Sherwood Court Long Term Care Centre (300 Ravineview Drive, Maple) is operated by Extendicare, a for-profit operator of long-term care homes in Canada. There are approximately 100 beds in private, semi-private and shared rooms.
Sherwood Court is formerly owned and operated by Revera.
Inspection Reports for Sherwood Court
Our research team at Caring Magazine carefully reviewed and summarized inspection reports for Sherwood Court You can read the original copies of the reports in the Government of Ontario website.
🔍 July 2023: Inspection
The inspection for Sherwood Court was led by Jennifer Brown and Nicole Lemieux. This report was categorized as a response to complaints and critical incidents.
- Safe Transferring: Non-compliance was noted regarding safe transferring and positioning of a resident. A Critical Incident Report indicated that a resident was improperly transferred, leading to an upper body injury and identified fracture. The staff member involved in the transfer admitted to providing assistance but denied any incident leading to injury.
- Heat Related Illness Prevention: The facility failed to implement its heat-related illness prevention and management plan for a resident during a heat advisory day. This oversight resulted in the resident being hospitalized due to hyperthermia and dehydration.
- Medication Administration: A medication error occurred where a resident was administered medication without a doctor’s prescription for four days due to a transcription error. This posed a risk of adverse drug reaction for the resident.
🔍 August 2022: Inspection
The inspection for Sherwood Court was conducted by Amandeep Bhela and a team of additional inspectors. The inspection focused on various complaints ranging from staffing and infection prevention to neglect and falls.
- Monitoring During Meals: There was an instance where no registered staff was present in the dining area during breakfast, violating the requirement for staff to monitor residents during meals. The issue was resolved with staff education and adjustments in monitoring practices.
- Locked Doors: The inspection found that doors to the spa room and linen closets were not consistently locked when not in use, posing a safety risk to residents. This was addressed through staff education and reinforcing locking protocols.
- Compliance with Health Orders: There were instances of non-compliance with directives regarding mask usage during a COVID-19 outbreak, potentially risking the transmission of the virus within the facility.
- Clear Direction in Plan of Care: The report identified discrepancies in meal preparation instructions between different care plan systems, leading to potential risks in meeting a resident’s dietary needs.
- Pest Control: The facility had not adequately addressed pest control recommendations, increasing the risk of pest infestation.
- Cleanliness and Sanitation: There were concerns regarding the cleanliness of dining areas after meals, with food debris left on floors. This was addressed following a public health inspection.
- Air Conditioning in Resident Rooms: As of the inspection date, not all resident rooms were equipped with air conditioning as required, posing a risk during high temperatures.
🔍 April 2022: Complaints Inspection
The inspection at Sherwood Court, conducted by Jack Shi and Lucia Kwok, covered various aspects of care and operations.
- Infection Prevention and Control Audits: The facility failed to conduct required IPAC audits during and after an outbreak, which could impact the effectiveness of their infection control measures.
- Recreational and Social Activities Program: The inspection identified a failure to provide scheduled recreational activities, likely due to staff absences, impacting the quality of life for residents.
- Nutrition Care and Hydration Programs: There were discrepancies in implementing dietary interventions for a resident at nutrition risk, indicating potential risks to the resident’s nutritional status.
- Menu Planning: Complaints indicated failures to provide planned menu items at meals, affecting the nutritional needs and satisfaction of residents.
- Dining and Snack Service: Issues were noted with food and fluid temperatures and proper techniques for assisting residents with eating, posing potential health risks.
- Infection Prevention and Control Program: Observations revealed inconsistent IPAC practices among staff, including improper hand hygiene and face mask usage, increasing the risk of infectious agent transmission.
🔍 November 2021: Complaints Inspection
The inspection at Sherwood Court, conducted by Moses Neelam, was focused on addressing specific complaints.
The licensee did not ensure that care outlined in a resident’s plan of care was provided as specified. This related to a resident (Resident #001) who was supposed to receive care from female staff only but received care from a male staff member.
The previously issued orders were found to be in compliance at the time of this inspection.
🔍 November 2021: Critical Incident Inspection
The Critical Incident System inspection conducted at Sherwood Court by Moses Neelam and Amandeep Bhela, focused on incidents of alleged abuse leading to injury and other incidents leading to injury.
- Non-Compliance in Safe Transferring and Positioning Techniques: The licensee failed to ensure that Personal Support Worker (PSW) #113 used safe transferring and positioning techniques when assisting resident #007. A Critical Incident Report (CIR) related to an unknown injury did not conclusively determine whether the injury was due to the transfer. Interviews revealed that the use of the lift independently by PSW #113 was unsafe, putting the resident at risk of injury.
- Failure in Reporting Suspected Abuse: Registered Practical Nurse (RPN) #116 failed to immediately report suspected abuse of resident #007 that resulted in a risk of harm, as required. The CIR regarding an unknown injury was submitted late, indicating suspected abuse days prior to the report. The delay was acknowledged by the Assistant Director of Care (ADOC) #106.
Two Written Notifications (WNs) for non-compliance were issued. A Voluntary Plan of Correction (VPC) was requested to ensure compliance in safe transferring and positioning of residents.
🔍 July 2021: Complaints Inspection
During the course of this inspection, Non-Compliances were not issued.
🔍 July 2021: Critical Incident Inspection
The inspection for Sherwood Court was conducted by Romela Villaspir as part of a Critical Incident System inspection. It addresses multiple incidents and compliance issues within the facility.
- Neglect of Resident: The incident involved a fall of resident #001 resulting in injury and hospitalization. Agency PSW #111 and Agency RN #112 were specifically mentioned for neglecting the resident after the fall. The resident was found groaning and crying in discomfort after the fall, but the discomfort was neither assessed nor addressed appropriately. The RN did not conduct a proper post-fall assessment, failed to address the resident’s discomfort, and did not inform the physician about the fall. Additionally, the RN and PSW did not use a lift machine for transferring the resident from the floor, which is a standard safety protocol.
- Inadequate Care Plan Revision: Resident #002 had a history of falls, including an unwitnessed fall leading to injury and hospitalization. The care plan for this resident, particularly after previous falls, did not demonstrate consideration of different approaches to prevent future falls. The falls were primarily due to the resident’s responsive behaviors, yet no referral was made to Behavioural Support Ontario (BSO) for a more tailored approach. The report highlighted the risk associated with not revising the care plan to include different strategies to prevent falls.
- Failure in Air Temperature Monitoring: The facility did not measure and document air temperatures in at least two resident bedrooms, as required. Thermometers were found outside the resident rooms instead of inside, leading to inaccurate temperature readings. Proper documentation of air temperatures at different times of the day was not maintained, which is crucial to ensure a safe living environment for residents, particularly to prevent heat-related illnesses.
- Lack of Required Training for Agency PSW: Agency PSW #100 performed duties without receiving necessary training in areas mandated by the Long-Term Care Homes Act. The PSW did not adhere to appropriate Infection Prevention and Control (IPAC) practices, indicating a gap in training. The IPAC Manager was unable to provide evidence of the PSW having received the required training before starting their responsibilities in the home. This issue raises concerns about the potential risk to residents and staff due to inadequate training of personnel.
- Failure to Ensure a Safe and Secure Environment: This non-compliance relates to inadequate measures in maintaining a safe environment, particularly regarding Infection Prevention and Control (IPAC) and the proper use of Personal Protective Equipment (PPE). Essential Care Givers (ECGs) were observed not adhering to the home’s IPAC practices, potentially risking the transmission of infection. For instance, an ECG entered a room on droplet/contact precautions without adequate PPE.
- Falls Prevention Policy: The facility failed to comply with its “Fall Prevention and Injury Reduction Program” policy. After falls, specific assessments and follow-ups were not completed as required by the policy. This includes instances where post-fall assessments were either not done or not completed timely, potentially leading to missed injuries or inadequate care after a fall.
- Infection Prevention and Control Program Implementation: Staff at the facility failed to fully participate in the implementation of the home’s IPAC program. Observations included staff not adhering to IPAC practices, such as not performing hand hygiene, not changing masks, or not disinfecting face shields after exiting a resident’s room on droplet/contact precautions. Additionally, there was an instance where a resident’s room required additional precautions signage, which was not posted, leading to confusion about necessary precautions.
A compliance order was issued to mandate the licensee to submit and implement a plan ensuring that residents who sustain falls are not neglected. This plan must include specific steps for post-fall assessments, safe resident transfers, physician notifications, and record-keeping of all actions.
🔍 May 2021: Other Inspection
During the course of this inspection, Non-Compliances were not issued.