TERRACE AT BISHOP'S GLEN, THE
Open-data reference.
TERRACE AT BISHOP'S GLEN, THE is a for profit - limited liability company facility in HOLLY HILL, FL with 60 certified beds and a 4-star overall CMS rating. The facility has 12 deficiency records on file. Total penalties: $9K.
900 LPGA BLVD, HOLLY HILL, FL 32117
Phone: 3862269000
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 105526
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 60
- Residents
- 46
- In Hospital
- No
- County
- Volusia
- Last Inspection
- Jun 11, 2025
Staffing Data
- RN Hours
- 0.71 (nat'l avg: 0.68)
- LPN Hours
- 1.07
- CNA Hours
- 2.26
- Total Nursing Hours
- 4.03 (nat'l avg: 3.89)
- PT Hours
- 0.01
- Nursing Turnover
- 50.9%
- RN Turnover
- 80.0%
What the CMS Record Reveals About TERRACE AT BISHOP'S GLEN, THE
TERRACE AT BISHOP'S GLEN, THE operates 60 certified beds in HOLLY HILL, FL with approximately 46 residents currently in care, and carries a CMS overall rating of 4 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (4★), staffing levels (3★), and quality measures (4★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 12 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $9K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 4.03 total nursing hours per resident day (national average 3.89), with RN coverage at 0.71 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, TERRACE AT BISHOP'S GLEN, THE falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 50.9%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (12 most recent)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 17, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 17, 2025
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Dec 5, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Nov 15, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 18, 2024
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Apr 18, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 18, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 18, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 18, 2024
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.
Category: Nursing and Physician Services Deficiencies
Corrected: May 29, 2022
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.
Category: Quality of Life and Care Deficiencies
Corrected: May 29, 2022
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: May 29, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 12.4% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 9.4% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.7% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 44.3% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 1.9% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 100.0% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.8% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 10.9% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 13.3% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 98.6% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 8.3% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 33.2% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 7.2% | Yes |
Penalty History 1 penalties totaling $9K
| Date | Type | Amount |
|---|---|---|
| Oct 17, 2024 | Fine | $9K |
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Understanding Nursing Home Data
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County Health Data
Health outcomes, access, and quality metrics for Volusia on PlainHealth
Frequently Asked Questions
What is the overall CMS rating for TERRACE AT BISHOP'S GLEN, THE?
What are the staffing levels at TERRACE AT BISHOP'S GLEN, THE?
How many beds does TERRACE AT BISHOP'S GLEN, THE have?
Does TERRACE AT BISHOP'S GLEN, THE have any deficiencies on record?
Has TERRACE AT BISHOP'S GLEN, THE received any fines or penalties?
Who owns TERRACE AT BISHOP'S GLEN, THE?
When was TERRACE AT BISHOP'S GLEN, THE last inspected?
What quality measures are tracked for TERRACE AT BISHOP'S GLEN, THE?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.