Carlingview Manor (2330 Carling Avenue, Ottawa) is operated by Extendicare, a for-profit operator of long-term care homes in Canada. There are approximately 300 beds in private, semi-private and shared rooms.
Carlingview Manor is formerly owned and operated by Revera.
Inspection Reports for Carlingview Manor
Our research team carefully reviewed and summarized inspection reports for Carlingview Manor. You can read the original copies of the reports in the Government of Ontario website.
🔍 December 2023: Inspection
The inspection for Carlingview Manor was completed by Dee Colborne and Saba.
- Plan of Care – Bariatric Bed: The licensee failed to provide a bariatric bed tailored to a resident’s needs. The resident required total assistance for repositioning in bed, which was challenging due to the inappropriateness of the bed. The resident’s care plan specified the need for repositioning every two hours, but due to the bed’s limitations, alternative methods were used to prevent skin breakdown.
- Plan of Care – Supervision: The licensee did not ensure the implementation of one-to-one observation as specified in a resident’s plan of care. This failure led to an incident where the resident, who was supposed to be under constant supervision, attempted to harm another resident. The assigned personal support assistant left the resident unattended a few minutes early, without waiting for their replacement.
🔍 October 2023: Inspection
The inspection for Carlingview Manor was completed by Dee Colborne and Laurie Marshall.
- Admission Authorization: The licensee failed to provide a written notice explaining the reasons for refusing a prospective resident’s admission. The Resident Services Coordinator (RSC) and Director of Care (DOC) confirmed that no refusal letter was issued to the applicant or their substitute decision maker (SDM).
- Transferring and Positioning Techniques: The licensee was ordered to ensure safe transfer and positioning techniques following an incident where a Personal Support Worker (PSW) inappropriately transferred a resident alone, resulting in a fall and significant injury. The resident’s care plan required two-person assistance. The licensee must conduct audits to ensure compliance with safe transfer techniques and document corrective actions.
🔍 August 2023: Inspection
The inspection for Carlingview Manor was led by Pamela Finnikin.
- Plan of Care – Documentation: The licensee failed to ensure clear and consistent documentation in the resident’s care plan. Specifically, the plan did not accurately reflect the resident’s right arm weakness due to a recent stroke, and the requirements for assistance in the kardex were inconsistent with the actual care needs.
- Plan of Care : There was a failure to provide care as specified in the resident’s plan of care, particularly regarding fall risk interventions and support needed for transfers and bed mobility. A Personal Support Worker (PSW) did not review the resident’s transfer status before providing care, and the resident was asked to stand up independently, which was against the care plan.
- Plan of Care: The inspection found that care provided to three residents (resident #001, #002, and #003) was not documented as required. This included multiple shifts where no documentation was completed, posing a risk as staff were unaware of the care provided.
🔍 May 2023: Inspection
The inspection for Carlingview Manor in Ottawa was led by Inspector Sarabjit Kaur.
- Plan of Care: The licensee failed to provide care as specified in the plan for resident #001. The plan of care required 1:1 monitoring to prevent inappropriate close contact with other residents. Despite this, resident #001 engaged in sexually inappropriate behavior with resident #002. This was the third such incident between these residents, indicating a pattern of behavior. The 1:1 assigned to resident #001 failed to fulfill their responsibility, resulting in moderate risk due to physical contact between the residents.
🔍 January 30, 2023: Inspection
The inspection for Carlingview Manor was conducted by Severn Brown, Laurie Marshall, Megan MacPhail, and Marko Punzalan.
- Transferring and Positioning Techniques: The licensee failed to ensure safe transferring techniques for a resident who required two-staff assistance for transfers. A Personal Support Worker (PSW) transferred the resident alone, resulting in the resident’s injury. The home’s investigation concluded that the transfer was unlikely to have caused the fracture, but the Safe Resident Handling policy required transfers according to the resident’s care plan.
- Use of Transferring and Positioning Devices: Two PSWs left a resident unattended on the toilet, attached to a transfer and positioning device, for an extended period. This action violated the policy stating that two staff must be present while the device is in operation and residents should not be left unattended.
- Report to the Director: The injury resulting from the improper transfer was not immediately reported to the Director, delaying potential intervention and response.
🔍 January 10, 2023: Inspection
The inspection for Carlingview Manor was conducted by Sarabjit Kaur and Erica McFadyen.
- Infection Prevention and Control: The licensee failed to comply with the requirement for hand hygiene agents to contain at least 70-90% alcohol. Certainty wipes used in the facility contained only 62% alcohol. This inadequate alcohol content in hand hygiene agents increases the risk of disease transmission among residents.
- Delay in Reporting Critical Incidents: The licensee did not inform the Director within one business day after an incident where a resident was injured, sent to the hospital, and experienced a significant change in health status. This delay meant the Director was not promptly informed of an incident within the home.
- Security of Drug Supply: The medication room on a specified floor was left unlocked with no registered staff present, posing a moderate risk as residents could access medications.
🔍 September 2022: Inspection
The inspection for Carlingview Manor was completed by Pamela Finnikin, Severn Brown and Marko Punzalan.
- Skin and Wound Assessment: The licensee failed to perform immediate skin assessments for residents #001 and #002 upon their return from the hospital. This oversight led to a delay in discovering and treating a new wound for resident #001, posing a moderate risk to the resident’s health.
- Dietitian Assessment: The licensee did not ensure that a registered dietitian completed assessments for residents #001 and #002 with altered skin integrity upon their return from hospital. The absence of dietitian consultation and assessment could have impacted the healing process for these residents, resulting in a moderate risk to their health.
🔍 January 2022: Inspection
During the course of this inspection, Non-Compliances were not issued.