Extendicare Peterborough (80 Alexander Avenue, Peterborough) is operated by Extendicare, a for-profit operator of long-term care homes in Canada. There are approximately 170 beds.
Inspection Reports for Extendicare Peterborough
Our research team carefully reviewed and summarized inspection reports for Extendicare Peterborough. You can read the original copies of the reports in the Government of Ontario website.
December 2023
The inspection, led by Patricia Mata, occurred both on-site (November 6-22) and off-site (November 23).
This inspection focused on several critical incidents and complaints, including equipment malfunction, improper transfer of a resident, staff to resident neglect, and allegations of resident-to-resident abuse. Following the inspection, various compliance orders previously issued were found to be satisfactorily addressed.
- Transferring and Positioning Techniques: Non-compliance was noted where a resident was injured due to improper transferring technique by a Personal Support Worker (PSW), contrary to the resident’s care plan which required a two-staff assist.
- Reporting Certain Matters to Director: The facility failed to promptly report an allegation of resident-to-resident abuse to the Director, potentially increasing the risk of further abuse.
- Initial Plan of Care: A failure was noted in completing a necessary pain assessment within 14 days of a resident’s admission, impacting the development of an effective pain management plan.
- Pain Management: The facility did not use a clinically appropriate assessment tool for a resident whose pain was not relieved by initial interventions.
- Infection Prevention and Control Program: Non-compliance was found in monitoring symptoms indicating the presence of infection in residents on every shift, particularly during an outbreak situation in the home.
- Reports Regarding Critical Incidents: There was a failure to immediately inform the Director of a COVID-19 outbreak in the home, after two residents tested positive, which posed a risk to the residents and community.
Another inspection was led by Chantal Lafreniere, focusing on falls, care quality, and pain management.
- Reporting and Complaints: The licensee failed to promptly report suspicions of improper or incompetent treatment that resulted in harm to a resident. There were instances where family complaints about the care provided were not immediately reported, nor were they investigated or responded to within the required 10 business days. This failure to act on complaints and concerns promptly put the residents at risk of continued improper care.
- Pain Management: There was non-compliance in monitoring residents’ responses to pain management strategies. Specifically, post-analgesic pain assessments were not properly completed, and a clinically appropriate assessment instrument was not used when residents continued to express pain. This oversight increased the risk of prolonged pain for the residents.
August 2023
The inspection took place over several days: May 17-18, 23-26, 29-31, and June 1-2, 2023. This comprehensive inspection covered a wide range of protocols, including Resident Care and Support Services, Food Nutrition and Hydration, Medication Management, Housekeeping, Laundry and Maintenance Services, Safe and Secure Home, Infection Prevention and Control, Prevention of Abuse and Neglect, Reporting and Complaints, Residents’ Rights and Choices, Pain Management, Falls Prevention and Management, and Resident Charges and Trust Accounts.
- Resident Lifestyle and Choices: A complaint was received about a resident not being allowed to engage in a specific lifestyle choice due to the facility being smoke-free. However, the policy was not uniformly applied, as staff were observed smoking on the property. The Senior Director of Care confirmed the policy did not apply to staff, creating an inconsistent environment and violating the Residents’ Bill of Rights.
- Application of Immobilization Device: A resident required a daily immobilization device, but it was not applied since admission. Staff, including the Physiotherapist, were unaware of how to apply it, and no training was provided. This failure put the resident at risk for mobility issues.
- Delayed Initiation of a Wellness Program: There was a delayed initiation of a wellness program for a resident. The necessary physician orders for the program were not obtained until 29 days after admission. This lack of collaboration among nursing staff, management, and the physician negatively impacted the resident’s well-being.
- Enhanced Staff Monitoring Without Consent: A resident was subjected to enhanced staff monitoring without consent, feeling like they were living in a jail. The monitoring continued for about three weeks, and no evidence of consent from the resident was found in the health care record.
- Sanitation of Resident Washrooms: A persistent pungent odor, likely from urine, was detected in a resident’s washroom, which had heavily soiled and wet flooring. The unsanitary condition had been known for over a year, and no effective actions were taken to address it, posing a risk of infection and creating an unlivable atmosphere.
- Investigation of Allegations of Abuse: Multiple allegations of staff-to-resident abuse were not promptly investigated. The Director of Care-Quality and Senior Director of Care acknowledged the absence of investigations, posing a risk to the safety of residents.
- Monitoring and Reporting Post-Fall Incidents: After several falls, a resident did not receive the required 72-hour monitoring, and a physician was not notified of changes in their health status post-incident. This failure endangered the resident and delayed necessary medical assessment and treatment.
- Security of Non-Residential Doors: Doors leading to non-residential areas were not properly secured, posing a risk to residents. The Environmental Services Manager was aware that one of these doors did not lock, yet no action was taken to rectify this issue.
- Resident-Staff Communication in Outdoor Areas: No resident-staff communication systems were available on outdoor patios, which were frequently used by residents and families. This absence risked delayed staff assistance and potential harm.
- Air Temperature Maintenance: The facility often had temperatures below the required 22 degrees Celsius, causing discomfort for residents. Despite this, maintenance staff and the Environmental Services Manager reported no issues with maintaining the required temperature.
- Accessibility of Mobility Aids: A resident’s mobility aid was kept out of reach, leading to an incident where the resident fell while attempting to self-transfer. The Physiotherapist and staff deliberately kept the mobility aid away to encourage the resident to seek staff assistance, which increased the risk of injury.
- Labeling of Personal Care Items: Personal care items in shared resident spaces were not labeled, raising concerns about infection risks, especially under infection prevention and control precautions (IPAC). The Infection Prevention and Control Lead acknowledged the issue but had no plan to address it.
- Food Storage and Serving Temperatures: Milk and creamer were served at room temperature, violating protocols for storing and serving fluids at proper temperatures, thus risking foodborne illness.
- Housekeeping and Odor Management: An offensive and lingering odor, likely from urine, was present in a resident’s washroom. The washroom’s floor was in a state of disrepair, contributing to the odor issue, and no plans were in place to resolve it, leading to an unpleasant living environment.
- Air Conditioning Control and Maintenance: Numerous Packaged Terminal Air Conditioner (PTAC) units had no control switches, rendering them inoperable to residents, their families, and staff. This issue, especially during hot weather, posed a risk of heat-related illness for residents.
April 2022
This inspection was conducted in reference to intake log #015088-21, concerns
related to dining services and infection prevention and control. During the course of this inspection, Non-Compliances were not issued.
October 2021
The inspection was a complaint inspection led by Inspector Chantal Lafreniere. This inspection focused on several complaints including bed refusal, discharge of a resident, and resident-to-resident abuse.
- Failure to Protect from Abuse: The facility failed to protect a resident from physical abuse by another resident. This incident involved two residents with mobility aids in a hallway confrontation, leading to physical abuse. The plan of care for the abusive resident had identified triggers and interventions for responsive behavior, yet the incident still occurred.
- Admission Refusal: The licensee failed to approve admission for three residents due to a reported lack of physical facilities necessary for care. This contradicts information from the Peterborough Regional Health Care Manager, indicating treatments could be managed in semi-private accommodations.
- Infection Prevention and Control: The facility did not ensure staff participation in the implementation of the IPAC program. Instances of non-compliance included screeners not wearing eye protection and Personal Support Workers (PSWs) failing to perform hand hygiene and wear proper Personal Protective Equipment (PPE).
- Discharge Process Non-Compliance: The facility failed to provide a written notice to a resident and their Substitute Decision Maker (SDM), detailing the justification for the resident’s discharge. This resident had been involved in a physical altercation with another resident and was discharged after being transferred to a hospital.
Another inspection was also conducted by Inspector Chantal Lafreniere from September 23 to October 5, 2021. The inspection focused on a resident-to-resident abuse incident (Log #005484-21) and a resident fall (Log #012112-21).
- Failure in Falls Prevention and Management: The facility did not comply with the Falls Prevention and Management requirements. The licensee’s program included a Head Injury Routine (HIR) for all unwitnessed falls, requiring hourly monitoring for four hours and every shift for 72 hours. For Resident #002, who experienced several unwitnessed falls, the HIRs were not completed as required. The clinical health record showed missing HIRs, and nursing staff confirmed these omissions. This failure increased the risk of potential complications related to head injuries for the resident.
A Voluntary Plan of Correction (VPC) was requested to ensure compliance with conducting appropriate assessments and post-fall assessments using clinically suitable instruments specifically designed for falls.
April 2021
The inspection, conducted by Inspector Karyn Wood from March 12 to 29, 2021, was a complaint inspection. This inspection addressed six logs related to allegations of staff-to-resident neglect and the denial of Substitute Decision Makers’ (SDMs) requests to be essential caregivers.
- Violation of Residents’ Bill of Rights: The licensee failed to ensure that two residents received visitors of their choice without interference when their SDMs’ requests to be essential caregivers were denied.
- Safe and Secure Environment Non-Compliance: The licensee failed to maintain infection prevention and control measures as per Directive #3, particularly regarding maintaining two meters distance between residents in common areas when not wearing a mask.
- Plan of Care Non-Compliance : The licensee failed to provide clear directions to staff related to resident transfers and did not ensure collaboration among staff for integrated and consistent care, especially during changes in a resident’s condition.
- Medication Incident Management Non-Compliance: The licensee did not properly review, analyze, and take corrective action on a medication incident involving a resident potentially missing three doses of medication.