Extendicare St. Catharines (283 Pelham Road, St. Catherines) is operated by Extendicare, a for-profit operator of long-term care homes in Canada. There are approximately 150 beds in private, semi-private and shared rooms.
Inspection Reports for Extendicare St. Catharines
Our research team at Caring Magazine carefully reviewed and summarized inspection reports for Extendicare St. Catharines. You can read the original copies of the reports in the Government of Ontario website.
🔍 December 2023: Inspection
The original inspection report can be read on the Government of Ontario website.
🔍 November 2023: Inspection
This inspection report for Extendicare St. Catharines, led by Emma Volpatti, Brittany Wood and others, addressed various complaints and critical incidents related to the prevention of abuse and neglect, falls prevention and management, and resident care and services.
- Plan of Care: Extendicare St. Catharines failed to provide clear directions to staff in the written plan of care for a resident, especially regarding medication administration and the use of a Personal Assistance Services Device (PASD). This lack of clarity in directives posed a risk of injury to the resident.
- Complaints Procedure: Extendicare St. Catharines did not forward a written complaint regarding the operation of the home to the Director as required.
- Reporting Abuse: Extendicare St. Catharines failed to report an incident of abuse between two residents that resulted in injury to both. This failure could have put the residents at further risk of harm or abuse.
- Restraining Techniques: A resident was restrained using a physical device contrary to their care plan, posing a risk of injury.
- Transferring and Positioning Techniques: Safe transferring techniques were not used when assisting a resident, leading to an unsafe transfer and potential risk of injury.
- Falls Prevention and Management: A post-fall assessment using a clinically appropriate assessment instrument was not conducted for a resident who had fallen, leading to potential undetected injuries.
- Responsive Behaviours: Extendicare St. Catharines failed to identify behavioral triggers for a resident with responsive behaviors in their care plan, increasing the risk of harm.
Compliance orders were issued to address failures in implementing physician’s orders and protecting residents from abuse. Extendicare St. Catharines is ordered to provide education to staff on relevant policies and maintain records of this training.
🔍 August 2023: Inspection
This inspection report for Extendicare St. Catharines, led by Adiilah Heenaye and Emily Robins, addressed a variety of issues, including unexpected resident death, alleged abuse, medication management, falls, and housekeeping services.
- Plan of Care: Extendicare St. Catharines failed to provide clear instructions in the written plan of care for a resident, particularly regarding medication administration, bathing schedules, and environment safety. This lack of clarity in the plan of care resulted in medication errors and increased risks for falls and potential injury.
- Abuse and Neglect Prevention: Extendicare St. Catharines failed to protect two residents from physical abuse and did not comply with their policy to promote zero tolerance of abuse and neglect.
- Staff Training: Extendicare St. Catharines did not ensure that agency staff received necessary training relevant to their responsibilities, especially regarding medication incidents.
- Oral Care: Extendicare St. Catharines failed to provide an oral health assessment and dental services for a resident, despite changes in their oral health status.
- Falls Prevention and Management: Extendicare St. Catharines did not follow their own policy regarding post-fall management procedures, putting a resident at risk of undiagnosed injuries from falls.
- Medication Management: Extendicare St. Catharines did not process physician orders within the required timeframe and failed to administer a resident’s medication as per the prescriber’s instructions, placing the resident at risk.
🔍 April 2023: Inspection
This inspection report for Extendicare St. Catharines, led by Jennifer Allen and Karlee Zwierschke, included a combination of complaint and critical incident inspections.
- Plan of Care: Extendicare St. Catharines failed to ensure that the care set out in a resident’s plan of care was based on the resident’s preferences, specifically relating to alcohol consumption. This was remedied by March 29, 2023.
- Resident’s Rights: Extendicare St. Catharines did not respect a resident’s right to timely medical care. A resident experienced pain and swelling, and there was a delay in diagnostic testing and treatment, leading to surgery.
- Plan of Care: Extendicare St. Catharines failed to provide clear directions for medication administration in the plan of care for a resident with unpredictable blood values, leading to confusion among staff and potential health risks for the resident.
- Minister’s Directives: Extendicare St. Catharines did not comply with two Minister’s Directives. One related to the reporting of glucagon use, and the other concerned proper masking protocols among staff in administrative areas.
- Falls Prevention and Management : Extendicare St. Catharines failed to follow their falls prevention and management program, specifically in conducting post-fall assessments and clinical monitoring, posing risks to residents.
- Pain Management: Extendicare St. Catharines did not follow their pain prevention and management program, especially in performing comprehensive pain assessments for new pain, which could lead to unmanaged pain for residents.
A Compliance Order was issued due to unsafe transferring and positioning techniques used by staff, and an Administrative Monetary Penalty of $1100.00 was levied for this non-compliance.
🔍 December 2022: Inspection
This inspection report for Extendicare St. Catharines, led by Barbara Grohmann and Cathy Fediash, encompassed both complaint and follow-up types.
- Plan of Care – Involvement of Residen: Extendicare St. Catharines failed to involve a resident’s substitute decision-maker in the development and implementation of the resident’s plan of care, particularly in relation to transportation needs. This oversight led to a missed medical procedure.
- Plan of Care: Nutrition interventions specified in a resident’s care plan were not provided during meals and snacks. This failure could impact the resident’s dietary goals and overall health.
- General Requirements for Programs: Extendicare St. Catharinesdid not consistently document interventions or actions taken under the nursing and personal support services program, particularly in bathing records for two residents, which could result in inconsistent care.
- Nutrition Care and Hydration Programs: Extendicare St. Catharines did not ensure food was served at safe and palatable temperatures and failed to document actions when temperatures were outside safe ranges. Additionally, there was a lack of consistent documentation for meal temperatures, which could risk serving food at unsafe temperatures.
- Obtaining and Keeping Drugs: Extendicare St. Catharines did not administer drugs to a resident as per the prescriber’s directions, and there was a lack of communication with the prescriber when the family or substitute decision-maker provided contrary directions. This could have affected the effectiveness of the medication and the resident’s health.
🔍 November 2021: Complaints Inspection
This inspection report for Extendicare St. Catharines, by inspectors Gillian Hunter and Aileen Graba, focused on a complaint.
- Failure to Investigate Allegations of Abuse: There were allegations of abuse by staff towards residents that were not immediately investigated. This lapse posed a risk of ongoing abuse and harm to residents.
- Failure to Report Abuse to the Director: Allegations of abuse were not reported promptly to the Director, contravening the requirements of the LTCHA. This delayed potential inquiries or inspections by the Director.
- Non-Compliance with Pain Management Policy: The home failed to comply with its own pain management policy, particularly in assessing and documenting residents’ pain, putting them at risk for inadequate pain management.
- Skin and Wound Care: The home did not conduct necessary skin assessments within 24 hours of a resident’s admission, increasing the risk for ineffective skin care interventions.
- Administration of Drugs: Medications were administered by unqualified personnel, contravening regulations and posing a risk for medication errors.
- Plan of Care Non-Compliance: The written plan of care for a resident did not adequately address pain management, leading to potential inadequate care.
- Failure in Sleep Pattern Assessment: The home did not assess a resident’s sleep patterns and preferences, which is essential for their overall well-being.
The inspectors issued several Compliance Orders (CO) and requested voluntary plans of correction (VPC) to address these issues.
🔍 November 2021: Critical Incident Inspection
This report details a critical incident system inspection at Extendicare St. Catharines, conducted by inspectors Gillian Hunter, Aileen Graba, and Cathy Fediash. The inspection was aimed at assessing various critical incidents reported at the facility.
The inspection identified a non-compliance issue concerning safe transferring and positioning of residents. A particular case was highlighted where a staff member provided care to a resident without proper assistance, leading to an injury. This incident highlighted a breach of the care plan which required assistance from two staff members for bed mobility.
A Compliance Order was issued to require Extendicare St. Catharines to ensure safe positioning techniques during resident care, especially for those at risk of falls. The order also mandated weekly audits to monitor the safety of resident positioning by the identified staff member.