Newmarket Health Centre: Reviews & Inspection Reports

Newmarket Health Centre (194 Eagle St, Newmarket) is owned and operated by York Region. There are approximately 130 beds.

Newmarket Health Centre is acclaimed for its satellite image due to its uncanny resemblance to a naked man. From the air, the facility appears to be shaped like a spread-eagled man, complete with male genitals.

The building is made up of four wings, which extend from a central section. The western wings give the appearance of arms, while the wings in the east look like legs, complete with knees and feet.

There is also a small, square shaped section at the top of the “torso” that looks like a head, and a rectangular section that juts out between the “legs.”

Inspection Reports for Newmarket Health Centre

Our research team carefully reviewed and summarized inspection reports for Newmarket Health Centre. You can read the original copies of the reports in the Government of Ontario website.

December 2023

Eric Tang led the inspection at York Region Newmarket Health Centre. The inspection included both onsite visits from December 5-8 and 11-12, 2023, and offsite work on December 13, 2023.

The inspection addressed a variety of concerns including falls prevention, pain, skin and wound care, staff-to-resident abuse and neglect, and infection prevention and control.

Plan of Care Involvement: There was a failure to fully involve a resident and their designated family members in the implementation of the resident’s plan of care, particularly concerning a transfer technique that resulted in the resident exhibiting responsive behavior and sustaining injuries. The resident’s family was not contacted as required by the plan of care, leading to risks for the resident.
Responsive Behaviors: The inspection found that the care provided did not fully integrate the management of responsive behaviors, as required. Despite the resident exhibiting responsive behavior during a transfer, the process was not stopped, resulting in the resident sustaining an injury.
Policy on Zero Tolerance of Abuse and Neglect: The facility failed to ensure compliance with their policy on zero tolerance of abuse and neglect. In one case, a staff member delayed reporting alleged neglect and improper care by another staff member. In another case, allegations of neglect towards multiple residents were not immediately reported. These delays could potentially expose residents to further risk and harm.
Skin and Wound Care: The facility did not ensure weekly reassessments by registered nursing staff for a resident with altered skin integrity. The resident’s electronic health records showed incomplete assessment information, which could lead to inadequate communication about the resident’s condition and impact their care.

July 2023

The first of two inspections was carried out by Vernon Abellera and team at York Region Newmarket Health Centre, with the report issued on July 18, 2023.

This comprehensive inspection, covering both complaint and critical incident aspects, involved multiple intakes related to various care aspects such as abuse and neglect prevention, medication incidents, resident care, skin and wound care, environmental services, unexpected deaths, and falls with injury.

Police Notification: The licensee failed to immediately notify the appropriate police service of alleged abuse towards residents. This non-compliance was observed in two separate incidents involving personal support workers (PSWs). The lack of immediate police notification could potentially increase the risk of recurrence of such incidents.
Staff Records: The inspection revealed that records for certain staff members, including PSWs and registered nurses (RNs), were incomplete, lacking necessary police record checks under the Vulnerable Sector Screening (VSS). This oversight could expose residents to staff with unknown criminal backgrounds.
Duty to Protect: The licensee did not adequately protect a resident from neglect, as evidenced by a critical incident report where a resident was found in an unacceptable condition. The failure of PSWs to perform hourly checks and provide necessary care placed the resident’s health and wellbeing at risk.
Reporting to Director: There was a failure to report abuse and neglect to the Director immediately as required. This delay in reporting could have increased the risk of harm to the resident and impacted the Director’s response.
Residents’ Bill of Rights: The licensee failed to ensure a resident’s right to be treated with courtesy, respect, and dignity was upheld. This was highlighted in an incident where inappropriate comments were made about the resident’s weight, and the resident’s preferences for activities of daily living were disregarded.
Plan of Care: The licensee did not ensure that the care outlined in a resident’s plan was provided as specified. This was evident in the failure to conduct hourly checks and documentation by PSWs and RNs, jeopardizing the resident’s safety and well-being.
Skin and Wound Care: The licensee failed to reassess a resident’s altered skin integrity at least weekly as required, resulting in compromised and prolonged wound healing.
Transferring and Positioning Techniques: There was a failure to ensure safe transferring and positioning techniques were used when assisting a resident, as indicated by a PSW performing a transfer without the assistance of another staff member, contrary to policy.

In the second of two inspections, there were no findings of non-compliance.

May 2023

In an inspection at York Region Newmarket Health Centre, inspectors Laura Crocker and Vernon Abellera evaluated several critical aspects of resident care from April 25 to 27, 2023.

This inspection primarily focused on the management of falls and the effectiveness of resident care and support services.

Plan of Care: The inspection identified non-compliance in reassessing and revising the plan of care when there were changes in a resident’s responsive behaviors. A Critical Incident Report indicated that a resident was hospitalized due to an injury. However, it was found that the resident’s care plan did not reflect recent changes, including a room transfer necessitated by a reassessment of the resident’s needs. The nurse and the Associate Director of Care acknowledged this oversight. Fortunately, this failure to update the care plan did not place the resident at risk.
Reports re Critical Incidents: Another non-compliance issue was identified concerning the reporting of critical incidents. Specifically, the home failed to inform the Director within one business day about a resident’s hospital transfer due to a fall that caused injury and resulted in a significant change in health condition. Although the resident’s condition change was communicated internally the next day, the Critical Incident Report to the Director was delayed by two days. This deviation from the home’s policy on Mandatory and Critical Incident Reporting did not have an impact or risk to the resident’s health, safety, or quality of life.

February 2022

In an inspection at the York Region Newmarket Health Centre, inspectors Amandeep Bhela and Catherine Ochnik reviewed multiple aspects of resident care from January 24 to 27, 2022.

This inspection was primarily initiated due to complaints and focused on various protocols including infection prevention and control, prevention of abuse, neglect, and retaliation, as well as maintaining a safe and secure environment for residents.

Non-Compliance with Investigation and Response Requirements: The inspection identified a failure to promptly investigate alleged incidents of abuse of residents. For instance, resident #001 reported abuse by a staff member, and resident #002 reported feeling anxious and scared due to an incident at night. These incidents were not immediately investigated, and in some cases, the administration was unsure if any investigation had taken place at all.
Failure in Reporting to the Director: There was also a failure to report incidents of abuse to the Director as required. The incidents involving residents #001 and #002 were not immediately reported to the Director, which is a requirement under the Long-Term Care Homes Act.
Infection Prevention and Control Program Non-Compliance: Observations indicated inconsistencies in implementing infection control measures. For example, a housekeeper was observed not wearing appropriate PPE while cleaning in an area under droplet contact precautions. Similarly, residents were not provided hand hygiene prior to meal service, and there was an instance of a private companion not wearing required PPE. These findings highlight lapses in the consistent practice of infection control protocols, potentially increasing the risk of illness transmission within the facility.

March 2021

In an inspection carried out at the York Region Newmarket Health Centre, led by Inspector Saran Daniel-Dodd, a key area of focus was the maintenance of a safe and secure environment for residents.

This inspection, conducted from March 3 to March 8, 2021, specifically addressed concerns raised in Log #003634-21 related to the home’s safety and security protocols.

Failure to Maintain a Safe and Secure Environment: The inspection found that the facility did not fully ensure a safe and secure environment for its residents, a fundamental requirement under the Long-Term Care Homes Act, 2007. Specifically, the issue pertained to the COVID-19 testing protocols for staff. The inspection revealed that a staff member who missed a scheduled COVID-19 swabbing clinic was allowed to enter and work in the home without completing the required test. This lapse was confirmed in an interview with the Acting Director of Care (DOC #100).
Risk of COVID-19 Transmission: The oversight in testing procedures posed a significant risk of COVID-19 transmission within the facility. Given the vulnerability of long-term care home residents to the virus, such lapses in safety protocols are particularly concerning.
Compliance with Minister’s Directive: The home’s failure to adhere to the mandated COVID-19 testing protocols contravened the Minister’s directive regarding surveillance testing and access to long-term care homes, as updated on February 16, 2021.

As a response to these findings, the licensee was requested to prepare a voluntary plan of correction (VPC) to address and rectify the identified non-compliance.