Terrace at Bishop's Glen, the
900 Lpga Blvd, Holly Hill, FL 32117
Terrace at Bishop's Glen, the is a nursing home in Holly Hill, Florida. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 5 of 5CMS overall star rating
- 4 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (386) 226-9000
- Last standard health inspection
- June 11, 2025 (1 year ago)
- Certified beds
- 60
- Residents per day, on average
- 54.4
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Bg SNF Opco LLC
- Chain
- Serenity Estates
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Florida average (12 vs 20).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 5 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of May 27, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 1 of 5.
Ownership
CMS lists this home under a new chain.
CMS update of April 29, 2026
Ownership
CMS lists this home under a new chain.
CMS update of January 14, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Ownership
CMS ownership records list new owners for this home.
Health citation
CMS removed citation F0758 from the health inspection on October 17, 2024.
CMS update of July 30, 2025
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
2 citations
Health inspection on June 11, 2025
CMS lists this as a standard inspection.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on July 17, 2025.
CMS has cited this home for F0695 2 times since 2024.
Citation F0812. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on July 17, 2025.
CMS has cited this home for F0812 2 times since 2024.
24 citations
Fire safety inspection on June 11, 2025
CMS lists this as a standard inspection.
Citation E0004. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on July 17, 2025.
Citation E0009. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Include a process for Emergency Preparedness collaboration.
CMS lists it as corrected on July 17, 2025.
Citation E0025. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create arrangements with other facilities to receive patients.
CMS lists it as corrected on July 17, 2025.
Citation E0030. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
List the names and contact information of those in the facility.
CMS lists it as corrected on July 17, 2025.
Citation E0034. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide a means of sharing information on occupancy/needs.
CMS lists it as corrected on July 17, 2025.
Citation E0035. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide family notifications of emergency plan.
CMS lists it as corrected on July 17, 2025.
Citation E0036. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Establish emergency prep training and testing.
CMS lists it as corrected on July 17, 2025.
Citation E0042. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet the requirements of an integrated health system.
CMS lists it as corrected on July 17, 2025.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 17, 2025.
Citation K0223. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on July 17, 2025.
Citation K0291. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on July 17, 2025.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on July 17, 2025.
Citation K0345. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on July 17, 2025.
CMS has cited this home for K0345 2 times since 2024.
Citation K0351. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on July 17, 2025.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on July 17, 2025.
CMS has cited this home for K0353 2 times since 2024.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on July 17, 2025.
Citation K0372. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on July 17, 2025.
Citation K0521. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on July 17, 2025.
Citation K0711. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on July 17, 2025.
Citation K0712. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on July 17, 2025.
Citation K0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on July 17, 2025.
CMS has cited this home for K0761 2 times since 2024.
Citation K0912. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have power receptacles that are properly grounded.
CMS lists it as corrected on July 17, 2025.
CMS has cited this home for K0912 2 times since 2024.
Citation K0918. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on July 17, 2025.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on July 17, 2025.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
1 citation
Health inspection on November 5, 2024
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
55 of 694 Florida homes (8%) got a citation at the actual harm level in 2024.
Citation F0760. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on December 5, 2024.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
1 citation
Health inspection on October 17, 2024
CMS lists this as a complaint inspection.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on November 15, 2024.
Fine
October 17, 2024 (2 years ago)
CMS fine of $8,512 on October 17, 2024.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of May 29, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 3 of 5.
5 citations
Health inspection on March 21, 2024
CMS lists this as a standard inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 18, 2024.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on April 18, 2024.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on April 18, 2024.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on April 18, 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on April 18, 2024.
4 citations
Fire safety inspection on March 21, 2024
CMS lists this as a standard inspection.
Citation K0345. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on April 16, 2024.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 16, 2024.
Citation K0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on April 16, 2024.
Citation K0912. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have power receptacles that are properly grounded.
CMS lists it as corrected on April 16, 2024.
CMS update of February 29, 2024
Name
CMS lists a new legal business name for this home.
Ownership
CMS no longer lists a chain for this home.
Ownership
CMS ownership records list new owners for this home.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
3 citations
Health inspection on April 7, 2022
CMS lists this as a standard inspection.
Citation F0727. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on May 29, 2022.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on May 29, 2022.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 29, 2022.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- WEINFELD, AVRUMDirect ownership interest · not applicable · since 01/01/2023
- WEISS, DANIELDirect ownership interest · not applicable · since 01/01/2023
- ISLAND CITY EQUITY PARTNERS LLCIndirect ownership interest · not applicable · since 01/01/2023
- MAJ CONSULTANTS LLCIndirect ownership interest · not applicable · since 01/01/2023
- WHEAT CHAFF LPIndirect ownership interest · not applicable · since 01/01/2023
- NUCKOLLS, MARYIndirect ownership interest · not applicable · since 01/01/2023
- TAPIA, JILLIndirect ownership interest · not applicable · since 01/01/2023
- ADAMS, MICHAELOperational/managerial control · not applicable · since 01/01/2023
- MUNIM, MOHAMMEDOperational/managerial control · not applicable · since 01/01/2023
- WEINFELD, AVRUMOperational/managerial control · not applicable · since 01/01/2023
Questions
When was Terrace at Bishop's Glen, the last inspected?
CMS lists June 11, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Terrace at Bishop's Glen, the have?
CMS lists 12 health citations since April 7, 2022. CMS also calls these deficiencies.
Has Terrace at Bishop's Glen, the been fined?
CMS lists 1 fine in the past three years, $8,512 in total.
What is the CMS star rating of Terrace at Bishop's Glen, the?
Its CMS overall star rating is 5 of 5.
Is Terrace at Bishop's Glen, the a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.