Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Terrace At Bishop's Glen, The during CMS and state inspections, most recent first.
A resident with chronic respiratory conditions was observed receiving oxygen therapy without a physician's order or documentation of care and equipment maintenance. Nursing staff confirmed the absence of required orders and documentation, despite facility policy mandating these practices.
Surveyors found that kitchen fryers were filled with used grease and covered in food grime, with additional grease and debris present on surrounding surfaces and the floor. Staff interviews revealed inconsistent cleaning practices, and the observed conditions did not align with facility policies or FDA Food Code standards for equipment cleanliness.
A resident with severe cognitive impairment was mistakenly given another resident's medications, leading to hospitalization for hypotension and aspiration pneumonia. The error occurred when an LPN prepared medications, but an RN unfamiliar with the residents administered them without proper verification. This incident highlighted a failure to follow the facility's medication administration policy.
A resident with dementia was prescribed ABH gel for psychotic disturbance without a 14-day stop order, leading to frequent use beyond the required period. The facility staff, including an LPN and the DON, acknowledged the oversight, confirming the lack of a stop order and frequent administration of the medication.
Failure to Obtain Physician Order and Document Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including COPD, chronic respiratory failure, and dependence on supplemental oxygen, was observed receiving oxygen therapy at a flow rate of 3.5 L/min via nasal cannula connected to an oxygen concentrator. Despite the ongoing administration of oxygen, there was no physician's order for oxygen therapy or for the care and maintenance of the oxygen delivery devices documented in the resident's medical record from admission through the time of the survey. Further review of the resident's medication administration record (MAR) and treatment administration record (TAR) for the relevant month revealed no evidence that oxygen therapy or care of the oxygen delivery devices was documented as provided or received. The resident's care plan did include interventions related to respiratory management, such as administering oxygen as ordered and monitoring respiratory status, but these interventions were not supported by corresponding physician orders or documentation of implementation. Interviews with nursing staff and the Assistant Director of Nursing confirmed that there was no physician's order for oxygen therapy or for the care of the oxygen equipment in the electronic medical record. Staff also acknowledged that administration of oxygen and related care should be documented on the MAR, but this was not found for the resident in question. Facility policy required a physician order for oxygen therapy, ongoing assessment, and documentation, none of which were present for this resident.
Failure to Maintain Sanitation and Food Handling Practices in Kitchen Fryers
Penalty
Summary
Surveyors observed that both fryers in the facility's kitchen were filled with used grease and had significant build-up of food grime and grease, with additional grease and food debris splattered on the sides of the fryers and the surrounding floor area. These unsanitary conditions were documented on two separate occasions, and photographic evidence was obtained. Further inspection revealed new grease build-up inside the front door area underneath the fryer. Staff interviews indicated conflicting accounts regarding cleaning responsibilities and frequency, with some staff stating the fryers had not been used for over a year, while others described daily cleaning routines. A review of facility policies showed that fryers and kitchen floors were to be cleaned regularly, with specific procedures for cleaning and sanitizing equipment and floors. The observations made by surveyors were not consistent with these policies or with FDA Food Code requirements, which mandate that equipment food-contact and nonfood-contact surfaces be kept free of grease, food residue, and other debris. No information was provided regarding any residents' medical history or condition at the time of the deficiency.
Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, resulting in a serious incident involving two residents. A resident with severe cognitive impairment was mistakenly administered another resident's medications, which included drugs for depression, cholesterol, high blood pressure, and diabetes. This error occurred during a medication pass when a Licensed Practical Nurse (LPN) prepared the medications for one resident, but they were administered to the wrong resident by a Registered Nurse (RN) who was unfamiliar with the residents on that hall. The resident who received the incorrect medications was subsequently transferred to a hospital for evaluation due to hypotension and other symptoms. The hospital report indicated that the resident had developed aspiration pneumonia and required intravenous fluids to address low blood pressure. The incident was attributed to a breakdown in the medication administration process, where one nurse prepared the medications and another nurse administered them without proper verification of the resident's identity. Interviews with facility staff revealed that the standard practice of medication administration was not followed, as the nurse who prepared the medications did not administer them. The facility's policy clearly states that the person who prepares the dose should be the one to administer it, and residents should be identified using two methods before medication administration. The incident highlighted a deviation from these established protocols, leading to the medication error and subsequent hospitalization of the resident.
Failure to Implement 14-Day Stop Order for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that as-needed (PRN) orders for psychotropic medications were limited to 14 days, as required, unless extended by a physician with documented rationale. This deficiency was identified in the case of a resident who was prescribed ABH gel, a combination of Ativan, Benadryl, and Haldol, for unspecified dementia with psychotic disturbance. The order for this medication was noted as indefinite, and the resident received the medication multiple times over a period extending beyond 14 days without a stop order or documented physician rationale for continuation. The resident, who had a history of encephalopathy, non-Alzheimer's dementia, and cognitive communication deficit, was admitted to the facility and had behaviors of screaming and hollering. The medication administration records showed frequent use of the ABH gel over several weeks. Interviews with facility staff, including an LPN and the DON, revealed that the oversight regarding the 14-day stop order was acknowledged as a miss, with the DON confirming the lack of a stop order and the frequent administration of the medication.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Holly Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Daytona Beach Health And Rehabilitation Center | 1.1 mi | ★★★★★ | 5 | 0 |
| Coastal Health And Rehabilitation Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Solaris Healthcare Daytona | 2.4 mi | ★★★★★ | 0 | 0 |
| Bridgeview Center | 2.5 mi | ★★★★★ | 1 | 0 |
| Emory L Bennett Memorial Veterans Nursing Home | 2.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.