Public Record
The Terrace at Bishop's Glen
Operated by Serenity Estates
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
- Health citations
- 12
- Fire safety findings
- 28
- Inspections on file
- 7
- Last inspection
- 2025-06-11
*CMS
*CMS
*CMS
*CMS
Citations
12 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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 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.
- 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.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0645Generalpotential for harm
PASARR screening for Mental disorders or Intellectual Disabilities
- 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.
- 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.
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.
- Inspection2 deficiencies
105526 06/11/2025 Terrace at Bishop's Glen, The 900 Lpga Blvd Holly Hill, FL 32117 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…
Read full statement of deficiencies - View inspection reportInspectionFire Safety24 deficiencies
- Inspection1 deficiency
105526 11/05/2024 Terrace at Bishop's Glen, The 900 Lpga Blvd Holly Hill, FL 32117 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…
Read full statement of deficiencies - Inspection1 deficiency
105526 10/17/2024 Terrace at Bishop's Glen, The 900 Lpga Blvd Holly Hill, FL 32117 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…
Read full statement of deficiencies - Inspection5 deficiencies
105526 03/21/2024 Terrace at Bishop's Glen, The 900 Lpga Blvd Holly Hill, FL 32117 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…
Read full statement of deficiencies - View inspection reportInspectionFire Safety4 deficiencies
- Inspection3 deficiencies
105526 04/07/2022 Terrace at Bishop's Glen, The 900 Lpga Blvd Holly Hill, FL 32117 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…
Read full statement of deficiencies
Ownership
Serenity Estates
5nursing homes nationwide, in CMS records
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 12 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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