Avamere at Englewood Heights

The licensee failed to implement the Negotiated Service Agreement (NSA) which directed staff to assist a resident with getting in and out of bed using two staff members, resulting in a fall and injuries requiring hospitalization.

Facility failed fire marshal re-inspection due to missing documentation regarding repair and re-testing of the commercial hood system.

Unable to provide acceptance testing documentation for new FACP.

Missing annual forward flow documentation; loaded sprinkler heads on exterior patio.

Unable to provide service documentation for hood system; suppression cylinders not hydro tested within 6 years; service report notes current deficiencies.

Multi-plug adapter without overcurrent protection in Room 309; extension cords in Room 309 and on building exterior.

Failed to provide documentation of annual 90-minute exit lighting test.

Penetration in the Executive Director's Office closet.

Failed to provide documentation for damper service.

Broken door frame on 3rd floor; multiple fire doors propped open with wedges or unapproved magnetic locks.

Electrical outlet without faceplate and broken in Room 304; open junction box in Break Room.

Fire drill documentation showed start times in between shift transitions and at all-staff meetings rather than varied times.

Failed to provide documentation showing fire and smoke damper service deficiencies were repaired and retested.

Broken 3rd floor Mechanical Room door frame; multiple fire doors (Rooms 317, 214, 122, 124, Dining Room, Copy Room) propped open with wedges or unapproved magnetic locks.

Missing faceplate and broken outlet in Room 304; open junction box in the Break Room.

No documentation of annual forward flow test; loaded sprinkler heads on exterior patio.

Multi-plug adapter without overcurrent protection, extension cord in Room 309, and extension cord taped to exterior riser.

Fire drill documentation showed inconsistent drill start times; some occurring in between shifts or at all-staff meetings.

Unable to provide documentation of commercial hood system repairs/retesting; suppression cylinders not hydro tested within last six years.

Facility failed to ensure staff followed policies regarding life-sustaining treatments for 1 resident (Resident 10) who had a Do Not Attempt Resuscitation (DNAR) order, resulting in CPR being performed.

Facility failed to ensure residents' pets had regular examinations and immunizations.

Facility failed to ensure staff who worked unsupervised with residents completed dementia and mental specialty training within the required time frame.

Facility failed to follow policies regarding life-sustaining treatments; staff performed CPR on a resident with a Do Not Attempt Resuscitation (DNAR) order.