West Oak Village (2370 Third Line, Oakville) is operated by Extendicare, a for-profit operator of long-term care homes in Canada. There are approximately 130 beds in private, semi-private and shared rooms.
West Oak Village is formerly owned and operated by Revera.
Inspection Reports for West Oak Village
Our research team at Caring Magazine carefully reviewed and summarized inspection reports for West Oak Village You can read the original copies of the reports in the Government of Ontario website.
🔍 October 2023: Inspection
The inspection report for West Oak Village, conducted by Indiana Dixon, Meghan Redfearn and Colleen Lewis, presents non-compliance issues in the facility.
- Plan of Care: The licensee failed to update a resident’s care plan when their care needs changed. This was highlighted by a critical incident report of an unwitnessed fall of a resident, resulting in a hip fracture. A review revealed that falls prevention interventions in the resident’s care plan weren’t reviewed or revised until after a second unwitnessed fall occurred. This oversight increased the risk to the resident.
- Duty of Licensee to Comply with Plan: The licensee failed to ensure that an intervention, as specified in a resident’s care plan, was in place. This was observed on two separate dates where the required intervention was absent, posing a moderate safety risk to the resident. However, the intervention was later observed to be in place.
🔍 July 2023: Inspection
The inspection report for West Oak Village, led by Sydney Withers, focused on a complaint concerning cleanliness, kitchen supplies, staffing, and laundry services.
- Cooling Requirements: The facility failed to effectively communicate its heat-related illness prevention and management plan, lacking two of four required components. The Executive Director (ED) acknowledged this deficiency.
- Air Conditioning Requirements: Non-compliance was noted in maintaining air conditioning in good working order. Specifically, temperatures in a resident dining room were recorded above the specified range of 22 to 26 degrees Celsius, reaching up to 27 degrees or higher on several days. This was attributed to malfunctioning rooftop units, with repairs pending.
- Air Temperature: There were gaps in the required thrice-daily documentation of air temperatures in designated cooling areas (DCAs), increasing risks of unaddressed uncomfortable conditions for residents.
- Laundry Service: The inspection revealed a failure in maintaining linens in good repair and free from stains, with observations of torn and stained sheets in storage areas and resident rooms.
🔍 June 2023: Inspection
The inspection report for West Oak Village details a follow-up inspection led by Daria Trzos. The inspection focused on various critical incidents and compliance orders.
- Implementation of Policy: The facility failed to implement a skin and wound procedure for a resident with altered skin integrity. This failure to follow protocol may have increased the risk of negative outcomes for the resident.
- Plan of Care: There was a failure to adhere to the specified plan of care regarding incontinent products for a resident. This non-compliance posed a risk of negative outcomes for the resident.
- Duty to Protect: The facility did not protect a resident from abuse, as evidenced by an incident during care provision resulting in altered skin integrity. This breach indicates a failure in safeguarding residents from potential abuse.
- Policy to Promote Zero Tolerance: Staff did not comply with the LTC-Resident Non-Abuse program’s STOP approach during resident care, resulting in the resident sustaining altered skin integrity. This non-compliance increased the risk of negative outcomes for the resident.
- Training: Only 50% of direct care providers received training in skin and wound care in 2022. This lack of comprehensive training poses risks to residents due to potential staff unfamiliarity with procedures for managing altered skin integrity.
🔍 April 2023: Inspection
The inspection for West Oak Village was led by Olive Nenzeko, addressing various intakes related to abuse and neglect prevention, falls prevention, and prior compliance orders.
- Infection Prevention and Control: An issue regarding infection prevention and control was resolved during the inspection. Incorrect signage for droplet contact precautions was posted on a resident’s room. The IPAC Lead corrected this by replacing it with appropriate signage. There was no risk to the resident as the original signage exceeded necessary precautions.
- Late Reporting: The facility failed to report an incident within one business day after a resident’s fall, which resulted in a significant change in their health condition and hospitalization. The report to the Ministry was delayed by seven days, though no risk was associated with this delay.
- Duty to Protect: The facility did not protect a resident from neglect by staff. A resident’s plan of care included specific interventions for responsive behaviors, which were not implemented at the time of a fall. This neglect was admitted by a staff member and confirmed as such by the Executive Director.
A compliance order was issued to West Oak Village to ensure strategies for managing responsive behaviors are developed and implemented. This includes re-educating staff, auditing the implementation of the resident’s care plan, and maintaining records of this education. The failure to manage a resident’s responsive behaviors may have contributed to a fall and subsequent injury.
🔍 December 2022: Inspection
The inspection report focuses on a follow-up and critical incident inspection at West Oak Village. Daria Trzos addressed specific intakes and compliance orders, with a focus on falls prevention and management, infection prevention and control, and resident care and support services.
- Infection Prevention and Control: The facility rectified a non-compliance issue related to the Infection Prevention and Control Standard (IPAC). Originally, there was no signage indicating additional precautions at the entrance to a resident’s room, despite the presence of PPE. This was corrected by posting the appropriate signage.
- Abuse Prevention: The staff failed to comply with the LTC-Resident Non-Abuse Analysis and Education policy, specifically the STOP Abuse intervention. The policy’s STOP approach (Stop, Think of alternatives, Observe for triggers, Plan another approach) was not followed during resident care, confirmed by the Executive Director.
- Unsafe Positioning Technique: There was a failure to use safe positioning devices or techniques when assisting a resident, increasing the risk of injury. This contravened the home’s policy and resident care plan requirements.
A compliance order was issued due to the licensee’s failure to protect a resident from abuse by staff. Evidence suggested excessive force was used during care, resulting in resident injury and hospitalization. The order mandates training for all PSWs on the home’s abuse policy and safe use of slider sheets, with proper documentation of these trainings.
🔍 August 2022: Inspection
The inspection report for West Oak Village details a comprehensive review covering critical incidents, complaints, and follow-up inspections. Barbara Grohmann, along with Daria Trzos, conducted the inspection.
- COVID Signs: The facility addressed an issue where signs indicating “COVID positive” or “Symptomatic and Full PPE” disclosed residents’ medical information. The signs were replaced with less specific, color-coded signs without written information, resolving the privacy concern.
- Residents’ Bill of Rights Violation: A resident’s right to give or refuse consent to treatment was violated. A procedure was performed despite the resident’s initial refusal and subsequent discomfort, leading the resident to feel uncomfortable and distressed.
- Plan of Care Issues: The facility failed to provide clear directions in a resident’s plan of care regarding the care and storage of their denture, resulting in the denture being misplaced.
- Failure to Document Air Temperatures: The facility did not adequately document air temperatures, failing to record them on several occasions. This oversight could have hindered the initiation of the heat-related illness plan.
- General Requirements for Programs: A procedure performed on a resident was not documented, violating the home’s policy requiring documentation of all care changes or differences.
The inspector issued a compliance order due to the failure to follow a physician’s order for a sample collection, leading to an invasive procedure that distressed the resident. The order also highlighted a failure to adhere to the resident’s plan of care.
🔍 January 2022: Inspection
The inspection report for West Oak Village was conducted by Parminder Ghuman. The inspection was focused on a Critical Incident System inspection.
- Infection Prevention and Control: The inspection identified a failure in ensuring all staff participated in the IPAC program. Specific instances of non-compliance included staff not wearing appropriate Personal Protective Equipment (PPE) while entering rooms requiring Droplet/Contact Precautions and failing to encourage or assist residents with hand hygiene before and after meals.
- Plan of Care: There was a failure to provide care as outlined in the plan of care for a resident at high risk for falls. The resident was observed without a wheelchair alarm, as specified in their care plan, thus putting them at actual risk of falling.
The facility was ordered to provide re-training to Personal Support Workers (PSWs) on IPAC practices, specifically regarding the use of PPE. The facility was also required to conduct daily audits for PPE use and assistance with hand hygiene for residents, with records kept for review.