Terrace At Bishop's Glen, The
Holly Hill, Volusia County, Florida · CCN 105526 · For-profit (LLC) · part of Serenity Estates (5 facilities, chain average 2.2 stars)
CMS rates Terrace At Bishop's Glen, The 3 of 5 overall as of August 2026. 60 certified beds, 53 residents a day on average. 12 citations on record from the current inspection cycles, 1 involving actual harm; 1 fine totalling $8,512.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★★☆☆ 3 of 5 |
|---|---|
| Health inspections | ★★★★☆ 4 of 5 |
| Staffing | ★☆☆☆☆ 1 of 5 |
| Quality measures | ★★★★☆ 4 of 5 |
| Quality: long-stay / short-stay | 5 / 3 of 5 |
Staffing
| Total nurse staffing | 3.71497 hours per resident per day |
|---|---|
| Registered nurses | 0.3747 hours per resident per day |
| Weekend total | 3.19716 hours per resident per day |
| Nursing staff turnover | 65.5% (registered nurses 75%) |
| Administrators who left | 1 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2025-06-11 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-17 |
| 2025-06-11 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-17 |
| 2024-11-05 complaint survey |
Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-12-05 |
| 2024-10-17 complaint survey |
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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-15 |
| 2024-03-21 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-04-18 |
| 2024-03-21 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · tag F0645 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-18 |
| 2024-03-21 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-18 |
| 2024-03-21 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-18 |
| 2024-03-21 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-18 |
| 2022-04-07 | 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. Nursing and Physician Services Deficiencies · tag F0727 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2022-05-29 |
| 2022-04-07 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-05-29 |
| 2022-04-07 | 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. Quality of Life and Care Deficiencies · tag F0688 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-05-29 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2024-10-17 | Fine | $8,512 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Island City Equity Partners LLC Organization | indirect ownership interest | — | 2023-01-01 |
| Maj Consultants LLC Organization | indirect ownership interest | — | 2023-01-01 |
| Wheat Chaff Lp Organization | indirect ownership interest | — | 2023-01-01 |
| Adams, Michael Individual | adp of the snf | — | 2023-01-01 |
| Munim, Mohammed Individual | adp of the snf | — | 2023-01-01 |
| Weinfeld, Avrum Individual | adp of the snf | — | 2023-01-01 |
| Weiss, Daniel Individual | adp of the snf | — | 2023-01-01 |
| Weinfeld, Avrum Individual | direct ownership interest | — | 2023-01-01 |
| Weiss, Daniel Individual | direct ownership interest | — | 2023-01-01 |
| Nuckolls, Mary Individual | indirect ownership interest | — | 2023-01-01 |
| Tapia, Jill Individual | indirect ownership interest | — | 2023-01-01 |
| Weinfeld, Avrum Individual | managing control - governing body | — | 2023-01-01 |
| Adams, Michael Individual | operational/managerial control | — | 2023-01-01 |
| Munim, Mohammed Individual | operational/managerial control | — | 2023-01-01 |
| Weinfeld, Avrum Individual | operational/managerial control | — | 2023-01-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Terrace At Bishop's Glen, The.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Volusia County.