Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
TERRACE AT BISHOP'S GLEN, THE
HOLLY HILL, FL · 60 certified beds · Last Life Safety survey June 11, 2025
CMS Certification Number 105526 · first certified February 1986
Ownership
Operated by SERENITY ESTATES · For profit - Limited Liability company
- Ownership changed September 30, 2022 (change of ownership)to THE TERRACE AT BISHOP'S GLEN from HOLLY HILL RHF HOUSING, INC
Position within FL
28 citations — more than 99% of the 694 certified nursing homes in FL. Compared within FL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 24 citations; the earlier surveys in the window averaged 2. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: September 2026 to April 2027. This facility’s last Life Safety survey was June 2025. Facilities in FL are typically surveyed 15–23 months after the last one (median 17), measured over 729 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
8 of the 28 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
How that compares
Compared with the median facility in FL, and nationally. Surveyors differ markedly between states, so the FL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 28 |
| Median facility in FL | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 7, 2022 | 0 |
| March 21, 2024 | 4 |
| June 11, 2025 | 24 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-06-11 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2025-06-11 |
| K-0912 | Have power receptacles that are properly grounded. | 2 | 2025-06-11 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2025-06-11 |
| K-0711 | Provide a written emergency evacuation plan. | 1 | 2025-06-11 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2025-06-11 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2025-06-11 |
| E-0025 | Create arrangements with other facilities to receive patients. | 1 | 2025-06-11 |
What the citations cover
- Smoke Deficiencies 8
- Emergency Preparedness Deficiencies 8
- Miscellaneous Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Emergency Preparedness Deficiencies | 8 |
| Miscellaneous Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Egress Deficiencies | 3 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 11, 2025 — 24 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (July 17, 2025) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (July 17, 2025) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (July 17, 2025) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (July 17, 2025) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (July 17, 2025) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (July 17, 2025) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (July 17, 2025) |
| E-0042 | Meet the requirements of an integrated health system. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 17, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (July 17, 2025) |
March 21, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 16, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 16, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (April 16, 2024) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (April 16, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.