Inspection visit
Fire Safety inspection
Citations
24 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0035GeneralS&S Dpotential for harm
Provide family notifications of emergency plan.
- 0036GeneralS&S Dpotential for harm
Establish emergency prep training and testing.
- 0042GeneralS&S Dpotential for harm
Meet the requirements of an integrated health system.
- 0711GeneralS&S Dpotential for harm
Provide a written emergency evacuation plan.
- 0004GeneralS&S Dpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0372GeneralS&S Dpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0009GeneralS&S Dpotential for harm
Include a process for Emergency Preparedness collaboration.
- 0025GeneralS&S Dpotential for harm
Create arrangements with other facilities to receive patients.
- 0030GeneralS&S Dpotential for harm
List the names and contact information of those in the facility.
- 0034GeneralS&S Dpotential for harm
Provide a means of sharing information on occupancy/needs.
- 0222GeneralS&S Dpotential for harm
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.
- 0223GeneralS&S Dpotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0291GeneralS&S Dpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0324GeneralS&S Dpotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Dpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351GeneralS&S Dpotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
- 0521GeneralS&S Dpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0712GeneralS&S Dpotential for harm
Have simulated fire drills held at unexpected times.
- 0761GeneralS&S Dpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0912GeneralS&S Dpotential for harm
Have power receptacles that are properly grounded.
- 0918GeneralS&S Dpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0923GeneralS&S Dpotential for harm
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the June 11, 2025 survey of TERRACE AT BISHOP'S GLEN, THE?
This was a inspection survey of TERRACE AT BISHOP'S GLEN, THE on June 11, 2025. The surveyor cited 24 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at TERRACE AT BISHOP'S GLEN, THE on June 11, 2025?
Yes, 24 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide family notifications of emergency plan."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.