Inspection Reports for
Merrill Gardens at Kirkland

WAC 388-78A-2410-1 Content of resident records. The facility failed to document monitoring for a resident's bruised arm, resulting in lack of records showing staff monitored the skin issue. This placed the resident at risk for worsening condition.

WAC 388-78A-2483 Tuberculosis One test. The assisted living facility is only required to have a staff person take one test if the staff person has any of the following: a documented history of a negative result from a previous two step skin test done no more than one to three weeks apart. The facility failed to ensure 2 of 3 sampled staff completed one TB test within three days of hire, placing residents at risk.

WAC 388-78A-2484 Tuberculosis Two step skin testing. Unless the staff person meets the requirement for having no skin testing or only one test, the assisted living facility must ensure that each staff person has an initial skin test within three days of employment. The facility failed to ensure 1 of 3 sampled staff completed an initial skin test within three days of hire, placing residents at risk.

WAC 388-78A-2466 Background checks Washington state name and date of birth background check valid for two years. The facility failed to complete a Washington State name and date of birth background check every two years for 12 of 12 sampled staff, placing residents at risk of abuse, neglect, or exploitation.

WAC 388-78A-2474 Training and home care aide certification requirements. The assisted living facility must ensure all administrators, designees, and caregivers meet long-term care worker training requirements including cardiopulmonary resuscitation and first aid. The facility failed to ensure one care staff completed first-aid training within thirty days of hire, but this deficiency was corrected by the exit conference.

WAC 388-78A-3040 Laundry. The assisted living facility must ventilate laundry rooms and areas to the outside. Two laundry room ventilation systems did not operate correctly but were cleaned and corrected by the exit conference.

IFC 405.2 (2021) - Required emergency drills were not performed as required; facility needs to perform one fire drill per shift within 30 days. Records of emergency evacuation drills were incomplete.

IFC 603.2.1 (2021) - Electrical receptacle in kitchen #K-1-15 shows signs of ware and damage.

IFC 603.6 (2021) - Extension cords were improperly used in multiple areas including wellness center and laundry storage.

IFC 606.3.3 (2021) - First semi-annual hood cleaning paperwork was not provided.

IFC 701.6 (2021) - Facility failed to provide paperwork for inspection and schedule of fire-resistance-rated construction.

IFC 705.2.4 (2021) - 5th floor double doors by room 512 will not latch properly.

IFC 903.5 (2021) - Missing paperwork for 5-year internal pipe testing and 5-year FDC hydro testing of sprinkler system. Missing escutcheon found in hallway near employee bathroom.

IFC 904.13.5.2 (2021) - Second semi-annual fire extinguishing system service paperwork was not provided.

IFC 907.8.1 (2021) - Fire alarm system report from 9/12/2024 shows 6 deficiencies; fire alarm system found in supervisor area.

IFC 907.8.3 (2021) - Sensitivity testing paperwork for smoke detectors was not provided.

IFC 915.1 (2021) WAC 51-54A - Carbon monoxide alarms and detectors need monthly testing, maintenance, and documentation.

IFC 1031.10.2 (2018) - Emergency light #75 by room 215 will not come on when test button is pushed.

IFC 1032.10 (2021) - Monthly 30-second activation test and annual 90-minute power test paperwork missing; annual test report shows 5 deficiencies.

NFPA 80 - Facility lacks schedule and documentation for fire door inspections and testing; annual inspection of fire doors needed.

WAC 388-78A-2040 Other requirements. The facility failed to ensure 100 of 100 residents resided in a safe environment approved by the State Fire Marshal due to multiple fire safety violations and missing documentation at the time of the fire marshal inspection.

IFC 0405.5 2018 - Records of required emergency evacuation drills were missing for the 3rd shift quarters 1 through 4.

IFC 604.3 2018 - Combustible storage was found blocking access to the electrical panel in the kitchen.

IFC 604.5 2018 - Extension cords were in use in the 2nd floor medication room, which is not permitted as a substitute for permanent wiring.

IFC 604.6 2018 - An open junction box was found in the kitchen office without approved covers.

IFC 607.3.3 2018 - The facility failed to provide documentation of the required second semi-annual hood cleaning for grease removal devices.

IFC 701.6 2018 WAC 51-54A - The facility lacked a schedule and documentation for annual inspection of fire-resistance-rated construction.

IFC 703.1 2018 - Firestop systems in the 3rd floor telephone/data room were not properly maintained or inspected.

IFC 705.2.4 2018 - Multiple fire doors throughout the facility, including elevator doors and resident laundry doors, failed to latch or close properly.

IFC 907.8 2018 - The fire alarm system was found in trouble and not fully operational.

IFC 907.8.3 2012, 2015, 2018 - The facility failed to provide documentation of required smoke detector sensitivity testing.

IFC 0915.1 2015, 2018 WAC 51-54A - Missing carbon monoxide alarm directly connected to a fossil fuel burning appliance in the commercial laundry room.

IFC 1031.10 2018 - Emergency lighting was not working in multiple locations including the 5th floor rooms 516 and 500, 4th floor resident laundry, 3rd floor resident laundry north, 2nd floor wellness center #58, hair salon, and parking garage sprinkler riser.

NFPA 72 10.6.5.2 - The fire alarm circuit breaker in the electrical room was missing the required lock device to keep it in the ON position.

NFPA 72 10.6.5.2 - Circuit identification and accessibility requirements were not met; the circuit disconnecting means lacked proper permanent identification and red marking.

NFPA 80 Fire Door Inspection and Testing - Resident door 410 had a gap on top of the door and lacked required inspection documentation and maintenance.

NFPA 80 Fire Door Inspection and Testing - Latching hardware did not operate or secure the door properly; auxiliary hardware interfered with operation; and signage and gasketing requirements were not met.

IFC 607.3.3 (2018) - Hoods, grease-removal devices, fans, ducts and other appurtenances must be cleaned at required intervals. The facility failed to produce a second hood cleaning within 6 months of their May 2022 hood cleaning.

IFC 701.6 (2018) WAC 51-54A - The owner must maintain an inventory of all required fire-resistance-rated construction and ensure annual inspections. The facility could not produce an annual fire wall inspection.

IFC 705.2 (2018) - Opening protectives in fire-resistance-rated assemblies and smoke barriers must be inspected and maintained. The facility could not produce an annual fire door inspection.

IFC 705.2.3 (2018) - Hold-open devices and automatic door closers must be maintained and operate properly. The doors to resident rooms 410 and 317 are held open with door stops.

IFC 705.2.4 (2018) - Swinging fire doors must close from the full-open position and latch automatically. The 4th floor cross corridor fire doors did not close and latch from the open position.

IFC 706.1 (2018) - Dampers protecting ducts and air transfer openings must be inspected and maintained. The facility could not produce a fire and smoke damper report.

IFC 903.5 (2009, 2012, 2015, 2018) - Sprinkler systems must be tested and maintained. The facility could not produce a five year internal sprinkler inspection, a three year full trip of the dry system, or a forward flow test. The annual sprinkler inspection did not include the entire facility, only common areas.

IFC 904.12.5 (2018) - Automatic fire-extinguishing systems protecting commercial cooking systems must be maintained. The facility could not produce a heat survey.

IFC 907.8 (2018) - Fire alarm inspection must include the entire building, horns and strobes, initiation devices and other required items. The facility could not produce a fire alarm inspection covering the entire building.