Avamere at Englewood Heights

The facility failed its first Fire Marshal re-inspection, indicating unresolved fire safety deficiencies from a previous inspection. The specific nature of the violations is not detailed in the report, but failure of a re-inspection suggests the facility did not adequately address previously cited issues within the expected timeframe. The facility's response was inadequate as they failed to correct deficiencies before the re-inspection, though this represents their first failed follow-up rather than persistent non-compliance across multiple attempts.

The inspection identified multiple routine fire safety violations including improper fire drill documentation, electrical hazards (exposed outlets, open junction boxes), propped fire doors, extension cords in use, missing maintenance documentation for sprinkler systems and dampers, and incomplete hood suppression system testing. The facility demonstrated an exemplary response by correcting 9 of 10 violations on-site during the inspection. Only one violation remains outstanding: the commercial hood suppression cylinders requiring hydrostatic testing, which was noted as still deficient on a 10/15/2025 service report.

The facility had routine fire safety maintenance violations including improper fire drill documentation, electrical hazards (exposed outlets, open junction boxes), propped fire doors, extension cords in use, and missing documentation for sprinkler testing and damper repairs. One issue persists: kitchen suppression system cylinders remain overdue for hydrostatic testing. The facility demonstrated exemplary response by correcting nearly all violations on-site during both inspections, showing immediate compliance with zero delay on all correctable items.

This was a complaint investigation regarding alleged smoking in a resident's room. The inspection found no evidence of smoking materials, the resident confirmed use of designated smoking areas only, and a signed smoking policy was on file dated August 27, 2025. The facility demonstrated ongoing compliance efforts with no violations observed, no fire occurred, and no injuries or evacuations took place.

The facility violated end-of-life directives by performing CPR on a DNAR resident during a cardiac arrest incident, despite having the POLST form on file in multiple locations. Staff claimed a blank POLST was found on the refrigerator and cited confusion about the resident's spouse insisting on CPR, though the facility had documented DNAR status in multiple systems. The facility responded with immediate in-service training on emergency medical-response procedures, a facility-wide POLST audit, and reinforced protocols for POLST accessibility during emergencies, though the incident represents a recurring deficiency previously cited in 2023.

This is an Informal Dispute Resolution (IDR) outcome letter following an April 10, 2025 inspection. The facility successfully disputed one of two citations (WAC 388-78A-2980 was deleted, while WAC 388-78A-2600 remained). The IDR letter itself does not describe the underlying violations or facility response quality, serving only as administrative notification of the dispute resolution outcome. Without the original Statement of Deficiencies, the nature and severity of violations cannot be assessed.

This is an administrative scheduling letter confirming an Informal Dispute Resolution meeting, not an inspection report documenting deficiencies or violations. The facility is disputing citations from a prior Statement of Deficiencies dated April 10, 2025, but this document does not describe what those violations were or evaluate the facility's response. No assessment of event severity or response quality can be made from this procedural correspondence.

The July 2023 inspection identified 16 routine fire safety violations including missing documentation of required testing (fire drills, sprinkler inspections, emergency lighting tests), combustible storage in mechanical rooms, unapproved electrical adapters, and minor maintenance issues. The facility demonstrated an exemplary response by correcting all violations within the prescribed timeframe, as confirmed by the August 2023 follow-up inspection showing approval status with all issues resolved. These were procedural and documentation deficiencies with no actual fire safety system failures or immediate danger to residents.

The facility failed to properly coordinate the return of a resident from skilled nursing rehabilitation, denying re-admission without direct assessment and excluding the responsible party from decision-making meetings, while also improperly charging for services not rendered during the resident's absence. The facility conducted some communication with the SNF and documented their determination, but failed to follow proper procedures for resident transfer coordination and billing practices. Additional consultations were provided regarding pet immunizations and food worker certification, indicating broader operational gaps.

The facility had recurring fire safety violations across multiple inspections from July 2022 to March 2023, primarily involving failed fire dampers, untested sprinkler heads, improper electrical equipment use, blocked fire doors, and obstructed egress routes. Many minor violations were corrected on-site during inspections, demonstrating immediate responsiveness. However, the facility repeatedly requested extensions for damper repairs over seven months (July 2022 to March 2023) before finally achieving full compliance in March 2023, showing delayed resolution of the most serious systemic issue. Overall response was adequate with good immediate corrections but slow follow-through on major repairs.