Garden City Manor: Reviews & Inspection Reports

Garden City Manor (168 Scott Street, St. Catherines) is operated by Extendicare, a for-profit operator of long-term care homes in Canada. There are approximately 200 beds in private, semi-private and shared rooms.

Garden City Manor is formerly owned and operated by Revera.

Inspection Reports for Garden City Manor

Our research team carefully reviewed and summarized inspection reports for Garden City Manor. You can read the original copies of the reports in the Government of Ontario website.

🔍 December 2023: Inspection

This inspection for Garden City Manor details a comprehensive investigation covering a range of critical incidents and complaints. The inspection team included Stephany Kulis and Jonathan Conti.

Staff Awareness of Resident Care Plans: The report notes the staff’s failure to be aware of a resident’s dietary requirements, leading to the resident receiving restricted food items. This oversight could cause discomfort to the resident.
Documentation and Plan of Care: There was a lack of proper documentation regarding the provision of care, specifically in relation to toileting schedules for a resident. This failure posed a risk that essential care might not have been provided.
Reporting of Incidents: The facility failed to report immediately to the Director regarding an alleged abuse incident involving a resident, leading to a risk of harm.
Equipment Maintenance: The report highlights a failure to maintain essential equipment, such as a fall prevention device for a high-risk resident, which increased the risk of injury.
Critical Incident Reporting: The facility did not inform the Director within the required timeframe about incidents involving missing controlled substances and a resident’s injury that led to a significant health condition change.
Emergency Drug Supply Management: Non-compliance was noted in managing the emergency drug supply, including failing to fax medication replacement forms daily, not having a pharmacist present for medication audits, and improper sign-out procedures for controlled substances.
Controlled Substance Audit: The facility failed to conduct monthly audits of controlled substance count sheets, leading to a lack of discrepancy identification and potential medication errors.

The facility was ordered to provide education on the resident’s plan of care, particularly regarding the use of a therapeutic device, and to develop a process to ensure its proper implementation.

🔍 November 2023: Inspection

This inspection for Garden City Manor focused on a series of critical incidents and complaints involving resident care and safety. The inspection team was led by Tracey Delisle and Stephanie Smith.

Plan of Care: The facility failed to update the plan of care with new interventions to mitigate falls and injuries from falls for a resident who had multiple falls since admission. This oversight resulted in a fall that caused injury and hospital transfer.
Duty to Protect: The licensee failed to protect a resident from physical abuse by another resident. An incident where a resident was injured by another resident using an assistive device was noted. Although actions were taken post-incident, the initial failure to prevent the abuse led to harm.
Reporting of Incidents: The facility did not immediately report a verbal threat incident between residents. The incident was reported four days late, contrary to the requirement for immediate reporting, potentially putting residents at risk of harm or abuse.
Pain Management: There was a failure to assess a resident’s pain using an appropriate pain screening tool when the resident complained of pain. This oversight led to delayed hospital transfer and risk of increased pain for the resident.
Responsive Behaviours: The facility did not consistently document a resident’s responses to interventions for responsive behaviours. This lack of documentation risked the effectiveness of interventions being unknown, potentially leading to continued or escalated responsive behaviours.
Reports Regarding Critical Incidents: A critical incident involving a resident’s fall was not reported to the Director, nor was an investigation conducted. This failure increased the risk of injury from falls due to a lack of immediate action and review.

🔍 August 2023: Inspection

During the course of this inspection, the inspector made relevant observations, reviewed records and conducted interviews, as applicable. There were no findings of non-compliance.

🔍 June 2023: Inspection

This inspection for Garden City Manor addressed several critical incidents and complaints related to resident care and facility management. The inspection team was led by Jennifer Allen.

Air Temperature Monitoring: There were seven instances where evening air temperature records were missing in four designated cooling areas between May 16 and 24, 2023. This failure to monitor temperatures posed a risk of exposing residents to uncomfortable or harmful temperature levels.
Pain Monitoring: The facility failed to complete a 72-hour pain monitoring for a resident who was transferred to the hospital due to significant injury and pain. This oversight contravened the home’s Pain Assessment and Management policy and potentially led to prolonged pain and inadequate interventions.
Plan of Care for Transferring Residents: A resident sustained a skin injury during a transfer due to unclear directions in the plan of care regarding transfer assistance requirements. The plan indicated medium fall risk but did not provide clear transfer instructions, leading to harm.
Reporting to the Director: The facility did not immediately report an incident of improper care, which contravened the Mandatory Reporting of Resident Abuse or Neglect Policy. The delay in reporting increased the risk to residents.
Foot Care Services: A resident did not receive adequate foot care services, including toenail cutting, which could impact comfort and lead to infection risks. This was a violation of the regulation requiring preventive and basic foot care services.
Transferring and Positioning: The facility was ordered to review and improve its transfer and lift policies and procedures, conduct audits, re-educate staff, and maintain records related to transferring and positioning techniques. This order was issued due to a failure in providing safe transfer assistance, resulting in a resident injury.

🔍 May 2023: Inspection

This inspection for Garden City Manor encompassed a range of issues including pain management, resident care, menu planning, abuse, housekeeping, and falls prevention. The inspection team included Nishy Francis and Karlee Zwierschke.

Furnishings Cleanliness: An issue with the cleanliness of a resident’s shared washroom was identified and remedied during the inspection. Housekeeping staff implemented a routine for more frequent checks.
Protection from Sexual Abuse: The facility failed to protect two residents from sexual abuse by another resident, despite both residents having moderate to severe cognitive impairments and an inability to consent.
Zero Tolerance Policy: The facility did not adhere to its policy on resident-to-resident abuse, specifically neglecting to conduct a skin assessment after an incident of inappropriate touching.
Abuse Investigation: The facility did not immediately investigate a witnessed incident of abuse as required by their own policy, which necessitates immediate and thorough internal investigation following such incidents.
Reporting Abuse to the Director: There was a delay in reporting an incident of inappropriate touching by a resident to the Director, contrary to the requirement of immediate reporting.
Responsive Behaviours Documentation: The facility failed to properly document assessments, interventions, and resident responses to interventions related to responsive behaviours, risking inadequate capture and analysis of these behaviours.

🔍 December 2022: Inspection

This inspection for Garden City Manor covered various aspects including a follow-up to a previous compliance order and complaints related to resident care and support services, as well as falls prevention and management. The inspection team included Erin Denton-O’Neill and Yuliya Fedotova.

Plan of Care – Mobility: The licensee failed to update a resident’s written plan of care concerning mobility interventions. Despite the physiotherapy assessment indicating the need for a wheelchair, the plan of care was not revised accordingly, leading to inconsistencies in the resident’s mobility support.
Plan of Care – Involving Resident’s Substitute Decision-Maker: The facility did not properly involve a resident’s substitute decision-maker (SDM) in the development and implementation of the resident’s plan of care. On multiple occasions, the SDM was not notified of the resident’s falls, hindering their ability to participate in care decisions.
Medication Management: There were instances where a resident did not receive their prescribed medication on the specified days, as confirmed by a physician. This non-compliance raised concerns about the effectiveness of symptom management for the resident.

🔍 February 2022: Complaints Inspection

The inspection for Garden City Manor addressed multiple concerns related to dining, continence care and bowel management, prevention of abuse and neglect, responsive behaviors, and other aspects of resident care. The inspection team included Lisa Bos.

Duty to Protect: The licensee failed to protect residents from physical abuse by other residents. This included incidents where residents sustained injuries due to altercations with other residents. The failure was acknowledged by the interim Director of Care.
Responsive Behavioural Huddle: It was noted that the registered staff did not complete the Responsive Behavioural Huddle as required when a resident demonstrated physical or verbally threatening behavior towards co-residents over a five-month period. This failure potentially put other residents at risk of abuse.
Protection from Physical Abuse: The licensee was ordered to ensure specific residents are protected from physical abuse by co-residents, to prevent certain residents from physically abusing co-residents, and to ensure staff complete the Responsive Behavioural Huddle for specific residents as per the home’s Responsive Behavioural Procedure.

🔍 February 2022: Critical Incident Inspection

The inspection for Garden City Manor was conducted by Lisa Bos, Aileen Graba, and Jennifer Allen. It was conducted concurrently with complaint inspection.

Plan of Care: The licensee failed to provide care as specified in the plan of care for falls prevention. A resident who required assistance to ambulate fell while using a mobility device because a PSW stepped away, resulting in injury.
Policy Compliance: There was a failure to comply with the home’s Falls Prevention and Injury Reduction policy and Health Records and Interdisciplinary Documentation policy. This included instances of inaccurate documentation of resident food and fluid intake and transferring a fallen resident before nursing assessment.
Responsive Behaviours Management: The licensee did not effectively manage a resident’s responsive behaviors, resulting in harm to co-residents. Despite documented instances of aggressive behaviors, no new interventions were implemented until after an incident where a co-resident was injured.
Infection Prevention and Control: There was a failure to ensure all staff participated in the infection prevention and control program. Observations showed residents were not offered hand hygiene assistance before and after meals, which could lead to ingestion of disease-causing organisms.

The licensee was requested to prepare written plans of correction for the identified non-compliances, aimed at ensuring compliance with relevant policies and procedures.