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Terrace at Bishop's Glen, the
900 Lpga Blvd, Holly Hill, FL 32117 · CMS Certification Number (CCN) 105526
At a glance
- CMS overall rating
- ★★★☆☆ 3 of 5
- Health inspection citations
- 12 in the last 3 inspection cycles (0 immediate jeopardy, 1 actual harm, 2 from complaints)
- Fire safety citations
- 28
- Fines (last 3 years)
- 1 fine, total $8,512
- Payment denials
- 0
- Most recent standard inspection
- June 11, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Florida average | U.S. average |
|---|---|---|---|
| Overall | ★★★☆☆ 3 of 5 | 3.3 | 3 |
| Health inspections | ★★★★☆ 4 of 5 | 2.9 | 2.8 |
| Staffing | ★☆☆☆☆ 1 of 5 This facility reported a high number of days without a registered nurse onsite. | 3.3 | 2.9 |
| Quality measures | ★★★★☆ 4 of 5 | 4.2 | 3.6 |
| Long-stay quality | ★★★★★ 5 of 5 | Not published | Not published |
| Short-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | June 11, 2025 | 2 | 2 | 0 |
| Cycle 2 | March 21, 2024 | 7 | 5 | 2 |
CMS weighted health inspection score: 20 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
12 health citations across 5 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
June 11, 2025: 2 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/17/2025 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/17/2025 |
November 5, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| G | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/05/2024 |
October 17, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0758 | 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. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/15/2024 |
March 21, 2024: 5 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| F | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/18/2024 |
| D | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/18/2024 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/18/2024 |
| D | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/18/2024 |
| D | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/18/2024 |
April 7, 2022: 3 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| F | F-0727 | 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. Nursing and Physician Services Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/29/2022 |
| D | F-0688 | 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. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/29/2022 |
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/29/2022 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Fire safety inspections
28 fire safety citations across 2 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 06/11/2025 | D | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | K-0912 | Have power receptacles that are properly grounded. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | K-0222 | 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. Egress Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | E-0042 | Meet the requirements of an integrated health system. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | E-0036 | Establish emergency prep training and testing. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | E-0035 | Provide family notifications of emergency plan. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | E-0034 | Provide a means of sharing information on occupancy/needs. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | E-0030 | List the names and contact information of those in the facility. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | E-0025 | Create arrangements with other facilities to receive patients. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | E-0009 | Include a process for Emergency Preparedness collaboration. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 06/11/2025 | D | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 07/17/2025 |
| 03/21/2024 | D | K-0912 | Have power receptacles that are properly grounded. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 04/16/2024 |
| 03/21/2024 | D | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 04/16/2024 |
| 03/21/2024 | D | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 04/16/2024 |
| 03/21/2024 | D | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 04/16/2024 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| October 17, 2024 | Fine | $8,512 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Staffing
| Measure | This facility | Florida average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.71 | 3.82 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.37 | 0.73 | 0.69 |
| LPN/LVN hours per resident per day | 1.12 | Not published | Not published |
| Nurse aide hours per resident per day | 2.22 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.2 | Not published | Not published |
| RN hours per resident per day, weekends | 0.26 | Not published | Not published |
| Total nursing staff turnover (%) | 65.5 | 41.4 | 45.8 |
| Registered nurse turnover (%) | 75 | Not published | Not published |
| Administrators who have left | 1 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Facility details
- Legal business name
- Bg SNF Opco LLC
- Ownership type
- For profit - Limited Liability company
- Chain
- Serenity Estates (5 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 60
- Average residents per day
- 52.8
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Both
- First approved for Medicare/Medicaid
- February 25, 1986
- County/parish
- Volusia
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Owners and managers reported to CMS
15 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| WEINFELD, AVRUM | DIRECT OWNERSHIP INTEREST | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WEISS, DANIEL | DIRECT OWNERSHIP INTEREST | Individual | NOT APPLICABLE | undefined undefined, NaN |
| ISLAND CITY EQUITY PARTNERS LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MAJ CONSULTANTS LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| WHEAT CHAFF LP | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| NUCKOLLS, MARY | INDIRECT OWNERSHIP INTEREST | Individual | NOT APPLICABLE | undefined undefined, NaN |
| TAPIA, JILL | INDIRECT OWNERSHIP INTEREST | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WEINFELD, AVRUM | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| ADAMS, MICHAEL | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MUNIM, MOHAMMED | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WEINFELD, AVRUM | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| ADAMS, MICHAEL | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MUNIM, MOHAMMED | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WEINFELD, AVRUM | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WEISS, DANIEL | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Check it yourself
- Medicare Care Compare: Terrace at Bishop's Glen, the. Full inspection reports, quality measures and staffing.
- AHCA licensed health care facility complaint form. The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 25, 2026. Not a ranking or endorsement.