Cycle 1
Health 2025-06-11 · Fire 2025-06-11
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
24 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Holly Hill, FL
Terrace At Bishop's Glen, The
4-star overall rating with 4-star inspections with $8,512 in total fines with 2 recent health deficiencies with 24 fire-safety deficiencies in the latest cycle
900 LPga Blvd, Holly Hill, FL
(386) 226-9000
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-02-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.71
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.03
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.56
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.69
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.91
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,302
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9845
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.17
Performance 18.57% · Measure score 6.17 · Achievement 6.17 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 8.95% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.35
Performance 50.00% · Measure score 3.35 · Achievement 3.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.36
Baseline 4.66 hours · Performance 3.47 hours · Measure score 1.36 · Achievement 1.36 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.75% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 115 · Observed rate 13.91% · Lower 95% interval 8.34% |
| Discharge to community | 52.51% |
50.57%
1.9 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 45.1% · Lower 95% interval 41.83% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 58 · Denominator 58 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 58 |
| Discharge self-care score | 47.37% |
53.69%
6.3 pts worse
|
Numerator 18 · Denominator 38 |
| Discharge mobility score | 36.84% |
50.94%
14.1 pts worse
|
Numerator 14 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 5.17% |
2.29%
2.9 pts worse
|
Numerator 3 · Denominator 58 · Adjusted rate 5.2% |
| Healthcare-associated infections requiring hospitalization | 8.95% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 13.43% · Lower 95% interval 5.13% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 80 |
| Staff flu vaccination coverage | 29.58% |
42%
12.4 pts worse
|
Numerator 21 · Denominator 71 |
| Discharge function score | 44.74% |
56.45%
11.7 pts worse
|
Numerator 17 · Denominator 38 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.43% |
96.28%
0.2 pts better
|
Numerator 27 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 95.65% |
25.2%
70.5 pts better
|
Numerator 22 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.1 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.2
0.5 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.9 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 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% |
99.2%
0.8 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 | 1.9% |
2.6%
0.7 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 5.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 44.3% |
3.7%
40.6 pts worse
|
11.4%
32.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 53.6% · Q3 40.5% · Q4 35.3% · 4Q avg 44.3% |
| Percentage of long-stay residents who lose too much weight | 9.4% |
5.9%
3.5 pts worse
|
5.4%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 10.0% · Q3 8.3% · Q4 0.0% · 4Q avg 9.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.3% |
15.7%
2.4 pts better
|
19.6%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 21.9% · Q3 3.7% · Q4 8.0% · 4Q avg 13.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.2% |
9.8%
2.6 pts better
|
16.7%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 4.5% · Q3 5.0% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 10.9% |
11.7%
0.8 pts better
|
16.3%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.4% |
9.8%
2.6 pts worse
|
14.9%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 23.1% · Q3 9.1% · Q4 13.0% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.4%
0.6 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.6% · Q4 1.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
0.8%
0.1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.2% |
12.5%
20.7 pts worse
|
19.8%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 42.6% · Q3 38.7% · Q4 33.5% · 4Q avg 33.2% |
| Percentage of long-stay residents with pressure ulcers | 8.3% |
5.1%
3.2 pts worse
|
5.1%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 9.4% · Q3 10.1% · Q4 6.7% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
9.3%
6.8 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 19.0% · Expected 13.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.6% |
94.7%
3.9 pts better
|
79.7%
18.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.6% |
26.2%
12.6 pts better
|
23.9%
10.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 15.5% · Expected 27.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-21 · Fire 2024-03-21
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-04-07 · Fire 2022-04-07
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-06-11
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
E42 · Emergency Preparedness Deficiencies
Fire Safety
Meet the requirements of an integrated health system.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-17
D · Potential for more than minimal harm
2024-03-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-03-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-03-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-03-21
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-04-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-11
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 2025-07-17
G · Actual harm
2024-11-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-17
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-03-21
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 2024-04-18
D · Potential for more than minimal harm
2024-03-21
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-18
F · Potential for more than minimal harm
2022-04-07
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2022-05-29
D · Potential for more than minimal harm
2022-04-07
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 2022-05-29
D · Potential for more than minimal harm
2022-04-07
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2022-05-29
Penalties and ownership
What sits behind the stars
$8,512
2024-10-17
Fine
Fine · fine $8,512
Fine
Ownership
Adams, Michael
Operational/Managerial Control · Individual
Munim, Mohammed
Operational/Managerial Control · Individual
Weinfeld, Avrum
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Daytona Beach Health And Rehabilitation Center
Daytona Beach, FL
2-star overall rating with 2-star inspections with $261,550 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Coastal Health And Rehabilitation Center
Daytona Beach, FL
3-star overall rating with 4-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Solaris Healthcare Daytona
Daytona Beach, FL
5-star overall rating with 5-star inspections with 2 recent health deficiencies
Jump out