A list of the most recent deficiencies for Allure of Lake Storey. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-18 | 2023-11-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-18 | 2023-11-21 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-08-17 | 2023-11-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-17 | 2023-11-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-17 | 2023-11-21 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-07-18 | 2023-08-17 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-07-18 | 2023-08-17 | N |
| Develop a communication plan. | Fire Safety | 2023-07-18 | 2023-08-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-07-18 | 2023-08-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-07-18 | 2023-08-17 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-07-18 | 2023-08-17 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-07-18 | 2023-08-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-07-18 | 2023-08-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-07-18 | 2023-08-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-18 | 2023-08-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-18 | 2023-08-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-18 | 2023-08-17 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2023-07-18 | 2023-08-17 | N |
| 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. | Health | 2023-07-14 | 2023-07-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-17 | 2022-10-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-17 | 2022-10-22 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-08-17 | 2022-10-22 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-08-17 | 2022-10-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-17 | 2022-10-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-17 | 2022-10-22 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-08-17 | 2022-10-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-17 | 2022-10-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-17 | 2022-10-22 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2022-08-17 | 2022-10-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-17 | 2022-10-22 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2022-08-17 | 2022-10-22 | N |
| 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. | Health | 2022-08-18 | 2022-08-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-17 | 2022-08-20 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-28 | 2022-03-11 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-05-07 | 2021-05-28 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-05-07 | 2021-05-28 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-05-07 | 2021-05-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-05-07 | 2021-05-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-05-07 | 2021-05-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-07 | 2021-05-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-07 | 2021-05-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-07 | 2021-05-20 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-04-29 | 2021-05-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-29 | 2021-05-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-29 | 2021-05-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-29 | 2021-05-12 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-04-29 | 2021-05-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-05-07 | 2021-05-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-07 | 2021-05-08 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-04-29 | 2021-04-29 | N |
