
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Nutrition and Dietary2F
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Pharmacy Service2D
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
- D
Ensure medication error rates are not 5 percent or greater.
Resident Assessment and Care Planning1D
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Nursing and Physician Services1F
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspection history
2025-06-11
2 health deficiencies · 24 fire-safety deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2024-03-21
7 health deficiencies · 4 fire-safety deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2022-04-07
3 health deficiencies · 0 fire-safety deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 47 min of nursing staff time a day, 19 min of it from a registered nurse.
This home
3 h 47 min
Florida average
3 h 51 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 100% of nursing staff and 100% of registered nurses left in the past year, along with 1 administrator.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$8,512 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2024-10-17 | Fine | $8,512 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident daysAbout the same | 2.0 | 2.0 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.7 pts better | 0.4 | 1.1 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1 pts better | 99.4% | 98.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine11.3 pts worse | 88.1% | 99.4% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.1 pts better | 2.4% | 2.5% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms13.6 pts worse | 19.0% | 5.4% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.7 pts better | 4.8% | 5.5% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication8.2 pts better | 5.7% | 13.9% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication6.6 pts better | 2.1% | 8.7% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened0.6 pts worse | 9.0% | 8.4% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased0.7 pts worse | 9.0% | 8.3% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.1 pts better | 0.2% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infectionAbout the same | 0.6% | 0.6% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence18.8 pts worse | 28.3% | 9.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.7 pts worse | 5.1% | 4.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine1.9 pts better | 97.5% | 95.6% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit3.9 pts better | 5.0% | 8.9% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.8 pts worse | 2.2% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine4.9 pts worse | 91.4% | 96.3% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission4.6 pts better | 21.2% | 25.8% | 23.4% |
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Who owns and runs it
15 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Adams, Michael | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Adams, Michael | Adp Of The SNF · Individual | 0% | 2 facilities |
| Island City Equity Partners LLC | Indirect Ownership Interest · Organization | 0% | 4 facilities |
| Maj Consultants LLC | Indirect Ownership Interest · Organization | 0% | 2 facilities |
| Munim, Mohammed | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Munim, Mohammed | Adp Of The SNF · Individual | 0% | 2 facilities |
| Nuckolls, Mary | Indirect Ownership Interest · Individual | 0% | 2 facilities |
| Tapia, Jill | Indirect Ownership Interest · Individual | 0% | 4 facilities |
| Weinfeld, Avrum | Direct Ownership Interest · Individual | 0% | 17 facilities |
| Weinfeld, Avrum | Managing Control - Governing Body · Individual | 0% | 17 facilities |
| Weinfeld, Avrum | Operational/Managerial Control · Individual | 0% | 17 facilities |
| Weinfeld, Avrum | Adp Of The SNF · Individual | 0% | 17 facilities |
| Weiss, Daniel | Direct Ownership Interest · Individual | 0% | 7 facilities |
| Weiss, Daniel | Adp Of The SNF · Individual | 0% | 7 facilities |
| Wheat Chaff LP | Indirect Ownership Interest · Organization | 0% | 4 facilities |
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Fire safety
28 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Emergency Preparedness8D
- D
Create arrangements with other facilities to receive patients.
- D
List the names and contact information of those in the facility.
- D
Provide a means of sharing information on occupancy/needs.
- D
Provide family notifications of emergency plan.
- D
Establish emergency prep training and testing.
- D
Develop and maintain an Emergency Preparedness Program (EP).
- D
Meet the requirements of an integrated health system.
- D
Include a process for Emergency Preparedness collaboration.
Smoke8D
- D
Provide properly protected cooking facilities.
- D
Have approved installation, maintenance and testing program for fire alarm systems.
- D
Install an approved automatic sprinkler system.
- D
Inspect, test, and maintain automatic sprinkler systems.
- D
Install corridor and hallway doors that block smoke.
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Have approved installation, maintenance and testing program for fire alarm systems.
- D
Inspect, test, and maintain automatic sprinkler systems.
Miscellaneous4D
- D
Provide a written emergency evacuation plan.
- D
Have simulated fire drills held at unexpected times.
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Gas, Vacuum, and Electrical Systems4D
- D
Have power receptacles that are properly grounded.
- D
Have generator or other power source capable of supplying service within 10 seconds.
- D
Have proper medical gas storage and administration areas.
- D
Have power receptacles that are properly grounded.
Egress3D
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- D
Install emergency lighting that can last at least 1 1/2 hours.
Services1D
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
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Other homes nearby
-
Daytona Beach Health And Rehabilitation Center
Daytona Beach, FL · Nhs Management
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 4 h 3 min
- Fines
- $0
-
Coastal Health And Rehabilitation Center
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★★★★★- Worst citation, 3 yrs
- D
- Nursing / resident / day
- 3 h 31 min
- Fines
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-
Solaris Healthcare Daytona
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★★★★★- Worst citation, 3 yrs
- D
- Nursing / resident / day
- 3 h 55 min
- Fines
- $0