Terrace at Bishop's Glen, the

Name: Terrace at Bishop's Glen, the
Address: 900 LPGA BLVD, Holly Hill, FL, 32117, US
Telephone: 3862269000

900 Lpga Blvd, Holly Hill, FL 32117 · Volusia County · 60 certified beds · avg 53 residents/day · certified since Feb 25, 1986

Part of chain: SERENITY ESTATES (5 facilities, chain avg rating 2.2★)

4/5

Health inspection rating (on-site)

Serious findings on record

$8,512

Fines, last 3 years

3.95

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Nov 5, 2024 · F-0760 · triggered by a complaint

The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.

Why it matters: A serious medication error can cause real harm, hospitalization, or worse.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Dec 5, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (12)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jun 11, 2025	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Jun 11, 2025	D · Potential for harm, one-off	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Nov 5, 2024	▲ G · Actual harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Oct 17, 2024	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint
Mar 21, 2024	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 21, 2024	D · Potential for harm, one-off	The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
Mar 21, 2024	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Mar 21, 2024	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Mar 21, 2024	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Apr 7, 2022	F · Potential for harm, facility-wide	The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing.
Apr 7, 2022	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Apr 7, 2022	D · Potential for harm, one-off	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (5 → 2).

Year	Citations	Serious (G–L)	Worst severity that year
2022	3	0	F
2024	7	1	G ▲
2025	2	0	D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $8,512.

Date	Type	Amount / length
Oct 17, 2024	Fine	$8,512

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Florida avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.95	4.03	3.95	top 43% in Florida; top 42% in the U.S.
Registered Nurse hours	0.40	0.76	0.69	bottom 8% in Florida; bottom 22% in the U.S.
Weekend total nurse staffing	3.40	3.68	3.50	bottom 33% in Florida; top 47% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.26	0.53	0.48	bottom 14% in Florida; bottom 24% in the U.S.
Total nursing staff turnover (%)	65.5	41.4	45.8	bottom 4% in Florida; bottom 9% in the U.S.
RN turnover (%)	75.0	46.0	42.9	bottom 8% in Florida; bottom 9% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.71, RN 0.37, weekend 3.20. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Island City Equity Partners LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	01/01/2023
Maj Consultants LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	01/01/2023
Nuckolls, Mary	Individual	Indirect Ownership Interest	NOT APPLICABLE	01/01/2023
Tapia, Jill	Individual	Indirect Ownership Interest	NOT APPLICABLE	01/01/2023
Weinfeld, Avrum	Individual	Direct Ownership Interest	NOT APPLICABLE	01/01/2023
Weiss, Daniel	Individual	Direct Ownership Interest	NOT APPLICABLE	01/01/2023
Wheat Chaff LP	Organization	Indirect Ownership Interest	NOT APPLICABLE	01/01/2023
Adams, Michael	Individual	Operational/Managerial Control	NOT APPLICABLE	01/01/2023
Adams, Michael	Individual	ADP of the SNF	NOT APPLICABLE	01/01/2023
Munim, Mohammed	Individual	Operational/Managerial Control	NOT APPLICABLE	01/01/2023
Munim, Mohammed	Individual	ADP of the SNF	NOT APPLICABLE	01/01/2023
Weinfeld, Avrum	Individual	Managing Control - Governing Body	NOT APPLICABLE	01/01/2023
Weinfeld, Avrum	Individual	Operational/Managerial Control	NOT APPLICABLE	01/01/2023
Weinfeld, Avrum	Individual	ADP of the SNF	NOT APPLICABLE	01/01/2023
Weiss, Daniel	Individual	ADP of the SNF	NOT APPLICABLE	01/01/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What systems do you use to prevent medication errors, and what happens when one occurs?"
"How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
"How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
"How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
"What is your current medication error rate, and what have you changed to bring errors down?"
"How many hours a day is a registered nurse physically in the building, including weekends?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
Daytona Beach Health and Rehabilitation Center	1.1 mi	Daytona Beach, FL	★★★★★	5/5
Coastal Health and Rehabilitation Center	1.8 mi	Daytona Beach, FL	★★★★☆	4/5
Solaris Healthcare Daytona	2.4 mi	Daytona Beach, FL	★★★★★	5/5
Bridgeview Center	2.5 mi	Ormond Beach, FL	★★★★☆	4/5
Emory L Bennett Memorial Veterans Nursing Home	2.5 mi	Daytona Beach, FL	★★★★☆	3/5
Gardens Healthcare & Rehabilitation Center	2.7 mi	Daytona Beach, FL	★★★★★	4/5
Ormond Rehabilitation and Nursing Center	3.2 mi	Ormond Beach, FL	★★★☆☆	3/5
Blue Palms Health and Rehabilitation Center of Day	3.2 mi	Daytona Beach, FL	★★★★☆	4/5
Indigo Manor	3.3 mi	Daytona Beach, FL	★★☆☆☆	1/5
Coquina Center	3.5 mi	Ormond Beach, FL	★★★☆☆	4/5
Beach Street Health and Rehabilitation Center	4.1 mi	Daytona Beach, FL	★★★★☆	3/5
Seaside Health and Rehabilitation Center	4.4 mi	Daytona Beach, FL	★★★★☆	4/5

Compare this facility with the 3 closest →

All facilities in Holly Hill →

Facility data as of CMS processing date 2026-08-01. CCN 105526.

The Care File

Visit checklist — Terrace at Bishop's Glen, the

900 Lpga Blvd, Holly Hill, FL 32117 · 3862269000

Health inspection rating 4/5 · CMS overall 3/5· Fines (3y): $8,512

Most serious findings on record:

▲ Nov 5, 2024 (F-0760, Actual harm, one-off): The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.

Questions for the administrator:

☐ "What systems do you use to prevent medication errors, and what happens when one occurs?"
☐ "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
☐ "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
☐ "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
☐ "What is your current medication error rate, and what have you changed to bring errors down?"
☐ "How many hours a day is a registered nurse physically in the building, including weekends?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 105526 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)