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This document was prepared by Residential Care Services for the Locator website.

Residential Care Services Investigation Summary Report

Provider/Facility: Sinclair Place (768930) Intake ID(s): 3630399

License/Cert. #: AL2187Investigator: Jones, Angela Region/Unit: RCS Region 3/Unit D Investigation

Date(s):03/13/201904/04/2019

through

Complainant Contact Date(s):Allegations:11- Quality of care and treatment: fall with injury09- Death General

Investigation Methods:Sample: Named and sample

residentObservations: General environment,

staff interacting withresidents, residentsinteracting withresidents, and staffproviding care andservices

Interviews: residents, nursing staff,facility staff andmembers not associatedwith the facility

Record Reviews: Named and sampleresident records, incidentreports, investigationreports, outside recordsand facility policy andsafety plan

Allegation Summary:Resident fell out of wheel chair striking his head. Resident was left in the wheel chair while not awake for a period of time priorto falling.

Unalleged Violation(s):See SOD 4/2/19

Yes No

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

Page 1 of 2This document was prepared by Residential Care Services for the Locator website.


The on-site investigation was conducted in relation to all allegations and/or incidents identified in the intakes. Based onobservation, interview and record review, failed facility practice was found on the original allegations and/or incidents during theinvestigation. Additional residents reviewed for care, services and safety had concerns and was cited. See Statement ofDeficiency dated 04/04/2019 for further information.





Date(s):03/13/201904/04/2019

through

Complainant Contact Date(s):Allegations:11- Quality of care and treatment: failure to monitor urine output


residentsObservations: General environment,


Interviews: residents, nursing staff,facility staff

Record Reviews: resident records, incidentreports, investigationreports, outside recordsand facility policy

Allegation Summary:Resident returned to facility with a time sensitive order that the facility failed to monitor for. Resident had to return to thehospital the next day for additional care.

Unalleged Violation(s):A deficiency not related to the original complaint was cited. See statement of deficiency dated 3/25/19 for further information.

Yes No

Conclusion /Action:



The on-site investigation was conducted in relation to all allegations and/or incidents identified in the intakes. Based onobservation, interview and record review, no failed facility practice was found on the original allegations and/or incidents duringthe investigation. Allegation not associated with the original complaint was cited. See Statement of Deficiency dated 04/04/2019



for further information.



Provider/Facility: Sinclair Place (768930) Intake ID(s): 3617632, 3618836


Date(s):02/27/201903/14/2019

through

Complainant Contact Date(s):Allegations:Quality of care ant treatment- low staffing and residents not receiving care and services

Investigation Methods:Sample: Residents Observations: General environment,

staff interacting withresidents, residentsinteracting withresidents, and staffproviding care andservices. Medicationsystem

Interviews: Residents, staff andothers not associatedwith the facility.

Record Reviews: Resident records, staffschedules and facilitypolicy

Allegation Summary:Residents were not receiving medication assistance per standards.

Unalleged Violation(s): Yes No

Conclusion /Action:



The on-site investigation was conducted in relation to all allegations and/or incidents identified in the intakes. Based onobservation, interview and record review, failed facility practice was found on the original allegations and/or incidents during theinvestigation. Additional residents reviewed for care, services and safety had concerns and was cited.


Residential Care ServicesInvestigation Summary Report



Date(s):02/27/201903/14/2019

through

Complainant Contact Date(s):Allegations:11- Quality of care and treatment- fall with injury, passed away


residentsObservations: General environment,


Interviews: Residents, staff and othernot associated with thefacility

Record Reviews: Resident records,incident and investigationreports, hospital recordsand facility policy.

Allegation Summary:Resident fell, sustaining an injury and was sent to the local hospital. Resident passed away from cardiac complications whichmay have contributed to the initial fall.

Unalleged Violation(s):Medication system

Yes No

Conclusion /Action:



The on-site investigation was conducted in relation to all allegations and/or incidents identified in the intakes. Based onobservation, interview and record review, no failed facility practice was found on the original allegations and/or incidents duringthe investigation. Additional residents reviewed for care, services and safety had no concerns.





Date(s):02/27/201903/14/2019

through

Complainant Contact Date(s):Allegations:11- Quality of Care and Treatment- fall with injury

Investigation Methods:Sample: Named resident and

sampled residentsObservations: General environment,


Interviews: Named resident,residents, nursing staff,facility staff and amember not associatedwith the facility

Record Reviews: Named and sampleresident records, incidentreports, investigationreports, outside recordsand facility policy

Allegation Summary:Resident was assessed to be independent with most aspects of activities of daily living, including ambulation. Resident fell ontoa knee, splitting open the skin. Resident was treated and returned to the facility. Resident did not have a pattern of falls.

Unalleged Violation(s):Medication system

Yes No

Conclusion /Action:



The on-site investigation was conducted in relation to all allegations and/or incidents identified in the intakes. Based onobservation, interview and record review, no failed facility practice was found on the original allegations and/or incidents during



the investigation. Additional residents reviewed for care, services and safety had no concerns.




License/Cert. #: AL2187Investigator: Wabinga, Jutta Region/Unit: RCS Region 3/Unit D Investigation

Date(s):11/29/201812/03/2018

through

Complainant Contact Date(s):Allegations:Quality of Care/Treatment

Investigation Methods:Sample: Named resident and two

current sampledresidents.

Observations: Residents, environment,and staff interacting withresidents, staff membersproviding care andservices.

Interviews: Named resident, otherresidents, staff members,administrative staff, andpersons not associatedwith the facility.

Record Reviews: Sampled residents andincident reports.

Allegation Summary:Concern for frequent staff turn over, alleged no nurse on staff,cost increase for personal care, lack of environmental upkeep.

Unalleged Violation(s):An on-site investigation was conducted and allegations identified in the intake related to lack of nursing staff, frequent staff turnover, increase of cost for care and services, and environmental upkeep were reviewed. The facility failed to update thenegotiated service agreement in a timely manner consistent with the needs of the resident following changes in the resident'sskin status. The facility failed to submit requested documentation during the complaint investigation, and failed to investigateaccidents and incidents.

Yes No

Conclusion /Action:



WAC 388-78A-2700 2 ci ciiiPage 1 of 2This document was prepared by Residential Care Services for the Locator website.


WAC 388-78A-3140 2WAC 388-78A-2140 1iii



Provider/Facility: Sinclair Place (768930) Intake ID(s): 3552623, 3560818, 3560925

License/Cert. #: AL2187Investigator: Pham, Phan Region/Unit: RCS Region 3/Unit D Investigation

Date(s):08/29/201809/13/2018

through

Complainant Contact Date(s):Allegations:Allegations of misappropriation of property.

Investigation Methods:Sample: Named residents and

three additionalresidents.

Observations: Named residents,residents, environment,staff interactions withresidents, staff membersproviding care andservices and safetymeasures.

Interviews: Named residents,residents, staff members,administrative andmembers associated withthe facility.


Allegation Summary:An on-site investigation was conducted and allegations identified in the intakes related to misappropriation of property, care andservices were reviewed. 1) The facility failed to complete a thorough investigation for an allegation of missing money for oneresident and failed to timely investigate allegations of misappropriation of personal property for two residents. 2) The facilityfailed to meet training and reporting requirements regarding financial exploitation in accordance with RCW 74.34.220(1). 3) Thefacility failed to timely report allegations of misappropriation of property to the departments Aging and Disability ServicesAdministration Complaint Resolution Unit hotline consistent with chapter 74.34 RCW as required by mandatory reporters.Additional residents reviewed for misappropriation of property, care, services and safety had no concerns.




Conclusion /Action:



1) WAC 388-78A-2630(1)(a) reporting,2) WAC 388-78A-2600(2)(a), RCW 74.34.220(1) financial exploitation training and reporting3)WAC 388-78A-2700(2)(c)(i)(ii)(iii) safety measures



Provider/Facility: Sinclair Place (768930) Intake ID(s): 3545969, 3546016, 3550954, 3551582


Date(s):08/09/201808/10/2018

through

Complainant Contact Date(s):Allegations:Allegations of misappropriation of property, residents waited up to one hour for meals, medication services, housekeeping notdone regularly, dietary services, infection control, quality of care and quality of life.

Investigation Methods:Sample: Named residents and

seven current sampledresidents.

Observations: Named residents,residents, environment,staff interactions withresidents, staff membersproviding care andservices and safetymeasures.

Interviews: Named residents,residents, staff members,administrative andmembers not associatedwith the facility.


Allegation Summary:An on-site investigation was conducted and allegations identified in the intakes related to misappropriation of property,insufficient staffing, infection control practices, dietary services, medication services, quality of care and quality of life werereviewed. The facility failed to 1) Ensure a staff member followed professional and the Assisted Living Facility's standards ofpractice for medication administration, 2) Ensure dietary staff implemented cold food holding temperature to less or equal to 41degrees Fahrenheit, 3) Ensure prompt efforts provided to resolve grievances to ensure residents did not wait up to an hour to beserved their meals. Additional residents reviewed for care, services, misappropriation of property and safety had no concerns.




Conclusion /Action:



WAC 388-78A-2210(1)(b) Medication services.WAC 246-215-03525(1)(b) Temperature control Potentially hazardous food.RCW 70.129.060(2) Grievances.


Completion DateLicense #: 2187

August 10, 2018

1Page 5of

Sinclair Place

Statement of Deficiencies

Plan of Correction

STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICES

AGING AND LONG-TERM SUPPORT ADMINISTRATIONPO Box 45819, Olympia, WA 98504

Licensee: Prairie Springs Aid Opco LLC

From:

DSHS, Aging and Long-Term Support Administration

Residential Care Services, Region 3, Unit D

PO Box 45819

Olympia, WA 98504

(360)664-8421

As a result of the on-site complaint investigation the department found that you are not in

compliance with the licensing laws and regulations as stated in the cited deficiencies in the

enclosed report.

You are required to be in compliance at all times with all licensing laws and regulations to

maintain your assisted living facility license.

Phan Pham, RN, Nurse Surveyor

I understand that to maintain an assisted living facility license I must be in compliance with all

the licensing laws and regulations at all times.

This document references the following complaint numbers: 3545969 , 3546016 ,

3550954 , 3551582

The department staff that inspected and investigated the assisted living facility:

The department has completed data collection for the unannounced on-site complaint

investigation on 8/9/2018 and 8/10/2018 of:

Sinclair Place

680 W Prairie St

Sequim, WA 98382

The following sample was selected for review during the unannounced on-site complaint

investigation : 9 of 49 current residents and 0 former residents.

Residential Care Services Date

DateAdministrator (or Representative)



August 10, 2018

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Sinclair Place


Plan of Correction


WAC 388-78A-2210 Medication services.

(1) An assisted living facility providing medication service, either directly or indirectly, must:

(b) Develop and implement systems that support and promote safe medication service for each

resident.

Based on observation, interview and record review, the facility failed to ensure a staff member

(MA A) followed professional and the Assisted Living Facility's standards of practice for

medication administration. The staff member pre-poured medications into medication cups and

stored the medications in the medication carts. The staff member also signed the medication

administration records when the medications had not been given for 17 residents. These failures

placed the residents at risk for experiencing health complications related to medication errors.

Findings include:

The facility's Medication Pass Competency Checklist stated:

Not to pre-pour medications and to complete medication administration record (MAR) after

passing medications.

On 08/09/18 at 4:30 p.m., Medication Aide (MA) A was observed removing a cup of

medications from a medication cart and brought the medications to Resident # 1.

There were medications cups stacked on top of one another in a medication cart. Medications

had been removed from the original packaging and placed into the cups. The cups were labeled

with initials and numbers.

At 4:40 p.m., there were medication cups contained medications had removed from the original

medication packages observed stacked in the medication carts. The cups labeled with initials

and numbers.

At 4:45 p.m., the Corporate Nurse (CN) as asked to look at the medications in the medication

cart and the CN said she observed 17 cups of medications that had been pre-poured. The CN

stated the medication cups were labeled with the residents' initials and room numbers.

Review of record revealed MA A had initialed in the MARs the evening and bedtime

medications as administered for 08/09/18.

At 4:57 p.m., MA A said he pre-poured the evening and bedtime medications that were

scheduled for 08/09/18 and signed the MARs. MA A stated he placed the residents' medications

in the medication cups, labeled the cups with the residents' initials, room numbers and locked

them in the medication carts. MA A stated he had been trained to sign the MARs after he

administered the medications and that pre-pouring was not a preferred practice.

At 5:10 p.m., the CN said MA A pre-poured the residents' medications and signed the MARs as

the medications had been administered. The CN stated staff members were trained not to pre-

pour medications and sign the MARs after administering the medications. The CN said the

Registered Nurse or the Executive Director was responsible for monitoring and observing staff

administer medications to ensure standards of practice were being followed.

This requirement was not met as evidenced by:



August 10, 2018

3Page 5of

Sinclair Place


Plan of Correction


Plan/Attestation Statement

I hereby certify that I have reviewed this report and have taken or will take active

measures to correct this deficiency. By taking this action, Sinclair Place is or will be

in compliance with this law and / or regulation on (Date)________________ . In

addition, I will implement a system to monitor and ensure continued compliance with

this requirement.

I understand that to maintain an assisted living facility license, the facility must be in

compliance with the licensing laws and regulations at all times.

Administrator (or Representative) Date

WAC 246-215-03525 Temperature and time control -- Potentially hazardous food, hot and

cold holding (2009 FDA Food Code 3-501.16).(1) Except during active preparation for up to two hours, cooking, or cooling or when time is

used as the public health control as specified under WAC 246-215-03530 , and except as

specified in subsections (2) and (3) of this section, POTENTIALLY HAZARDOUS FOOD must

be maintained:(b) At 41 F (5 C) or less.

Based on observation and interview, the facility failed to ensure dietary staff implemented cold

food holding temperature to less or equal to 41 degrees Fahrenheit (F). This failure placed the

residents risk for contracting food borne illness.

Findings include:

On 08/09/18 at 5:30 p.m., two meat sandwiches and six bowls of cottage cheese observed on the

table in the kitchen.

At 5:56 p.m., a staff member prepared to deliver a sandwich and a bowl of cottage cheese to

Resident # 2.

At 5:58 p.m., Chef D was asked to measure the temperature of Resident # 2's sandwich and the

cottage cheese. Chef D measured the temperatures and said the roast beef sandwich was 73

degrees F and the cottage cheese was 63 degrees F. Chef D said she was new and not familiar

with the cold food temperature requirements.

On 08/10/18 at 12:15 p.m., during lunch, two meat sandwiches were seen on plates ready for

serving and two potato salad bowls on the cart in the kitchen.




August 10, 2018

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Sinclair Place


Plan of Correction


At 12:25 p.m., Chef C was asked to measure the temperature of a sandwich and a potato salad

bowl. Chef C measured the temperatures and said the turkey sandwich was 66 degrees F and the

potato salad was 74 degrees F.

At 12:50 p.m., Chef C stated he tried to keep cold food temperature below 40 degrees F. Chef C

said it was his responsibility to maintain cold foods at the proper temperatures.






this requirement.




WAC 388-78A-2660 Resident rights. The assisted living facility must:

(1) Comply with chapter 70.129 RCW, Long-term care resident rights;

RCW 70.129-060 Grievances. A resident has the right to:

(2) Prompt efforts by the facility to resolve grievances the resident may have, including those

with respect to the behavior of other residents.

Based on observation and interview, the facility failed to ensure prompt efforts provided to

resolve insufficient staffing to ensure residents did not wait up to an hour to be served and

provided adequate time for residents to consume their meals for five sampled residents

(Residents #4, #5, 6, 7 & 8). These failures placed the residents at risk for experiencing distress

and decreased their quality of life.

Findings include:

On 08/09/18 at 5:43 p.m., Resident # 4 was in the dining room eating. Resident # 4 said she

waited since five o'clock for her meal and it "bothered" her.

At 5:43 p.m., Resident # 5 shared a table with three other residents. Resident # 5 said mealtime

was at 5:00 p.m. and his table had not received their meals. The resident said, "I don't like it."

Staff members served Resident # 5's table at 5:50 p.m.




August 10, 2018

5Page 5of

Sinclair Place


Plan of Correction


At 5:46 p.m., Resident # 6 and Resident # 8 shared a table with two other residents. Resident #

6 said he waited over 40 minutes and that was "way too long." Resident # 8 said he waits over

40 minutes every meal. Resident # 8 stated residents had spoken with facility management

about the long wait, but nothing happened. Staff members served Resident # 6's and Resident #

8's table at 5:52 p.m.

At 5:47 p.m., Resident # 7 said he waited almost one hour for his meal and that was his normal

wait time. Resident # 7 said other residents ate and left the dining room by the time he received

his plate. The resident said he has left the dining room without eating because he had waited too

long. A Staff member delivered a plate of food to Resident # 7 at 5:54 p.m.

At 6:07 p.m., Chef D said she tried to get the residents served within 30 minutes.

On 08/10/18 at 12:30 p.m., the Corporate Nurse said staff members were responsible for meeting

the resident needs and ensuring residents did not wait up to one hour for meals.






this requirement.






Provider/Facility: Sinclair Place (768930) Intake ID(s): 3538895, 3538972, 3539527, 3541462


Date(s):07/12/201807/17/2018

through

Complainant Contact Date(s):Allegations:The facility did not have adequate staff to provide care and services for residents.Unqualified staff were administering medications to residents.


three current sampledresidents.

Observations: Named resident,residents, environment,staff interactions withresidents, staff membersproviding care andservices and safetymeasures.

Interviews: Named resident,residents, staff members,administrative and amember not associatedwith the facility.


Allegation Summary:An on-site investigation was conducted and allegations identified in the intakes related to unqualified staff and medicationservices were reviewed. The Assisted Living Facility failed to ensure qualified staff were available to provide medication servicesin a timely manner and failed to ensure care and services were provided timely to maintain resident dignity. Additional residentsreviewed for care, services and safety had no concerns.


Conclusion /Action:





RCW 70.129.140(1) QOL-rightsWAC 388-78A-2210(2) Medication services



Provider/Facility: Sinclair Place (768930) Intake ID(s): 3534450, 3536251


Date(s):07/05/201807/05/2018

through

Complainant Contact Date(s):Allegations:Allegations of misappropriation of property, inadequate staffing and quality of care.


seven current sampledresidents.

Observations: Named resident,residents, environment,staff interactions withresidents, staff membersproviding care andservices and safetymeasures.

Interviews: Named resident,residents, staff members,administrative and amember not associatedwith the facility.


Allegation Summary:An on-site investigation was conducted and allegations identified in the intakes related to misappropriation of property,inadequate staffing, and quality of care/services were reviewed. The facility failed to provide housekeeping in the residentspersonal quarters and laundry services as scheduled. Additional residents reviewed for care, services and safety had noconcerns.


Conclusion /Action:





See WAC 388-78A-2170-2-b.



Provider/Facility: Sinclair Place (768930) Intake ID(s): 3527412, 3529892, 3532832


Date(s):06/19/201806/19/2018

through

Complainant Contact Date(s):Allegations:Allegations of misappropriation of property, injury of unknown origin, quality of care and dietary services.

Investigation Methods:Sample: Named residents and four

current sampledresidents.

Observations: Named residents,residents, environment,staff interactions withresidents, staff membersproviding care andservices, dietary services,and safety measures.

Interviews: Named residents,residents, andinterdisciplinary teammembers.


Allegation Summary:An on-site investigation was conducted and allegations identified in the intakes related to fall with injury, injury of unknownorigin, misappropriation of property, and dietary services were reviewed. The facility failed to provide sufficient staffing toensure residents did not wait up to an hour to be serve and provided adequate time for residents to consume their meals.Additional residents reviewed for care, services and safety had no concerns.


Conclusion /Action:



WAC 388-78A-2300(1)(b) Food and Nutritional Services


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