B
79/100TERRACE AT BISHOP'S GLEN, THE Inspection Report, Violations & Safety Grade (HOLLY HILL, Florida)
900 LPGA BLVD, HOLLY HILL, Florida 32117
Phone: 3862269000
CMS Overall:5/5
Overview & Bed Count
Certified Beds
60
Avg Residents/Day
54.4
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Volusia
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall5/5
Health4/5
Staffing2/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | Florida Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.31 | 0.73 | -0.42 |
| Total Nurse Hours per Resident per Day | 3.78 | 3.86 | -0.07 |
| CMS Staffing Rating | 2/5 | 3.3/5 | - |
| Nursing Staff Turnover | 100.0% | 41.5% | - |
Health Citation History
12 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-06-11 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2025-06-11 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D – Moderate Harm Potential |
| 2024-11-05 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | G – Actual Harm |
| 2024-10-17 | Pharmacy Service Deficiencies | 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 – Moderate Harm Potential |
| 2024-03-21 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2024-03-21 | Resident Assessment and Care Planning Deficiencies | PASARR screening for Mental disorders or Intellectual Disabilities | D – Moderate Harm Potential |
| 2024-03-21 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2024-03-21 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2024-03-21 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2022-04-07 | Nursing and Physician Services Deficiencies | 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. | F – Moderate Harm Potential |
| 2022-04-07 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2022-04-07 | Quality of Life and Care Deficiencies | 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. | D – Moderate Harm Potential |
Fire Safety Citation History
28 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-06-11 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | D – Moderate Harm Potential |
| 2025-06-11 | Emergency Preparedness Deficiencies | Include a process for Emergency Preparedness collaboration. | D – Moderate Harm Potential |
| 2025-06-11 | Emergency Preparedness Deficiencies | Create arrangements with other facilities to receive patients. | D – Moderate Harm Potential |
| 2025-06-11 | Emergency Preparedness Deficiencies | List the names and contact information of those in the facility. | D – Moderate Harm Potential |
| 2025-06-11 | Emergency Preparedness Deficiencies | Provide a means of sharing information on occupancy/needs. | D – Moderate Harm Potential |
| 2025-06-11 | Emergency Preparedness Deficiencies | Provide family notifications of emergency plan. | D – Moderate Harm Potential |
| 2025-06-11 | Emergency Preparedness Deficiencies | Establish emergency prep training and testing. | D – Moderate Harm Potential |
| 2025-06-11 | Emergency Preparedness Deficiencies | Meet the requirements of an integrated health system. | D – Moderate Harm Potential |
| 2025-06-11 | Egress Deficiencies | 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 – Moderate Harm Potential |
| 2025-06-11 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | D – Moderate Harm Potential |
| 2025-06-11 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | D – Moderate Harm Potential |
| 2025-06-11 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
| 2025-06-11 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | D – Moderate Harm Potential |
| 2025-06-11 | Smoke Deficiencies | Install an approved automatic sprinkler system. | D – Moderate Harm Potential |
| 2025-06-11 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2025-06-11 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
| 2025-06-11 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | D – Moderate Harm Potential |
| 2025-06-11 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | D – Moderate Harm Potential |
| 2025-06-11 | Miscellaneous Deficiencies | Provide a written emergency evacuation plan. | D – Moderate Harm Potential |
| 2025-06-11 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | D – Moderate Harm Potential |
| 2025-06-11 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | D – Moderate Harm Potential |
| 2025-06-11 | Gas, Vacuum, and Electrical Systems Deficiencies | Have power receptacles that are properly grounded. | D – Moderate Harm Potential |
| 2025-06-11 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | D – Moderate Harm Potential |
| 2025-06-11 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
| 2024-03-21 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | D – Moderate Harm Potential |
| 2024-03-21 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2024-03-21 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | D – Moderate Harm Potential |
| 2024-03-21 | Gas, Vacuum, and Electrical Systems Deficiencies | Have power receptacles that are properly grounded. | D – Moderate Harm Potential |
Total Penalties & Fines
$8,512
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-10-17 | Fine | $8,512 | - |
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the HOLLY HILL area at no cost.
Find Safe, Vetted Facilities Near HOLLY HILL
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the HOLLY HILL area at no cost.
Find Safe, Vetted Facilities Near HOLLY HILL
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.