Extendicare Burloak

Extendicare Burloak (5959 New Street, Burlington) is operated by Extendicare, a for-profit operator of long-term care homes in Canada. There are approximately 145 beds in private, semi-private and shared rooms.

---

Inspection Reports for Extendicare Burloak

Our research team at Caring Magazine carefully reviewed and summarized inspection reports for Extendicare Burloak. You can read the original copies of the reports in the Government of Ontario website.

🔍  November 2023: Inspection

The inspection at Extendicare Burloak was a complaint inspection led by Dusty Stevenson.

• Falls Prevention and Management: The home failed to comply with the post-fall management procedure, particularly in notifying a resident’s substitute decision maker (SDM) after a fall. The resident’s SDM was not informed of the fall until they called the home the following day. The Director of Care (DOC) confirmed that it was expected for the staff to contact the resident’s SDM immediately following a fall.
• Medication Management System: The home did not follow its procedure for the acquisition and administration of medication for a resident. There was a failure to comply with the home’s Medication Administration procedure after a resident did not receive post-operative medication as specified in the order. The home’s internal investigation revealed no reorder record for the medication, and the staff did not notify the physician when the medication was unavailable.
• Compliance Order: The licensee was ordered to ensure residents requiring 1:1 monitoring were scheduled with staff and to create a contingency plan for periods when coverage wasn’t available. This order was issued because a resident who required 24-hour 1:1 monitoring to reduce fall risk had an unwitnessed fall during a period when the 1:1 staff member was not present.

Additionally, an Administrative Monetary Penalty (AMP) of $1,100 was issued due to the licensee’s failure to comply with the requirements, leading to the issuance of the compliance order.

🔍  September 2023: Inspection

The inspection report for Extendicare Burloak was a critical incident inspection focused on falls prevention and management. Led by Brittany Wood and Colleen Lewis, the inspection assessed specific incidents and the home’s compliance with relevant protocols.

• Plan of Care: The home did not adhere to its fall prevention and management protocols as outlined in a resident’s plan of care. Specifically, it was observed that a fall intervention, which should have been in place according to the resident’s plan of care, was absent. This omission was particularly noted in relation to the resident’s wheelchair use. Staff confirmed that the prescribed fall intervention was not implemented as required.

🔍  June 2023: Critical Incident Inspection

The inspection report for Extendicare Burloak was conducted as a critical incident system inspection. The inspection addressed several specific incidents, including cases of falls and physical abuse among residents.

Led by Stephanie Smith and Indiana Dixon, this inspection focused on evaluating the facility’s adherence to falls prevention and management protocols, infection prevention and control, and prevention of abuse and neglect.

• Duty to Protect: The home failed to protect a resident from physical abuse by another resident. The incident involved one resident entering another’s room, rummaging through belongings, and subsequently kicking the room owner in the leg when confronted, resulting in injury that required treatment. The aggressor was removed from the area following the incident.

🔍  February 2023: Inspection

The inspection report for Extendicare Burloak, conducted by Jennifer Allen and Nishy Francis, focused on addressing complaints and follow-ups on previously issued compliance orders.

The inspection covered various aspects including resident care and support services, skin and wound prevention and management, housekeeping, laundry, maintenance services, medication management, infection prevention and control, and prevention of abuse and neglect.

The inspection also addressed multiple intakes, including complaints about the absence of a registered nurse, physical abuse of a resident, laundry service, and follow-ups to high-priority compliance orders from a previous inspection.

1. Reporting to The Director: The home failed to immediately inform the director of a physical abuse incident involving two residents. This delayed action required to respond to the incidents and placed residents at risk of harm.
2. Duty to Protect: There was a failure in protecting a resident from physical abuse by another resident. The incident resulted in actual harm to the resident’s health and wellbeing, indicating a breach in the home’s commitment to a safe and supportive environment.
3. Responsive Behaviours: The inspection identified non-compliance with the home’s Responsive Behaviour Procedure Policy following a physical altercation between two residents. This policy required completing an Responsive Behaviour Huddle assessment after each physical responsive behaviour incident, which was not done in this case.

The inspection found that the home was in compliance with previously issued orders related to the Long-Term Care Homes Act.

🔍  November 2022: Inspection

The inspection for Extendicare Burloak, led by Daria Trzos, Kelly Hayes and Olive Mameza Nenzeko, was both a follow-up to previous compliance orders and a response to critical incident and complaint logs.

• Infection Prevention and Control (IPAC): Non-compliance was noted with regard to staff adherence to Routine Practices and Additional Precautions, particularly in the proper use of Personal Protective Equipment (PPE) during a COVID outbreak.
• Use of Personal Assistance Services Device (PASD): A failure was identified in including the use of PASD in a resident’s care plan without consent from the resident or their substitute decision-maker.
• Integration of Assessments for Skin and Wounds: There was a lack of collaboration among staff in the assessment of residents with altered skin integrity, leading to inconsistencies in care plans.
• Participation in the Development of Care Plans: The inspection found that a resident’s substitute decision-maker was not given the opportunity to fully participate in the development and implementation of the resident’s care plan.
• Revising Care Plans for Fall Interventions: The report highlighted failures in reviewing and revising care plans when the residents’ needs changed, particularly concerning fall interventions and skin integrity.
• Maintenance of the Facility: The report noted that the home and furnishings, especially in serveries, were not maintained in a good state of repair.
• Management of Hypoglycemia and Medication Errors: The report identified issues with the management of hypoglycemia and errors in the medication management system.
• Safe Transfer Techniques and Skin Assessment Post-Hospitalization: The facility was found non-compliant in using safe transferring techniques and in conducting skin assessments after hospitalization.
• Nutritional Care and Hydration Monitoring: Failures in monitoring and evaluating food intake of residents with nutritional risks were noted.

The inspection resulted in several compliance orders aimed at addressing these issues, including orders related to neglect, wound management, weekly skin assessments, and the proper implementation of policies and procedures.

🔍  April 2022: Complaints Inspection

The inspection report for Extendicare Burloak, led by Daria Trzos and Barbara Grohmann, focused on a range of critical areas. The inspection was a response to a complaint related to nutrition, personal care, continence care, and staffing issues.

• Infection Prevention and Control (IPAC) Program: Staff were not consistently implementing hand hygiene practices before and after meals or snacks for residents. There were lapses in the donning and doffing of Personal Protective Equipment (PPE), with staff not following the established order, which could increase the risk of spreading infectious organisms. Additional precaution practices, such as the proper posting of precaution signage on residents’ doors and the availability of PPE, were not uniformly followed.
• Plan of Care: The care plan for a resident with a feeding device lacked clear directions, potentially impacting the resident’s care quality. This was indicative of a broader issue where the care plans did not provide sufficient clarity or were not updated according to changes in residents’ needs. There was a specific instance where the plan for a resident’s grooming, agreed upon by the resident’s substitute decision-maker, was not updated in the care plan. This failure raised concerns about the responsiveness of the care planning process to residents’ changing needs.

These findings led to the issuance of two Written Notifications (WNs) and one Voluntary Plan of Correction (VPC), indicating areas where the home must take corrective actions.

🔍  April 2022: Critical Incident Inspection

The inspection for Extendicare Burloak, conducted by Inspector Daria Trzos, reveals several critical findings.

• Plan of Care: The licensee failed to provide care as specified in the residents’ plans, particularly regarding interventions for safety due to conditions and behaviors. This non-compliance increased the risk to residents’ safety.
• Failure to Protect Residents from Neglect: There was a failure to protect a resident from neglect. An incident involving a resident occurred due to not following the resident’s care plan and the home’s policy. Moreover, the home lacked a process for preventive maintenance of a specific door type, leading to the resident’s harm.
• Door Policy: The licensee failed to develop a written policy dealing with permitting or restricting unsupervised access to secure outdoor areas. This was highlighted by an unexpected death of a resident, where it was found that no one was assigned to check if specific doors were locked or unlocked.
• Medication Administration Issues: There were failures in administering drugs as per prescribers’ directions, leading to medication errors. This included administering medications intended for another resident.
• Maintenance Services: The licensee failed to ensure schedules and procedures for routine, preventive, and remedial maintenance. This was evidenced by the lack of documented routine or preventive maintenance, especially concerning exit doors, door hardware, and associated alarm systems.
• Inadequate Designated Lead for Housekeeping, Laundry, Maintenance: The designated lead for housekeeping, laundry, and maintenance did not have a minimum of two years experience in a managerial or supervisory capacity.
• Failure in Quarterly Evaluation of Medication Management: The interdisciplinary team, including the Medical Director, Administrator, Director of Nursing and Personal Care, and the pharmacy service provider, did not meet quarterly to evaluate the effectiveness of the medication management system.

As a result of these findings, several orders were issued to the licensee, including compliance orders and requests for written plans of correction. The licensee is required to ensure that all residents who need specific interventions for their safety receive them as indicated in their care plans. Additionally, they must develop and implement a written policy regarding the access to secure areas and ensure proper maintenance routines are established.