Public Record
The Terrace at Bishop's Glen
From CMS
Facility profile
- CMS overall rating
- 3 / 5
- Certified beds
- 60
- Avg. residents per day
- 48.3
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 40
- Inspections on file
- 7
- Last inspection
- 2025-06-11
*CMS
*CMS
*CMS
Citations
40 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0291Generalpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351Generalpotential for harm
Install an approved automatic sprinkler system.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0372Generalpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0521Generalpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0711Generalpotential for harm
Provide a written emergency evacuation plan.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0761Generalpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0912Generalpotential for harm
Have power receptacles that are properly grounded.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
- 0004Generalpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0009Generalpotential for harm
Include a process for Emergency Preparedness collaboration.
- 0025Generalpotential for harm
Create arrangements with other facilities to receive patients.
- 0030Generalpotential for harm
List the names and contact information of those in the facility.
- 0034Generalpotential for harm
Provide a means of sharing information on occupancy/needs.
- 0035Generalpotential for harm
Provide family notifications of emergency plan.
- 0036Generalpotential for harm
Establish emergency prep training and testing.
- 0042Generalpotential for harm
Meet the requirements of an integrated health system.
- 0222Generalpotential for harm
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.
- 0223Generalpotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0760Seriousactual harm
Ensure that residents are free from significant medication errors.
- 0758Generalpotential for harm
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.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0645Generalpotential for harm
PASARR screening for Mental disorders or Intellectual Disabilities
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0761Generalpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0912Generalpotential for harm
Have power receptacles that are properly grounded.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0727Generalpotential for harm
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.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0688Generalpotential for harm
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.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- Inspection26 deficiencies
F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that…
Read full statement of deficiencies - View inspection reportInspection26 deficiencies
- Inspection1 deficiency
F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, medical record review, facility documents review, and facility policy review, the facility failed to…
Read full statement of deficiencies - Inspection1 deficiency
F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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…
Read full statement of deficiencies - Inspection9 deficiencies
F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that a Preadmission…
Read full statement of deficiencies - View inspection reportInspection9 deficiencies
- Inspection3 deficiencies
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the…
Read full statement of deficiencies
FAQ
Questions and answers
- What is The Terrace at Bishop's Glen?
- The Terrace at Bishop's Glen is a Medicare- and Medicaid-certified nursing home in Holly Hill, FL, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 105526.
- What is the CMS rating for The Terrace at Bishop's Glen?
- The Terrace at Bishop's Glen has a CMS overall rating of 3 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does The Terrace at Bishop's Glen have?
- The Terrace at Bishop's Glen is certified for 60 beds. It serves an average of 48.3 residents per day.
- How many citations does The Terrace at Bishop's Glen have?
- The Terrace at Bishop's Glen has 40 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was The Terrace at Bishop's Glen last inspected?
- The Terrace at Bishop's Glen was last inspected on June 11, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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