Extendicare Bayview (550 Cummer Avenue, North York) is operated by Extendicare, a for-profit operator of long-term care homes in Canada. There are approximately 200 beds.
Inspection Reports for Extendicare Bayview
Our research team carefully reviewed and summarized inspection reports for Extendicare Bayview. You can read the original copies of the reports in the Government of Ontario website.
October 2023 🚨
The inspection was led by Rajwinder Sehgal, with additional inspection by Susan Semeredy. The on-site inspection dates spanned September 13 to 26, 2023, with off-site inspection on September 22, 2023.
- Violation of Residents’ Privacy and Dignity: Residents #004 and #007 reported a lack of privacy during care, with staff members intruding their personal space. This issue was noted in the Residents’ Council meeting minutes from January 2023. Such intrusions were described as invasive and uncomfortable, impacting residents’ emotional well-being.
- Non-Adherence to Heat-Related Illness Prevention Plan: The home failed to implement their heat illness prevention plan. On multiple occasions, room temperatures reached 28 degrees Celsius without any documented action to ensure resident safety, posing significant health risks.
- Improper Food Temperature Management: The home did not accurately record food temperatures, raising concerns about potential foodborne illnesses. Observations revealed that the temperatures of cold food items were often not within safe ranges, and staff were unsure of the correct procedures to follow in such cases.
- Deficiencies in Personal Protective Equipment (PPE) Usage: Staff were observed not following proper procedures for removing PPE in isolation situations, increasing the risk of infectious disease transmission.
- Delayed Reporting of Disease Outbreak: The home did not immediately report a confirmed outbreak to the Director as required, though this was not found to pose a risk to residents.
- Inadequate Resident Care Plans: The care plans for some residents were either not updated timely or not followed correctly. This included incorrect use of assistive devices for ambulation and inadequate staff assistance for transfers and bathing, potentially compromising resident safety and well-being.
- Lack of Resident and Family Council Involvement: The home failed to consult the Residents’ Council in conducting satisfaction surveys and did not respond in writing within the required 10 days to concerns raised by the council.
- Deficiencies in Quality Improvement Reporting: The home’s report on the continuous quality improvement initiative lacked specific details relevant to the home, failing to meet regulatory requirements.
- Issues with Nutritional Care and Hydration Programs: The home did not maintain a written record of the dietitian’s evaluation of the menu cycle, and there was an inability to access these records during the inspection.
May 2023 🚨
- Non-Compliance in Implementing Fall Prevention Plan: A resident’s plan of care specified particular fall prevention interventions, which were not implemented as observed on a specific date. The personal support worker (PSW) acknowledged forgetting to apply the fall prevention measures, and the Assistant Director of Care (ADOC) admitted that the resident’s care plan was not correctly followed. This oversight increased the risk of falls and injury for the resident.
- Failure in Clinical Monitoring Post-Fall: After a resident experienced a fall resulting in injuries, the staff did not complete all the required clinical monitoring checks as per the home’s policy. This lapse in monitoring could have led to missed assessments for potential post-fall complications. The Registered Practical Nurse (RPN) and ADOC acknowledged that one of the scheduled clinical monitoring checks was not completed as required.
March 2023 🚨
- Inadequate Revision of Care Plans: A resident who had an injury of unknown cause was sent to the hospital and diagnosed with an injury. Despite the change in their mobility status, their care plan was not updated to reflect the need for not using their assistive device, putting the resident at risk of further injury.
- Failure to Report Resident-to-Resident Abuse: There was a delay in reporting an incident between two residents that resulted in harm. Although no injuries were initially observed during their altercation, an injury was discovered later. The incident should have been reported immediately when the harm was determined.
- Lack of Interventions for Responsive Behaviours: Residents #002 and #003 were involved in an altercation, with resident #002 subsequently showing physical resistance during care activities. Their plan of care did not include strategies to manage these behaviours. Additionally, the interaction between residents #002 and #003, where resident #003 exhibited aggressive behaviours towards resident #002, was not adequately addressed in their care plans. The home relied on external behaviour outreach programs instead of in-house support, increasing the risk of harm to residents and staff.
January 2023 🚨
- Infection Prevention and Control (IPAC) Non-Compliance: The IPAC lead did not ensure the use of non-expired hand hygiene agents. Expired sanitizer was discovered in resident areas, indicating a lapse in monitoring and replacement protocols. This was rectified by January 6, 2023.
- Expired Cleaning and Disinfection Products: On January 5 and 6, 2023, expired Oxivir Tb solution disinfectants were found on housekeeping carts. Staff were unaware of the expiration, indicating a gap in inventory monitoring. This was corrected by January 10, 2023, with expired products replaced and removed.
- Non-Compliant Housekeeping Procedures: An unattended cleaning cart with open, unlabeled buckets of cleaning solution was observed, violating housekeeping policies. This posed a risk to residents, particularly in areas accessible to them.
- Falls Prevention and Management Lapses: Staff failed to implement the home’s falls prevention and management strategies for a resident at risk of falls. Despite multiple falls in six months, necessary identifying items were not in place for the resident, increasing their risk.
- Inadequate COVID-19 Swabbing Protocol Compliance: Staff improperly collected COVID-19 samples, not following the Ontario Health guidelines. This raised concerns about the accuracy of test results and potential spread of infectious diseases.
June 2022 🔎
- Non-Compliance in Air Temperature Monitoring: The licensee failed to comply with regulations regarding the monitoring and documentation of air temperatures in resident bedrooms not served by air conditioning. According to the home’s floor plan, there were 87 such bedrooms, but only three were being monitored regularly.
- Insufficient Temperature Documentation: Maintenance staff reported selecting 10 resident bedrooms randomly for daily temperature measurement, but these were not properly reflected in the home’s Indoor Air Temperature log. The Environmental Services Manager (ESM) confirmed that the temperatures of the 87 resident bedrooms without air conditioning were not measured and documented daily as required.
- Potential Risk of Heat-Related Illness: The failure to measure and document temperatures daily in all resident bedrooms not serviced by air conditioning posed a potential risk to residents’ health, specifically increasing the risk of heat-related illness.
November 2021 🚨
Two inspections were completed in November 2021. The below summarizes the complaints inspection.
- Non-Compliance with Plan of Care in Fall Prevention: The home failed to implement a falls prevention plan of care for a resident at risk of falls. During meal services, a specified intervention, intended to minimize accident risks and associated harm, was not provided as outlined in the care plan.
- Inadequate Provision of Nutritional Supplements: A resident identified as being at nutritional risk did not receive the specified nutritional supplement as ordered. Even after the Registered Dietitian (RD) changed the supplement order, the new supplement was not provided as required during the identified period.
- Action Required from the Licensee: The licensee was requested to prepare a written plan of correction to ensure compliance with the care plans, specifically regarding the provision of care and nutritional supplements as specified in the resident’s plan.
The below summarizes the critical incident inspection:
- Falls Prevention: Several intakes (Log #000634-21, Log #002765-21, Log #006490-21, Log #006641-21, Log #011749-21, Log #011757-21, Log #013832-21) were related to falls prevention, indicating a focus on how the home manages and attempts to prevent falls among residents.
- Significant Injury Incident: One intake was related to an incident that resulted in significant injury to a resident. This highlights a serious occurrence, necessitating a detailed investigation into the circumstances and the home’s response.
- Medication Incident: Another intake was concerned with a medication incident, pointing towards issues in medication management or administration.