Inspection Reports for Merrill Gardens at Kirkland
14 Main St S, Kirkland, WA 98033, WA, 98033
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20
15
10
5
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Inspection Report
Life Safety
Deficiencies: 20
Jan 29, 2025
Visit Reason
The Office of the State Fire Marshal conducted a fire protection inspection at the facility to assess compliance with fire safety codes and regulations.
Findings
Multiple deficiencies were identified related to emergency drills, electrical receptacles, extension cords, door operation, sprinkler system testing, fire extinguishing system service, fire alarm system maintenance, smoke detector sensitivity, carbon monoxide detection, emergency lighting, and fire door inspection and testing. Several required documents and tests were missing or outdated.
Deficiencies (20)
| Description |
|---|
| Facility will need to perform one fire drill per shift in the next 30 days. |
| Kitchen #K-1-15 receptacle shows signs of ware. |
| Wellness center has a multi plug in-use. |
| Laundry storage has multi-plugs in-use. |
| Extension cord in-use for ecolab system. |
| Front desk has an extension cord in-use connected to a power strip. |
| First semi-annual hood cleaning paperwork not provided. |
| Facility needs to identify and establish a schedule for inspection of Fire-Rated construction. |
| 5th floor double doors by room 512 will not latch. |
| 5-Year internal pipe Testing paperwork not provided. |
| 5-Year FDC Hydro testing paperwork not provided. |
| Missing Escutcheon found in hallway from parking lot by employee bathroom. |
| Second semi-annual service paperwork not provided. |
| Report performed on 9/12/2024 shows 6 deficiencies; Fire Alarm System is found in supervisor. |
| Sensitivity Testing paperwork not provided. |
| Carbon Monoxide Alarms and Detectors need to be tested, maintained and documented on a monthly schedule. |
| #75 emergency light by room 215 will not come on when test button is pushed. |
| 30-second monthly activation test paperwork not provided. |
| Annual 90 minute power test had 5 deficiencies on report. |
| Facility needs to identify and establish a schedule for inspection of Fire Doors; Annual inspection of fire doors will need to be performed and completed. |
Report Facts
Deficiencies cited: 6
Annual 90 minute power test deficiencies: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Van Gorkum | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Levi Novak | Maintenance Director | Owner's representative who signed the report |
Inspection Report
Follow-Up
Deficiencies: 7
Jun 18, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies related to food worker cards, background checks, training, tuberculosis testing, infection control, water temperature, and ventilation were corrected or addressed.
Deficiencies (7)
| Description |
|---|
| Failure to ensure food service staff maintained valid food worker cards. |
| Failure to ensure valid Washington State and national fingerprint background checks for staff. |
| Failure to ensure direct care staff met all training requirements including orientation, specialty training, and CPR/first aid certification. |
| Failure to ensure newly hired caregiver staff completed required tuberculosis two-step skin testing. |
| Failure to ensure housekeeping staff implemented safe infection control practices during housekeeping and laundry tasks. |
| Failure to maintain hot water temperatures between 105°F and 120°F in resident apartments and facility sinks, risking burns. |
| Failure to provide proper mechanical ventilation and airflow in multiple bathrooms, laundry rooms, and housekeeping utility closets. |
Report Facts
Staff with invalid food worker cards: 3
Staff missing valid background checks: 1
Direct care staff missing training requirements: 3
Newly hired caregiver staff missing TB tests: 3
Housekeeping staff failing infection control: 2
Resident apartments with hot water above 120°F: 4
Facility sinks with hot water above 120°F: 12
Rooms lacking proper ventilation: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Caregiver | Named in deficiencies related to food worker card, background checks, training, and medication administration |
| Staff H | Cook | Named in deficiency related to food worker card |
| Staff I | Cook | Named in deficiency related to food worker card |
| Staff J | Dining Services Director | Interviewed regarding food service and tray service |
| Staff A | Executive Director | Interviewed regarding missing staff records and training compliance |
| Staff C | Caregiver | Named in training deficiencies |
| Staff D | Caregiver | Named in training deficiencies |
| Staff B | Caregiver | Named in tuberculosis testing deficiency |
| Staff K | Housekeeper | Named in infection control deficiency |
| Staff L | Housekeeper | Named in infection control deficiency |
| Staff N | Senior Maintenance Director | Interviewed regarding water temperature and ventilation issues |
| Staff M | Maintenance Director | Mentioned in relation to ventilation training |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 9
Mar 19, 2024
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation following a failed third fire marshal inspection on 02/20/2024, to assess compliance with fire safety regulations and licensing laws.
Findings
The facility failed to provide required documentation during the fire marshal inspection, resulting in multiple fire safety violations including missing paperwork for night shift drills, lack of annual fire-rated construction inspection, and malfunctioning fire doors and emergency lighting. Subsequent follow-up showed corrections were made, but initial noncompliance placed residents at risk.
Complaint Details
Complaint investigation was initiated due to a failed third fire marshal inspection on 02/20/2024. The complaint was substantiated with multiple fire safety violations found. The Executive Director stated the facility was unable to provide requested documents to the Fire Marshal at the time of inspection, preventing compliance. Follow-up showed corrections were made.
Deficiencies (9)
| Description |
|---|
| Missing paperwork for night shift fire drills for Quarters 1, 2, 3, and 4 |
| No annual inspection of fire-rated construction |
| Third floor telephone/data room firestop systems not maintained |
| Multiple fire doors on various floors would not latch or close properly |
| Fire alarm found in trouble condition |
| Smoke detector sensitivity testing reports incomplete or deficient |
| Emergency lighting not working in multiple locations |
| No established schedule for NFPA 80 fire door inspection and testing |
| Facility failed to ensure 100 residents resided in a safe environment approved by the State Fire Marshal |
Report Facts
Total residents: 108
Resident sample size: 0
Closed records sample size: 0
Compliance Determination Completion Dates: Completion dates 07/17/2024 and 04/19/2024 referenced in follow-up letter
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kailash Sharma | ALF Licensor | Department staff who conducted the on-site verification and investigation |
| Laurie Anderson | Field Manager | Signed correspondence related to compliance determination and investigation |
| Executive Director | Interviewed during investigation; new to facility since January 2024; provided documentation and statements regarding corrections |
Inspection Report
Life Safety
Deficiencies: 15
Feb 20, 2024
Visit Reason
The Office of the State Fire Marshal conducted a fire protection inspection at Merrill Gardens at Kirkland to assess compliance with fire safety codes and regulations.
Findings
Multiple deficiencies were identified including missing emergency evacuation drill records, combustible storage blocking electrical panel access, extension cords in use, open junction boxes, missing semi-annual hood cleaning documentation, fire doors not latching properly, fire alarm in trouble, missing carbon monoxide alarms, and emergency lighting failures. Several deficiencies were corrected during the inspection.
Deficiencies (15)
| Description |
|---|
| Missing emergency evacuation drill records for 3rd shift quarters 1, 2, 3, 4 |
| Combustible storage found blocking access to the electrical panel in kitchen |
| Extension cord in use in 2nd floor med room |
| Open junction box found in kitchen office |
| Second semi-annual hood cleaning paperwork not provided |
| Facility needs to establish schedule for inspection of fire-rated construction |
| Multiple fire doors not latching or closing properly on various floors and locations |
| Fire alarm found in trouble |
| Smoke detector sensitivity testing paperwork not provided |
| Missing carbon monoxide alarm directly connected to fossil fuel burning appliance in commercial laundry room |
| Multiple emergency lighting failures on 5th, 4th, 3rd, and 2nd floors and parking garage |
| Fire alarm circuit breaker missing required lock device |
| Facility needs to establish schedule for inspection of fire doors including resident doors |
| Resident door 410 has gap on top of door |
| Latching hardware does not operate or secure door properly; auxiliary hardware interfering with operation; no field modification voiding label; meeting edge protection and signage issues |
Report Facts
Missing evacuation drills: 4
Fire doors not latching or closing: 9
Emergency lighting failures: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Van Gorkum | Deputy State Fire Marshal | Signed inspection report |
| Brian G. Madgett | General Manager | Named as Owner or Authorized Representative |
Inspection Report
Re-Inspection
Deficiencies: 16
Jun 2, 2023
Visit Reason
The Office of the State Fire Marshal conducted a reinspection of Merrill Gardens at Kirkland to verify correction of violations identified during a prior inspection.
Findings
The reinspection found that some violations from the initial inspection remained uncorrected, including failure to produce certain inspection reports and incomplete fire and safety inspections. Several items were noted as completed or scheduled for repair.
Deficiencies (16)
| Description |
|---|
| The facility could not produce an annual fire wall inspection. |
| The facility could not produce a fire and smoke damper report. |
| The facility could not produce a forward flow test for the sprinkler system. |
| The facility could not produce a heat survey. |
| The annual fire alarm inspection did not include the entire facility, just the common areas. |
| The annual fire alarm inspection did not include the entire building, horns and strobes, initiation devices and other items required in NFPA 72. |
| The facility could not produce a second hood cleaning within 6 months of their May 2022 hood cleaning. |
| The facility could not produce an annual fire wall inspection. |
| The facility could not produce an annual fire door inspection. |
| The doors to resident rooms 410 and 317 are held open with door stops. |
| The 4th floor cross corridor fire doors did not close and latch from the open position. |
| The facility could not produce a fire and smoke damper report. |
| The facility could not produce a five year internal sprinkler inspection for all of their sprinkler systems. |
| The facility could not produce a three year full trip of the dry system. |
| The facility could not produce a forward flow test. |
| The facility could not produce a heat survey. |
Report Facts
Next inspection scheduled date: Apr 8, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Bloor | Deputy State Fire Marshal | Issued the inspection report and signed multiple pages |
| Reza Baharmast | GM | Owner or Authorized Representative who signed the inspection report |
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