Tag 0695 · Severity D
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2025-07-17For-profit
Terrace at Bishop's Glen, the
900 Lpga Blvd, Holly Hill, FL 32117
(386) 226-9000 · Serenity Estates
At a glance
CMS data snapshot: 2026-08-01 · Sources and limitations
| Ownership | For profit - Limited Liability company | Certified beds | 60 |
|---|---|---|---|
| Estimated occupancy | 88.0% | Latest inspection | 2025-06-11 |
County and Florida comparison
Navy: facility · Teal: county · Gray: Florida
Overall rating
Facility: 3 of 5
Health-inspection score
Facility: 20.0 points
Total nurse staffing
Facility: 3.71 hours/day
RN staffing
Facility: 0.37 hours/day
Staff turnover
Facility: 65.5%
Latest health deficiencies
Facility: 2 deficiencies
View data table
| Metric | Facility | County | Florida |
|---|---|---|---|
| Overall rating | 3 of 5 | 4 of 5 | 3 of 5 |
| Health-inspection score | 20.0 points | 18.0 points | 38.5 points |
| Total nurse staffing | 3.71 hours/day | 3.56 hours/day | 3.63 hours/day |
| RN staffing | 0.37 hours/day | 0.50 hours/day | 0.62 hours/day |
| Staff turnover | 65.5% | 48.8% | 41.8% |
| Latest health deficiencies | 2 deficiencies | 2 deficiencies | 6 deficiencies |
Comparisons describe CMS data; they are not recommendations.
Inspection history
2025-06-11
2 deficiencies
Highest severity: D
Immediate-jeopardy citations: 0
Tag 0812 · Severity D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction 2025-07-172024-03-21
7 deficiencies
Highest severity: F
Immediate-jeopardy citations: 0
Tag 0812 · Severity F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction 2024-04-18Tag 0645 · Severity D
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2024-04-18Tag 0686 · Severity D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-04-18Tag 0695 · Severity D
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-04-18Tag 0759 · Severity D
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2024-04-182022-04-07
3 deficiencies
Highest severity: F
Immediate-jeopardy citations: 0
Tag 0727 · Severity F
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 · Deficient, Provider has date of correction 2022-05-29Tag 0677 · Severity D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2022-05-29Tag 0688 · Severity D
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 · Deficient, Provider has date of correction 2022-05-29Staffing composition
2.22 hours/dayNurse aide
1.12 hours/dayLPN
0.37 hours/dayRN
- Total staffing
- 3.71 hours/day
- County median
- 3.56 hours/day
- Florida median
- 3.63 hours/day
- Weekend total
- 3.20 hours/day
- Staff turnover
- 65.5%
- RN turnover
- 75.0%
Reported averages, not a real-time staffing schedule.
Resident outcomes
Lower is generally better
Hospitalizations
2.3 per 1,000 daysworseFlorida: 2.1 per 1,000 days · County: 1.9 per 1,000 days20250101-20251231
Emergency-department visits
0.6 per 1,000 daysbetterFlorida: 1.0 per 1,000 days · County: 0.8 per 1,000 days20250101-20251231
Falls with major injury
1.9%betterFlorida: 2.2% · County: 3.3%2025Q2-2026Q1
Pressure ulcers
5.9%worseFlorida: 4.2% · County: 4.3%2025Q2-2026Q1
Urinary tract infections
0.6%unavailableFlorida: 0.0% · County: 0.3%2025Q2-2026Q1
Antipsychotic medication use
2.3%betterFlorida: 7.0% · County: 8.6%2025Q2-2026Q1
These group measures do not predict an individual resident’s experience.
Questions to ask
Use these prompts during a tour or phone call
How many RNs are typically on site during days, nights, and weekends?
Suggested because of: rn staffingWhat is driving staff turnover, and what is being done to retain nurses and aides?
Suggested because of: staff turnoverHow does the care team prevent and treat pressure injuries?
Suggested because of: pressure ulcersWhat operational changes followed the facility's most recent penalty?
Suggested because of: penaltiesHow will the care plan be developed, reviewed, and shared with our family?
Suggested because of: general care planning
Facility Details
- County
- Volusia County
- Certified beds
- 60
- Average daily residents
- 52.8
- Ownership
- For profit - Limited Liability company
- Provider type
- Medicare and Medicaid
- In hospital
- No
- Date certified
- 1986-02-25
- CCN
- 105526
Staffing Data
| Reported measure | Value |
|---|---|
| Nurse aide hours | 2.22143 |
| Lpn hours | 1.11885 |
| Rn hours | 0.3747 |
| Reported total hours | 3.71497 |
| Weekend total hours | 3.19716 |
| Weekend rn hours | 0.26135 |
| Adjusted total hours | 3.94896 |
| Total turnover percent | 65.5 |
| Rn turnover percent | 75 |
| Administrators left | 1 |
Hours are per resident per day; turnover values are percentages. Missing values are not zero.
Penalties & Enforcement
$8,512.00Total fines
1Number of fines
0Payment denials
| Date | Type | Amount |
|---|---|---|
| 2024-10-17 | Fine | $8,512.00 |
Totals reflect the supplied CMS records, not a lifetime total.
Citations
2Health citations
28Fire safety citations
Health counts describe the latest rating cycle. Fire counts cover supplied fire-safety records.
Serious Deficiencies
FL counts scope/severity G–L as serious deficiencies. Immediate jeopardy is J–L; these are not interchangeable.
1
Ensure that residents are free from significant medication errors.
Ownership & Operators
| Name | Role | Share |
|---|---|---|
| WEINFELD, AVRUM | DIRECT OWNERSHIP INTEREST | NOT APPLICABLE |
| WEISS, DANIEL | DIRECT OWNERSHIP INTEREST | NOT APPLICABLE |
| ISLAND CITY EQUITY PARTNERS LLC | INDIRECT OWNERSHIP INTEREST | NOT APPLICABLE |
| MAJ CONSULTANTS LLC | INDIRECT OWNERSHIP INTEREST | NOT APPLICABLE |
| WHEAT CHAFF LP | INDIRECT OWNERSHIP INTEREST | NOT APPLICABLE |
| NUCKOLLS, MARY | INDIRECT OWNERSHIP INTEREST | NOT APPLICABLE |
| TAPIA, JILL | INDIRECT OWNERSHIP INTEREST | NOT APPLICABLE |
| WEINFELD, AVRUM | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE |
| ADAMS, MICHAEL | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| MUNIM, MOHAMMED | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| WEINFELD, AVRUM | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| ADAMS, MICHAEL | ADP OF THE SNF | NOT APPLICABLE |
| MUNIM, MOHAMMED | ADP OF THE SNF | NOT APPLICABLE |
| WEINFELD, AVRUM | ADP OF THE SNF | NOT APPLICABLE |
| WEISS, DANIEL | ADP OF THE SNF | NOT APPLICABLE |
Helpful resources
Educational information, not medical or legal advice. Data & methodology