Extendicare Laurier Manor (1715 Montreal Road, Gloucester) is operated by Extendicare, a for-profit operator of long-term care homes in Canada. There are approximately 240 beds in private, semi-private and shared rooms.
Inspection Reports for Extendicare Laurier Manor
Our research team at Caring Magazine carefully reviewed and summarized inspection reports for Extendicare Laurier Manor You can read the original copies of the reports in the Government of Ontario website.
🔍 November 2023: Inspection
This inspection report for Extendicare Laurier Manor, by Martin Orr, Saba Wardak and Gurpreet Gill, covered a range of complaints and critical incidents, including pest control, alleged resident-to-resident abuse, resident care and services issues, and a COVID-19 outbreak.
- Infection Prevention and Control: The licensee failed to ensure that staff followed the Infection Prevention and Control standard issued by the Director, particularly regarding hand hygiene as part of Routine Practices. During the inspection, several instances were observed where staff did not perform hand hygiene after assisting residents, which is critical to prevent disease transmission. These instances included not sanitizing hands after assisting a resident with a beverage, touching a resident’s used cup, and applying clothes protectors to multiple residents without hand hygiene before and after each interaction.
- Staff Training and Awareness: Staff interviews confirmed that they were aware of the hand hygiene protocols but failed to adhere to them in practice. This lapse indicates a gap in the implementation of training or oversight in following established protocols.
- Risk of Disease Transmission: The lack of proper hand hygiene practices among staff members increases the risk of disease transmission among residents and staff within the facility, which is especially concerning given the context of a COVID-19 outbreak.
🔍 September 22, 2023: Inspection
During the course of this inspection, the inspector(s) made relevant observations, reviewed records and conducted interviews, as applicable. There were no findings of non-compliance.
🔍 September 14, 2023: Inspection
This inspection for Extendicare Laurier Manor, by Margaret Beamish, Pamela Finnikin, and Saba Wardak, focuses addressed various critical incidents, including alleged staff-to-resident abuse, resident-to-resident abuse, a fall resulting in significant condition change, and issues of infection prevention and control, among others.
- ⚠️ Reporting Abuse to Director: The licensee failed to report suspicions of abuse immediately to the Director. In one case, allegations of verbal abuse towards a resident were not reported to the Director until a day after the staff were made aware. In another instance, incidents of alleged sexual abuse noted in a resident’s chart were not reported to the Director immediately, leading to a delay in the investigation.
- ⚠️ Notifying Police of Alleged Abuse: The licensee failed to ensure immediate notification of the appropriate police service in cases of alleged abuse. In one documented case, police were not notified on the day staff became aware of allegations of verbal abuse. This delay could potentially hinder the investigation process and put residents at risk of harm.
🔍 June 2023: Inspection
Conducted by Pamela Finnikin and Maryse Lapensee, the inspection for Extendicare Laurier Manor covered various critical incidents, including medication management, prevention of abuse and neglect, and alleged staff-to-resident abuse.
- ⚠️ Medication Management System: The licensee failed to comply with the Medication Management System policy, particularly in the management of insulin, narcotics, and controlled drugs. The policy required two nurses to count and sign off on narcotic and controlled substances every shift change. However, there was an incident where only one nurse counted a resident’s narcotic sheet, violating the policy.
- Documentation of Care Plan: The licensee did not document the provision of care as required in the resident’s plan of care. There was missing documentation for all interventions and tasks assigned on four evening shifts. This lack of documentation could lead to a lack of awareness among staff about the care provided to the resident.
- Falls Prevention and Management: The licensee failed to comply with the Falls Prevention and Management policy. A specific incident was noted where a resident was left on the floor for four and a half hours after a fall, contrary to the policy which requires staff to transfer the resident post-fall after assessment and approval by a nurse.
🔍 April 2023: Inspection
The inspection for Extendicare Laurier Manor, led by Severn Brown and Emily Prior, included a follow-up on a compliance order and addressed various complaints and critical incidents.
- ⚠️ Reporting Abuse to the Director: The licensee failed to immediately report an allegation of staff-to-resident abuse to the Director. A Registered Practical Nurse (RPN) received an abuse allegation from a family member but failed to inform the Director immediately, leading to a delay in reporting the incident.
- ⚠️ Safe Transferring Techniques: A Personal Support Worker (PSW) failed to use safe transferring techniques after a resident’s fall, contrary to the home’s Zero-Lift policy. The PSW manually lifted the resident, which is against the policy and could increase the risk of injury to the resident.
- Fall Prevention and Management: The licensee did not comply with its Falls Prevention and Management policy. A resident fell and was not assessed by a nurse before being moved, as required by the policy. This incident was not reported to a nurse immediately, and the resident was transferred back to bed without a prior assessment, leading to a delay in medical attention and an increased risk of further injury.
🔍 January 2023: Inspection
Led by Severn Brown, Karen Buness and Laurie Marshall, the inspection for Extendicare Laurier Manor covered physical altercation between residents, alleged neglect and abuse, complaints regarding food temperatures and resident feeding, medication reconciliation errors, and unwitnessed falls resulting in injury.
- ⚠️ Dining and Snack Service: The licensee failed to ensure food and fluids were served at a temperature that is both safe and palatable to residents. Complaints were made by a resident about the serving temperature of food, and subsequent interviews and reviews of council meeting minutes confirmed ongoing complaints regarding food temperatures.
- Skin and Wound Care: The licensee failed to ensure that a resident, upon return from the hospital, received a skin assessment by a registered nursing staff member. Interviews with nursing staff confirmed that a skin assessment was supposed to be performed and documented for every resident returning from the hospital, but no such documentation was found in the resident’s chart.
- Infection Prevention and Control: The licensee failed to implement standards or protocols issued by the Director with respect to infection prevention and control. Specifically, staff used branded Personal Care Wipes instead of alcohol-based hand sanitizer for resident hand hygiene, contradicting the home’s hand washing procedures and best practice recommendations.
The licensee was ordered to comply with written policies and protocols for the medication management system, specifically for medication reconciliation. This order followed an incident where two Registered Practical Nurses and a Registered Nurse did not follow the medication reconciliation policy, leading to the incorrect administration of a resident’s medication and subsequent hospital admission.
🔍 March 2022: Inspection
This inspection for Extendicare Laurier Manor was conducted by Gurpreet Gill and Amanda Nixon. The inspection investigated various critical incidents and complaints including alleged resident-to-resident sexual abuse, staff to resident abuse and neglect, medication incidents, and a choking incident resulting in harm to a resident.
- ⚠️ Plan of Care: The licensee failed to ensure a written plan of care for a resident that set out the planned care. Specifically, the resident’s plan of care did not include their socially inappropriate behavior or any interventions for staff on how to respond or manage this behavior. This omission posed a potential risk of harm to residents.
- Plan of Care Instructions: The plan of care for another resident included directions to staff to “monitor closely” due to swallowing and choking risks. However, the direction was not clear, as evidenced by staff interviews indicating uncertainty on how to implement this intervention. The inconsistency in monitoring residents with similar risk factors potentially increased the risk of harm.
The licensee was requested to prepare a written plan of correction to ensure there is a written plan of care for each resident, setting out clear directions to staff and others who provide direct care.