Park Lane Terrace

Park Lane Terrace, located at, is operated by APANS Health Services. It has a capacity of approximately 130 beds.

Global News investigated the care and living conditions in April 2019, after a damning 172-page inspection report showed dozens of infractions, including abuse, medication errors and staffing shortages.

February 2023 🔎

Conducted over several days in late January and early February 2023, the inspection addressed multiple complaints and critical incidents, mainly concerning falls prevention, plan of care, skin and wound care, and the duty to protect residents. The lead inspector for this operation was Lisa Vink.

Key findings included instances where the care home did not fully comply with the Fixing Long-Term Care Act. Specific issues included failures in implementing and documenting care plans, especially in relation to mobility aids, skin integrity, and involving substitute decision-makers (SDMs) in care planning. There were also lapses in staff awareness and access to residents’ care plans, impacting the delivery of prescribed treatments.

The report highlighted several non-compliance issues, all of which were remedied by the licensee before the inspection concluded.

November 2022 🔎

The inspection, led by Nishy Francis with additional inspector Angela Finlay, took place from October 19 to November 1, 2022. It covered several complaints and follow-ups related to staffing, maintenance, skin and wound care, medication management, falls prevention, bowel and continence care, and prevention of abuse.

• Enhanced Cleaning Non-Compliance: The licensee failed to comply with the Minister’s Directive for enhanced environmental cleaning and disinfection during an outbreak.
• Plan of Care Non-Compliance: There was a failure in providing care as specified in a resident’s plan, particularly in notifying the physician about continence care findings.
• Emergency Reporting Non-Compliance: The licensee did not immediately inform the Director of an emergency involving an unplanned evacuation due to a gas smell.
• Continence Care Program Non-Compliance: The licensee failed to implement the continence care and bowel management program.
• Outbreak Reporting Non-Compliance: There was a failure to promptly inform the Director when an outbreak of a disease of public health significance was declared.
• Falls Prevention and Management Non-Compliance: The home did not fully implement its falls management program, including inadequate post-fall documentation and assessments.

October 2021 🚨

The inspection, conducted by Daria Trzos and Farah Khan, identified multiple instances of non-compliance.

• Failure to Protect Residents from Abuse: There was an incident where a resident was physically injured by another resident, indicating a failure to protect residents from abuse. The presence of a distracted contract worker who did not intervene in time aggravated the situation. This incident was acknowledged as abuse by the Director of Clinical Services (DOCS).
• Neglect of Residents: The staff neglected a resident by failing to communicate and document essential care tasks. Subsequent shifts were unaware of changes in the resident’s condition, leading to delayed medical attention and hospitalization. This pattern of inaction jeopardized the resident’s health and well-being.
• Non-Compliance with Care Plans: Security staff, responsible for managing residents with responsive behaviors, did not have access to individualized care plans. This lack of access increased the risk of harm to residents, as staff were unable to implement appropriate strategies to prevent physical aggression.
• Failure in Hand Hygiene Protocol: The home did not adequately implement a hand hygiene program before and after meals for residents, increasing the risk of disease transmission.
• Violation of Residents’ Rights: A staff member’s interaction with a resident was deemed disrespectful, violating the resident’s right to be treated with courtesy, respect, and dignity.
• Inadequate Policy Adherence: The home failed to comply with its own Bladder – Indwelling Catheter Care & Maintenance policy. This involved a resident readmitted with a medical device, where necessary monitoring and change of the device as per physician’s orders were not followed.
• Ineffective Management of Responsive Behaviours: The staff failed to implement strategies for a resident demonstrating responsive behaviors as per their care plan, especially during meal times.

July 2020 🚨

The Critical Incident System inspection, conducted on July 29, 2020, by Lesley Edwards and Jessica Paladino, revealed several areas of non-compliance.

• Accommodation Services: The licensee failed to keep the home, furnishings, and equipment clean and sanitary. Specific issues included unclean dining areas with food splashes, debris, dust, and cobwebs observed on multiple dates in July 2020. The Director of Environmental Services confirmed these cleanliness issues.
• Conditions of License: The licensee did not fully comply with a previous compliance order (CO #004) from November 2019. They failed to adequately implement a resident identification system for medication administration and did not complete required training for staff administering medications by the compliance due date.
• Plan of Care: There was a failure to ensure a written plan of care for each resident, specifically highlighted by the case of a resident at risk of falling. The resident’s plan of care did not include a specified intervention to mitigate this risk, confirmed through observations and staff interviews.

April 2020 🚨

The inspection report was completed by Michelle Warrener. This report was an amendment to an earlier inspection (2019_549107_0017) and included a Critical Incident System inspection.

• Non-Compliance in Safe Transferring and Positioning: The facility failed to ensure safe transferring and positioning of residents. Specifically, an incident involved a resident being transferred with a mechanical lift by only one staff member, contrary to the policy requiring two.
• Policy Non-Compliance in Falls Prevention and Management: The facility did not adhere to its falls prevention and management policies. Post-fall assessments, pain assessments, and head injury routines were not conducted as required for several residents who had falls.
• Non-Compliance in Medication Administration: The facility failed to document medication administration according to its own policy, particularly in recording the administration on the electronic Medication Administration Record (eMAR).
• Issues with Food Temperature Control and Thermometer Calibration: Dietary staff did not comply with policies on food temperature control and thermometer calibration. Food temperatures were recorded below the required range, and thermometers were not calibrated monthly as required.
• Failure in Ensuring Secure Storage of Drugs: There was a failure to securely store drugs. An open medication pouch with a pill was found unattended on a medication cart.
• Plan of Care Non-Compliance: The facility did not include necessary information in the written plan of care for residents, particularly in relation to the use of a device implemented for a resident after an incident.
• Non-Compliance with Locking Non-Residential Areas: Doors leading to non-residential areas were not kept locked as required, posing safety risks.

February 2020 🚨

The inspection report was conducted by inspectors Michelle Warrener, Jessica Paladino, and Lesley Edwards.

1. Unsafe Transferring Techniques: The facility failed to ensure safe transferring and positioning techniques during resident transfers. A critical incident highlighted the transfer of a resident with a mechanical lift by only one staff member, contrary to the policy requiring two staff members.
2. Non-Compliance with Policies: There were multiple instances where staff did not adhere to the facility’s policies, especially regarding post-fall assessments and medication administration.
3. Improper Storage of Drugs: The facility was found non-compliant in ensuring that drugs were stored securely and locked.
4. Plan of Care Inconsistencies: There were failures in maintaining an accurate and comprehensive plan of care for residents, particularly in documenting the use of certain devices and assessing resident behaviors.
5. Food Service Non-Compliance: The facility did not comply with policies related to food temperature control and thermometer calibration, which impacted food safety and palatability.
6. Drug Administration Issues: The facility failed to administer drugs to residents as per the prescriber’s directions.

Additional, a Critical Incident Inspection was conducted by Lesley Edwards.

1. Dietary Services and Staffing Issues: There were numerous non-compliances regarding dietary services, including a lack of necessary supplies and equipment for food production and service. Frequent menu substitutions were noted due to unavailable ingredients. Furthermore, there was a failure to meet the minimum required staffing hours for food service workers, leading to challenges in meal preparation and service, including the use of paper plates and altered meal quality.
2. Pest Control: The facility did not take immediate action to address pest problems, specifically rats spotted near garbage bins. Although pest control measures were eventually implemented, there was a delay in response.
3. Housekeeping, Laundry, and Maintenance: The designated lead for these services did not meet the required qualifications, lacking both a post-secondary degree or diploma and the necessary managerial or supervisory experience.
4. Food Production and Menu Planning Non-Compliance: Issues were found with food production documentation, specifically in recording menu substitutions. Additionally, the planned menu items were not consistently available at meals, and there was a lack of communication about menu changes to residents.
5. Dining and Snack Service: The facility failed to effectively communicate daily and weekly menus to residents, with discrepancies noted between posted menus and actual meals served.