Extendicare Oshawa: Reviews & Inspection Reports

Extendicare Oshawa (82 Park Road North, Oshawa) is operated by Extendicare, a for-profit operator of long-term care homes in Canada. There are approximately 175 beds.

Inspection Reports for Extendicare Oshawa

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

🔍 August 2023: Inspection

The inspection at Extendicare Oshawa was a comprehensive evaluation addressing various critical and complaint-related issues. The inspection covered multiple aspects including resident care and support services, medication management, housekeeping, nutrition, infection prevention and control, and more.

Plan of Care: Issues were found in medication management and diagnostic imaging follow-ups, where the staff failed to ensure availability of prescribed medication and proper follow-up on diagnostic imaging for a resident, risking the resident’s health.
Documentation: Inadequate documentation was noted for skin/wound care and turning/repositioning schedules, increasing the risk for deterioration of the resident’s skin condition.
Duty to Protect: The facility failed to protect residents from neglect and abuse. Specific incidents included staff not responding to call bells for assistance and physical and verbal abuse of a resident by staff members.
Complaints Procedure: Complaints sent to management by residents’ families were not forwarded to the Director as required, compromising the residents’ safety and well-being.
Failure in Orientation Training: Staff members did not receive mandatory training on various critical aspects such as the Residents’ Bill of Rights, the home’s mission statement, abuse and neglect policies, and mandatory reporting duties.
Infection Prevention and Control Issues: Non-compliance with IPAC standards was observed, including inadequate personal protective equipment and insufficient support for resident hand hygiene before meals.
Additional Training for Direct Care Staff: Staff lacked training in key areas including skin and wound care, pain recognition, and the use of restraints and assistive devices.

A Compliance Order was issued to address medication administration issues, including developing a system for timely medication administration and conducting audits to ensure adherence to medication schedules.

🔍 May 2023: Inspection

The inspection report of Extendicare Oshawa addressed various complaints and critical incidents. The primary focus of this inspection was on fall incidents, allegations of staff to resident abuse, and issues related to abuse and neglect.

Plan of Care: The facility failed to meet residents’ care needs as per their plans, particularly in hydration management. There was a failure to refer a resident to a medical doctor and dietitian when fluid intake goals were not met, contrary to the home’s policy.
Oral Care: A complaint indicated that a resident did not receive proper oral care as outlined in their care plan. Observations confirmed that mouth care was not completed on two occasions, posing a risk to the resident’s well-being.
Masking Requirements: The facility did not comply with the COVID-19 guidance document for long-term care homes regarding universal masking. Staff members were observed not following proper masking protocols, leading to a compliance order for re-training and auditing of staff adherence to universal masking.

🔍 September 2022: Inspection

The inspection report for Extendicare Oshawa highlights various areas of non-compliance and critical issues.

Cooling Requirements: The facility failed to implement its heat-related illness prevention and management plan, despite high temperatures, affecting resident comfort and potentially their health.
Infection Prevention and Control: The facility did not comply with the infection prevention and control (IPAC) standard, specifically regarding environmental controls and hand hygiene before meals. Furthermore, there was a delay in reporting a COVID-19 outbreak to public health authorities.
Bathing: The facility did not adhere to the bathing preferences of a resident, denying them the quality of life and potentially impacting personal hygiene.
Safe and Secure Home: Non-compliance with COVID-19 directives was noted, particularly concerning readmission of a resident from the hospital without proper testing and isolation.
Administration of Drugs: Medication was administered without a prescription, posing a risk to the resident’s health.
Plan of Care: The facility failed to assess resident needs before increasing medication and did not involve the substitute decision-maker in care plan changes.
Medication Management System: Non-compliance in implementing medication reconciliation policies was found, leading to the administration of discontinued medication.

🔍 May 2022: Critical Incident Inspection

The inspection report for Extendicare Oshawa, conducted by Lynda Brown and Cristina Montoya, focused on multiple critical incidents. These incidents included alleged staff to resident improper care, physical abuse, medication incidents, a disease outbreak, and an environmental hazard.

Investigation of Alleged Abuse: The licensee did not immediately investigate an allegation of abuse of resident #008 by a staff member. The allegation was reported to an RN, and a second incident was reported to an RPN, but the RPN failed to report it immediately. The Assistant Director of Care (ADOC) initiated an investigation only after a few days when they became aware of the allegation.
Reporting Investigation Results to Director: There was a failure to ensure that the person who suspected neglect of resident #007 by a staff member immediately reported the suspicion to the Director. The report was submitted only after several days, and the Director of Care involved in the investigation was no longer in the home.
Notification Requirements: The licensee did not ensure that resident #008 and their Substitute Decision Maker (SDM) were notified of the results of the investigation into alleged staff to resident neglect immediately upon completion.
Reports to Director: The licensee failed to include necessary details in reports to the Director regarding incidents of alleged neglect and abuse. This included the names of staff involved and long-term actions planned to correct the situation and prevent recurrence.

🔍 April 2022: Complaints Inspection

The inspection report for Extendicare Oshawa focused on a Complaint inspection. This inspection addressed a complaint related to medication incidents, insufficient staffing, and two Critical Incidents (CI) related to missing or unaccounted controlled substances.

Medication Incident: The licensee failed to properly document and report a medication incident involving a resident. Two Registered Practical Nurses (RPNs) discovered that a resident was missing their narcotic analgesic, but they did not immediately report the missing narcotic, complete a medication incident report, or notify the necessary authorities and individuals.
Document and Report Multiple Medication Incidents: A complaint revealed that several residents did not receive their medications as prescribed due to insufficient staffing. The medication incident report did not account for all residents affected, and those involved were not properly assessed, nor were the incidents reported as required.
Drug Administration: Drugs were not administered to residents in accordance with the prescriber’s directions. An anonymous complaint indicated that residents in a specified area did not receive their medications as prescribed, which was confirmed by the ADOC.
Staffing and Work Environment: Observations indicated that residents were congregated in close proximity without masks, contrary to physical distancing guidelines. This non-compliance demonstrated a failure to maintain a safe and secure environment for residents.

Due to the severity and scope of the non-compliances, particularly regarding the medication incidents and the risk to residents, a Compliance Order was issued. The licensee was ordered to retrain all registered staff, including agency staff, on the home’s medication incident policy.

🔍 April 2022: Follow-Up Inspection

The follow-up inspection at Extendicare Oshawa, conducted by Lynda Brown, was a comprehensive evaluation addressing multiple aspects of the facility’s operations. This inspection included follow-ups related to Infection Prevention and Control (IPAC), a Critical Incident (CI) related to a disease outbreak, and two complaints concerning IPAC, housekeeping, and supplies. The inspection also identified additional non-compliance related to medication incidents.

Safe and Secure Environment: The licensee failed to ensure the home was a safe and secure environment, particularly in maintaining physical distancing and mask usage among residents in common areas, as directed by COVID-19 guidelines.
Infection Prevention and Control Program: There was a failure in daily monitoring of infection in residents, especially during an outbreak. This lack of monitoring and inaccurate record-keeping hampered effective outbreak management.
Housekeeping Procedures: The facility did not adequately implement housekeeping procedures, particularly in cleaning high-touch surfaces in resident rooms.
Maintenance Services: The inspection revealed that maintenance services were not adequately available to ensure the building and its systems were maintained in good repair.
Occupancy of Licensed Beds: There was a failure to ensure all beds licensed for occupancy were available for occupation, with several rooms being used for storage or remaining unoccupied due to maintenance issues.
Monitoring Symptoms of Infection: The facility did not effectively monitor and record symptoms of infection in residents on every shift, leading to potential undetected infections and delayed actions.
Maintenance of Home and Equipment: The licensee failed to maintain the home, furnishings, and equipment in a safe condition and good state of repair, as evidenced by rooms not being used due to maintenance issues.