Inspection Reports for Merrill Gardens at The University
5300 24th Ave NE, Seattle, WA 98105, WA, 98105
Back to Facility Profile
Inspection Report
Follow-Up
Census: 33
Deficiencies: 3
Jul 10, 2025
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, indicating the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to food sanitation, tuberculosis testing, and pet certification were corrected.
Deficiencies (3)
| Description |
|---|
| Failure to have a system in place to ensure ready-to-eat food was labeled, dated, and safe for residents to consume. |
| Failure to ensure 2 of 2 staff members completed the required one-step tuberculosis skin test (TST). |
| Failure to ensure pets living on premises were certified by a veterinarian to be free of diseases transmittable to humans. |
Report Facts
Residents present during inspection: 33
Sample size for review: 7
Staff without valid food handler permits: 2
Staff without valid tuberculosis skin test: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Faith Le | NCI | Department staff who did the on-site verification. |
| Erin Steinbrenner | Nursing Consultant Institutional | Department staff who did the on-site verification. |
| Staff G | Executive Chef | Observed kitchen and confirmed staff without valid food handler permits. |
| Staff H | Dining Room Server | Hired staff without valid food handler permit on file. |
| Staff I | Dining Room Server | Hired staff without valid food handler permit on file. |
| Staff B | Caregiver | Hired staff without valid one-step tuberculosis skin test documentation. |
| Staff D | Caregiver | Hired staff without valid one-step tuberculosis skin test documentation. |
| Staff A | Administrator | Stated no additional tuberculosis test records completed after hire for Staff C and Staff D. |
Inspection Report
Follow-Up
Census: 36
Capacity: 45
Deficiencies: 2
Feb 27, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to fire and life safety inspections.
Findings
The follow-up inspection found no deficiencies, indicating the facility met Assisted Living Facility licensing requirements. However, earlier complaint investigations identified noncompliance with fire and life safety inspection documentation requirements.
Complaint Details
Complaint investigation conducted from 09/07/2023 through 09/08/2023 found the facility failed initial and follow-up fire and life safety inspections on 03/23/2023, 04/27/2023, 06/01/2023, and 08/07/2023 due to lack of required documentation. The complaint was substantiated with citations written.
Deficiencies (2)
| Description |
|---|
| Facility unable to provide documentation for the 4 year fire and smoke damper inspection. |
| Facility unable to provide documentation that the Fire Department Connection has been hydrostatically tested. |
Report Facts
Total residents: 36
Total licensed beds: 45
Resident sample size: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Prentice | Complaint Investigator | Conducted on-site verification and complaint investigation |
| Jamie Singer | Field Manager | Signed inspection and compliance documents |
Inspection Report
Follow-Up
Census: 35
Deficiencies: 2
Feb 20, 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. Prior deficiencies related to staff continuing education and tuberculosis skin testing were corrected.
Deficiencies (2)
| Description |
|---|
| Failed to ensure continuing education credits for 1 of 5 sampled staff, leaving all 35 residents without up-to-date CE hours. |
| Failed to ensure 2 of 5 sampled staff completed two-step tuberculosis skin testing within required timeframes, placing 35 residents at risk. |
Report Facts
Residents present during inspection: 35
Sampled residents for review: 7
Sampled staff for CE review: 5
Sampled staff for TB testing review: 5
Hours of approved CE missing: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Nursing Assistant, Certified (NA-C) | Named in deficiency related to missing continuing education credits |
| Staff A | Caregiver | Named in deficiency related to tuberculosis skin testing |
| Staff B | Dining Room Server | Named in deficiency related to tuberculosis skin testing |
| Staff F | General Manager | Interviewed regarding tuberculosis testing records and scheduling difficulties |
| Staff G | General Manager in-Training | Interviewed regarding tuberculosis testing records and scheduling difficulties |
Inspection Report
Enforcement
Census: 36
Deficiencies: 1
Jan 24, 2024
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Merrill Gardens at The University to assess compliance with fire and life safety regulations, resulting in the imposition of a civil fine.
Findings
The facility failed their fourth follow-up Fire and Life Safety Inspection, placing 36 residents, staff, and visitors at risk. This deficiency was previously cited and remains uncorrected.
Deficiencies (1)
| Description |
|---|
| Failure to ensure compliance with the Washington State Patrol Office of State Fire Marshal during the fourth follow-up Fire and Life Safety Inspection. |
Report Facts
Civil fine amount: 1000
Residents/staff/visitors at risk: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter regarding the civil fine. |
| Jamie Singer | Field Manager | Contact person for the plan of correction and appeals process. |
Inspection Report
Life Safety
Deficiencies: 19
Apr 27, 2023
Visit Reason
The inspection was conducted by the Office of the State Fire Marshal to assess compliance with fire safety, fire alarm, sprinkler system, and related life safety codes at the Merrill Gardens at the University residential care facility.
Findings
The facility was found to be unable to provide documentation for multiple required fire safety inspections and maintenance activities, including annual fire wall inspections, sprinkler system testing, fire alarm system testing, smoke alarm testing, fire door inspections, emergency lighting tests, and carbon monoxide detector testing. Several fire safety equipment and systems were noted to be in disrepair or not functioning properly.
Deficiencies (19)
| Description |
|---|
| Facility is unable to provide documentation for the 4 year fire and smoke damper inspection. |
| Facility was unable to provide documentation that the Fire Department Connection has been hydrostatically tested in accordance with NFPA 25. |
| Facility is unable to provide documentation that the annual fire wall inspection has been completed. |
| Facility is unable to provide documentation for the annual fire alarm system testing. |
| Facility is unable to provide documentation for the monthly single station smoke alarm testing. |
| Facility is unable to provide documentation for the 5 year internal piping inspection of the sprinkler system. |
| Facility is unable to provide documentation for the 3 year dry system full flow trip test. |
| Facility is unable to provide documentation for the quarterly sprinkler system inspections. |
| Facility is unable to provide documentation for the semi-annual hood cleaning. |
| Facility is unable to provide documentation for the semi-annual kitchen suppression system servicing. |
| Facility is unable to provide documentation for the monthly carbon monoxide detector testing. |
| Facility is unable to provide documentation for the monthly 30 second activation test for the emergency lights. |
| Facility is unable to provide documentation for the annual 90 minute power test for the emergency lights. |
| The main fire alarm panel is in trouble state and needs to be repaired. |
| Assisted living office fire door has a prop and disabled latch mechanism; door to employee lounge is propped open; corridor fire door by room 419 is not closing properly. |
| Electrical room on parking level has large amounts of storage blocking the electrical panel. |
| Facility cannot provide documentation for twelve planned and unannounced fire drills in the previous 12 months. |
| Extension cords without overcurrent protection found in first floor activity room; cords cannot be daisy chained. |
| Facility is unable to provide documentation for the emergency evacuation/lockdown plan. |
Report Facts
Inspection date: Apr 27, 2023
Next inspection scheduled on or after: May 27, 2023
Fire Department Connection hydrostatic test pressure: 150
Fire Department Connection hydrostatic test duration: 2
Emergency lighting test duration: 30
Annual emergency lighting power test duration: 90
Working space clearance dimensions: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charles W Hendrick | Maintenance Director | Signed as Owner or Authorized Representative on multiple inspection reports |
| Michael Sundholm | General Manager | Signed as Owner or Authorized Representative on inspection report dated 03/23/2023 |
| Arthur Jesse Ward | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal on multiple inspection reports |
Loading inspection reports...
