Deer Park Villa (150 Central Avenue, Grimsby) is a nursing home that is owned and operated by Niagara Region. There are approximately 40 beds.
Inspection Reports for Deer Park Villa
Our research team carefully reviewed and summarized inspection reports for Deer Park Villa. You can read the original copies of the reports in the Government of Ontario website.
December 2023: Inspection
The Proactive Compliance Inspection, overseen by lead inspector Emmy Hartmann and additional inspector Barbara Grohmann, highlighted several areas of non-compliance, all of which were addressed by the licensee during the inspection period.
- Plan of Care: There were issues with the implementation and effectiveness of the plans of care for certain residents. In one instance, a necessary intervention during meals was not being used, leading to its removal from the resident’s care plan upon reassessment. In another case, the interventions for a resident’s health condition were found to be poorly accepted and ineffective, yet no revisions were made to address this. These instances point to a need for more vigilant monitoring and timely reassessment of residents’ care plans.
- Medication Management: The inspection found that the home’s policy for the destruction and disposal of narcotics and controlled substances did not comply with the requirements under the Act. Specifically, the policy incorrectly stated that narcotics could be destroyed by one member of the registered nursing staff and one other staff member. This was promptly revised by the Director of Resident Care to align with legal standards, ensuring a more secure and compliant medication management system.
- Dietary Referral Follow-Up: The home failed to provide care as specified in the plan of care following a dietary referral for a resident. The Registered Dietitian (RD) put a plan in place but did not document a follow-up as intended, raising concerns about the effectiveness and adaptation of dietary interventions.
- Secure and Safe Home Environment: The inspection identified that doors leading to non-residential areas like serveries were not consistently locked when unsupervised. This poses a risk as these areas contain potentially hazardous materials. The Nutrition and Environmental Manager acknowledged this oversight and affirmed the expectation that such areas should be secured.
December 2022: Critical Incident Inspection
The Critical Incident System inspection, conducted by Nishy Francis as the lead inspector along with Jobby James and Ruzica Subotic-Howell, focused on falls prevention and management, infection prevention and control (IPAC), and staffing, training, and care standards. The report reveals some of these non-compliances were remedied during the inspection.
- Infection Prevention and Control: The facility initially failed to implement the April 2022 IPAC Standard for Long-Term Care Homes, specifically the requirements for additional precautions including the disposal of Personal Protective Equipment (PPE). Additionally, there was a failure to ensure the IPAC program included evidence-based policies and procedures, with specific reference to the use of PPE. Both these non-compliances highlighted lapses in following up-to-date IPAC practices and utilizing PPE according to evidence-based policies, potentially increasing the risk of infection transmission among staff and residents.
- Minister’s Directive: Deer Park Villa was found non-compliant for not conducting IPAC self-audits as per the Minister’s Directive. The facility used an outdated version of the COVID-19 Self-Assessment Audit Tool, which missed critical updates like the requirement for waste receptacles in resident rooms for PPE disposal. This non-compliance underlines the importance of keeping audit tools and practices current to ensure effective IPAC measures.
- Director of Nursing and Personal Care: The facility did not meet the required hours for the Director of Care (DOC) in a home with a licensed bed capacity of 40 beds. The DOC’s working hours were split between the DOC role and the IPAC lead role, failing to fulfill the minimum requirement of 24 hours per week dedicated to the DOC position. This shortfall could affect the overall management and supervision of care in the facility.
December 2021: Proactive Compliance Inspection
The Proactive Compliance Inspection, conducted by inspectors Lisa Bos and Lisa Vink, identified several areas of non-compliance, affecting various aspects of resident care and facility operations.
- Plan of Care: There were failures in following residents’ rest routines as per their plans of care. In multiple instances, residents were not assisted to bed for their rest periods, and their preferences or requests were not adequately adhered to. This non-compliance points to a need for more vigilant implementation of care plans to ensure resident needs and preferences are met.
- Bathing: The facility did not consistently meet the requirement of bathing residents at least twice a week. This was attributed to staffing challenges, specifically when working below the planned PSW staffing complement. This shortfall in care could negatively impact residents’ hygiene and overall well-being.
- Oral Care: The inspection found that oral care was not provided consistently, as evidenced by dry toothbrushes and staff confirmations. This neglect could potentially impact residents’ oral health and hygiene.
- Availability of Supplies: Deer Park Villa failed to ensure that necessary oral care supplies, particularly a specific device for oral care, were available. This lack of essential supplies could adversely affect the oral hygiene of residents.
- Skin and Wound Care: The facility did not comply with the requirement to reposition dependent residents every two hours, as observed over an extended period. This oversight could increase the risk of skin breakdown for residents.
- Infection Prevention and Control: There was a failure in ensuring all staff participated in the IPAC program, particularly in adhering to PPE policy. This could increase the risk of infectious disease transmission within the facility.
- Resident-Staff Communication and Response System: The communication and response system was not functioning independently of the bed alarm, and it was not operational when the bed alarm batteries needed replacement. This issue could hinder timely assistance for residents in need.
August 2021: Critical Incident Inspection
The Critical Incident System inspection, conducted by Cathy Fediash, identified two main areas of non-compliance related to fall prevention and management.
- Plan of Care: The licensee failed to ensure that the plan of care was based on an assessment of the resident’s fall prevention and management needs. Specifically, after a resident experienced a fall, the fall prevention and management device did not respond. The subsequent assessment did not include the necessary interventions in the resident’s plan of care or the Point of Care (POC) tasks. This lack of communication and implementation of assessed needs in the care plan meant that staff providing direct care were not aware of these needs or the requirement to provide them. This oversight indicates a significant gap in ensuring that care plans are updated and communicated effectively following incidents like falls.
- Use of Equipment: The facility failed to ensure that a resident’s fall prevention and management device was used in accordance with the manufacturer’s instructions. The device was observed to be hanging and not secured as required, and it was noted that the resident had the ability to remove a portion of this device. The care plan and POC tasks were revised only after the resident had removed the device multiple times. The failure to use the device as per the manufacturer’s instructions posed a risk to the resident, as the device could not alert staff in a timely manner if the resident fell.
May 2020: Critical Incident Inspection
During the course of this inspection, Non-Compliances were not issued.
January 2020: Critical Incident Inspection
During the course of this inspection, Non-Compliances were not issued.