Avamere at Englewood Heights Memory Care

The facility experienced a respiratory illness outbreak affecting at least two residents. The facility responded appropriately by posting outbreak signs, implementing PPE use, separating residents, increasing cleaning, and making proper notifications. However, a deficiency was identified: staff had not completed required annual N95 fit testing when the outbreak occurred, violating WAC 388-78A-2610(1). The facility's outbreak response was strong overall, but the lapsed fit testing represents a gap in preparedness that could compromise infection control effectiveness.

The facility had two routine fire safety documentation violations: fire drills conducted during shift transitions rather than within designated shifts, and missing annual 90-minute emergency lighting test documentation. The facility demonstrated an exemplary response by correcting both violations immediately during the September follow-up inspection, resolving all issues within 30 days with no persistent deficiencies. These were procedural documentation issues with no impact on actual resident safety or fire protection systems.

The Department of Social and Health Services completed a full inspection and complaint investigation of Avamere at Englewood Heights Memory Care on April 16, 2025, and found no deficiencies. The facility was in full compliance with all regulatory requirements at the time of inspection. No violations or issues requiring corrective action were identified.

The facility failed to provide contracted nail care to residents as specified in Negotiated Service Agreements, resulting in overgrown toenails curling under residents' toes. Additionally, the facility undertook extensive kitchen construction following water damage and mild mold without notifying Construction Review Services as required, placing residents at risk of non-compliant construction work. The facility acknowledged both deficiencies, implemented corrective actions, and completed a follow-up inspection on 12/13/2023 with no deficiencies found, demonstrating adequate response and resolution.

The facility had three separate violations: failure to complete tuberculosis screening within three days of hire for multiple staff members (cited twice, February and June 2023), failure to post menus and provide meal choices, and an inadequate disaster preparedness plan lacking essential emergency protocols. The facility responded with timely corrective action plans, completed all corrections by the target dates, and passed a follow-up inspection in August 2023 with no deficiencies found, demonstrating good follow-through on systemic issues.

The facility had multiple routine fire safety documentation deficiencies across three inspections (May and June 2023), including missing records for fire drills, sprinkler inspections, alarm testing, and emergency lighting tests, plus minor physical issues like storage clearance violations and a blocked laundry door. The facility responded exemplarily by systematically correcting all violations between inspections, providing missing documentation, and achieving full compliance by the August 2023 follow-up inspection where all previous violations were confirmed corrected. The violations were entirely administrative/documentation-based with no actual fire safety system failures or immediate danger to residents.