Inspection Reports for Avamere at Englewood Heights

The Office of the State Fire Marshal conducted a fire safety inspection at the facility on 10/30/2025 to assess compliance with fire protection codes and regulations.

Multiple violations were observed including issues with fire drill documentation, electrical hazards, power taps, fire door maintenance, duct and air transfer openings, sprinkler system testing, fire extinguishing system service, fire alarm acceptance testing, and emergency lighting power testing. Several violations were corrected during the inspection.

The inspection was conducted due to a complaint of smoking within a resident room at Avamere at Englewood Heights.

The inspection found no signs of smoking materials present and no fire, injuries, evacuations, or relocations occurred. The facility has a signed smoking policy and will continue efforts to maintain compliance. The inspection was approved with no violations observed.

Complaint #197540 regarding smoking in a resident room was investigated and found unsubstantiated; no violations were observed.

The inspection and complaint investigation were conducted due to allegations that facility staff performed CPR on a resident with a Do Not Attempt Resuscitation (DNAR) order and concerns about the facility's clarity regarding contract cost increases.

The facility failed to follow policies and procedures regarding life-sustaining treatments for one resident, resulting in CPR being performed despite a DNAR order. The facility did not honor the resident's advance directives properly. The facility is attempting to resolve financial concerns related to contract cost notices. Additional deficiencies related to pet care and staff training were noted and corrected.

The complaint investigation found that staff performed CPR on a resident with a DNAR order, which was a failed practice. The facility did not follow policies and procedures regarding life-sustaining treatments. The complaint was substantiated with a failed provider practice identified and citation written.

This document is the result of an Informal Dispute Resolution (IDR) process addressing disputes raised by the facility in response to a Statement of Deficiencies (SOD) report dated April 10, 2025.

After review, the IDR decision upheld no change to WAC 388-78A-2600 and deleted the deficiency related to WAC 388-78A-2980 from the SOD.

The inspection was conducted as a complaint investigation regarding allegations that facility staff performed Cardio-Pulmonary Resuscitation (CPR) on a resident who had a Do Not Attempt Resuscitation (DNAR) order and concerns about the facility's clarity on contract cost increases.

The investigation found that the facility staff performed CPR on a resident with a DNAR order, which was a failed practice and violation of policies and procedures. The facility did not honor the resident's advance directives. However, the facility was attempting to resolve financial concerns related to contract cost increases and no failed practice was identified in that regard.

The complaint investigation was substantiated with a failed provider practice identified related to performing CPR on a resident with a DNAR order. The resident's spouse requested CPR despite the DNAR status, leading to confusion among staff. The facility had a recurring deficiency related to POLST form availability and staff protocol adherence.

The inspection was conducted as an unannounced complaint investigation regarding multiple allegations including delayed staff response to resident calls for assistance, improper medication administration, missing resident belongings, and failure to notify Construction Review Services of facility modifications.

The facility failed to respond timely to resident calls for assistance, resulting in extended wait times and resident harm risk. The facility also failed to notify the required department of planned and implemented modifications to the physical structure. Other allegations such as medication administration, missing belongings, and billing errors were found to have no failed facility practice.

The complaint involved a named resident who fell and waited 55 minutes for assistance, among other allegations including improper billing, medication administration issues, missing belongings, and failure to notify CRS of facility modifications. The complaint was substantiated with citations issued for failure to respond timely to calls for assistance and failure to notify CRS.

The Office of the State Fire Marshal conducted a fire safety inspection at the facility on 07/07/2023.

Multiple fire safety violations were observed including improper disposal of smoking items, combustible materials stored in prohibited areas, unapproved use of multiplug adapters, lack of documentation for fire drills and equipment maintenance, blocked self-closers on doors, and failure to provide required testing and maintenance reports for fire sprinkler systems, extinguishing systems, emergency lighting, and alarms.

The inspection was conducted as a complaint investigation regarding allegations that the facility did not properly explain transfer processes, denied a resident's return without seeing them, excluded the responsible party from meetings, and charged for care not received.

The facility failed to meet Assisted Living Facility requirements, including not maintaining a current license, failing to ensure signed negotiated service agreements for residents, inadequate tuberculosis screening for new staff, insufficient staff orientation and training, and improper food sanitation practices. The facility was found to have charged for care and services not provided to a resident.

The complaint alleged the facility did not explain transfer processes, excluded the responsible party from meetings, denied the resident's return without seeing them, and charged for care not received. The investigation substantiated these allegations and identified failed provider practices.

The Office of the State Fire Marshal conducted a re-inspection at the facility to verify correction of previously cited violations that had not been corrected.

The re-inspection found that repairs related to dampers protecting ducts and air transfer openings were still incomplete, with scheduled repairs and retesting planned. Additional time was approved multiple times for compliance.

The document confirms the facility's request for an Informal Dispute Resolution (IDR) regarding the Statement of Deficiencies dated April 10, 2025, and schedules a virtual meeting for May 15, 2025.

The letter does not contain inspection findings but addresses the dispute of specific citations (WAC 388-78A-2600 and WAC 388-78A-2980) and outlines the IDR process.