Extendicare Rouge Valley (551 Conlins Road, Toronto) is operated by Extendicare, a for-profit operator of long-term care homes in Canada. There are approximately 190 beds.
Inspection Reports for Extendicare Rouge Valley
Our research team carefully reviewed and summarized inspection reports for Extendicare Rouge Valley. You can read the original copies of the reports in the Government of Ontario website.
October 2023
The inspection at Extendicare Rouge Valley, a long-term care home in Toronto, was conducted by a team led by Vernon Abellera, alongside inspectors Fatemeh Heydarimoghari and Miko Hawken. This inspection, which took place both on-site and off-site between September 18 and 29, 2023, was initiated due to various complaints and critical incidents. It also included follow-up on previous compliance orders.
- Accommodation Rate Communication: Non-compliance was noted as the home failed to provide 30 days’ written notice to a resident about an increase in accommodation rates, due to an incorrect email address. This issue was resolved during the inspection.
- Resident Dignity and Respect: There was a case where a resident (#007) was treated inappropriately with unnecessary personal protective equipment, leading to emotional distress. This was recognized as a failure to respect the resident’s dignity.
- Infection Prevention and Control: The home did not follow evidence-based policies for Infection Prevention and Control (IPAC), as unnecessary precautions were taken for resident #007.
- Neglect of Resident: There was an incident of neglect involving resident #011, who did not receive timely care and meals from a staff member, posing a moderate risk to the resident.
- Skin and Wound Care: The home failed to conduct a necessary skin assessment for resident #005 upon their return from the hospital, risking delayed treatment and healing.
June 2023
The inspection at Extendicare Rouge Valley in Toronto, conducted by lead inspector Julie Dunn and additional inspector Laura Crocker from June 7 to 12, 2023, was a response to a complaint about the facility’s air conditioning system. This inspection included both on-site and off-site evaluations.
The primary concern addressed during this inspection was the lack of air conditioning in the facility. The inspection protocols used were centered on ensuring a safe and secure home environment and adhering to infection prevention and control standards.
- Cooling Requirements: The facility failed to implement its heat-related illness prevention and management plan when temperatures in certain areas rose above 26 degrees Celsius. As a result, the inspectors issued a compliance order requiring the licensee to: educate staff on the home’s Preventing Heat-Related Illnesses Policy; develop a communication system to alert the team when temperatures reach 26 degrees Celsius or higher; and implement a daily audit sheet to ensure policy adherence.
- Air Conditioning Requirements: The facility was found non-compliant for not maintaining adequate air conditioning, affecting the comfort level of residents. The following actions were ordered: engagement of a HVAC Engineer/Technician to repair and service the air conditioning system; daily monitoring and recording of air temperatures in each resident’s room; review of temperature records and documentation of actions taken for temperatures at 26 degrees Celsius or above.
March 2023
The inspection at Extendicare Rouge Valley in Toronto, led by Angie King with Fatemeh Heydarimoghari and Joanne Zahur as additional inspectors, took place on March 2-3 and 6-13, 2023.
It was prompted by multiple complaints and critical incident reports concerning residents’ rights, skin and wound care, fall prevention, and allegations of abuse.
- Non-Compliance in Plan of Care: A Critical Incident Systems report highlighted a case where a resident suffered multiple fractures due to a fall. Despite being at medium risk for falls, the required fall prevention interventions were not in place. Staff, including a Personal Support Worker (PSW), Physiotherapist (PT), and Registered Practical Nurse (RPN), were aware of the resident’s specific fall prevention needs, including a safety device while seated, but the Assistant Director of Care (ADOC) admitted the care plan lacked clear directives. Another incident involved a PSW providing unassisted personal care to a resident, contrary to the care plan that required two staff for such tasks. This deviation from the plan resulted in the resident’s fall. The ADOC and RPN confirmed the PSW’s non-compliance with the care plan.
- Delay in Reporting Abuse: An allegation of physical abuse from staff to a resident was reported 102 days after the incident. The ADOC decided not to submit the report immediately, as they concluded the incident wasn’t abuse. This failure to promptly report alleged abuse could lead to unaddressed abuse incidents in the facility.
- Inadequate Infection Prevention Control: Agency staff were observed wearing masks below their nose, violating the facility’s Infection Prevention and Control (IPAC) standards that mandate masks to cover both the mouth and nose. The IPAC lead confirmed the universal masking requirement, emphasizing the potential risk of infection transmission due to improper masking.
- Inadequate Reporting in Investigations:The facility failed to include essential details in their reports to the Director. Specifically, names of staff members who were present at or discovered the incident, and names of all staff who responded to the incident, were missing. This lack of detailed reporting hampers the ability to identify staff-related trends in the facility.
March 2022
The inspection was triggered by several critical incidents including resident falls requiring hospital transfer, a follow-up to a previous compliance order regarding medication administration, and general inspection protocols. The inspection was completed by Diane Brown and Julie Dunn.
- Plan of Care Non-Compliance: The licensee failed to ensure that care specified in the plan of care was provided. This included an incident where a resident fell due to inadequate safety measures, specifically the absence of a safety device on the chair they were seated in. In another case, a resident’s fall prevention intervention was not provided, leading to a fall. Documentation revealed the intervention was marked ‘not applicable’ when it was not available.
- Failure in Documentation: There was a failure to document actions taken with respect to a resident under a program, including reassessments and the resident’s responses to interventions. This was highlighted by an incident where a resident refused a physiotherapy program, which was not documented prior to their fall.
The licensee was requested to prepare written plans of correction to address these non-compliances, particularly focusing on ensuring the implementation of care as per the plan of care and proper documentation of all actions related to resident care programs.
October 2021
The inspection was focused on a Critical Incident System Report related to falls management.
- Plan of Care Non-Compliance: The care specified in a resident’s plan, particularly for assistance with transfers, was not provided as outlined. A PSW confirmed not following the care plan instructions during transfers, acknowledged by the RPN and DOC. This non-compliance posed a risk of harm to the resident.
- Failure in Documentation: The licensee did not adequately document actions taken in relation to a resident’s care, including assessments, reassessments, interventions, and responses. A specific case involved a resident’s fall, where interventions in the care plan were noted as resolved without documented rationale. The ADOC confirmed the expectation of proper documentation for changes in interventions.
A Voluntary Plan of Correction (VPC) was requested to ensure compliance with the care plan and adequate documentation of care actions.
May 2021
- Medication Administration Issues (WN #1): Two residents did not receive their medication as prescribed, leading to a hospitalization for one. Investigation revealed medication was not sent from the pharmacy for a period, and discrepancies could have been earlier detected by registered staff.
- Medication Timing Error: A student RPN administered medication at the wrong time, resulting in an incorrect dosage for a resident. The Director of Care (DOC) confirmed that the supervising RPN did not ensure adherence to prescriber’s instructions.
- Infection Prevention and Control Measures (WN #2): Non-compliance with Directive #3 related to wearing eye protection. Observations noted visitors and caregivers not wearing face shields as required, posing a potential risk of infectious transmission.
- Medication Management Policy Non-Compliance (WN #3): Failure to adhere to the Medication Management policy, specifically regarding narcotic medication administration and documentation. An RPN was observed not signing the narcotic count sheet immediately after administration, and discrepancies were found in narcotic medication records.
- Medication Incident Reporting Failure (WN #4): An RN failed to complete a medication incident report and inform the necessary parties after a medication omission was discovered. This resulted in a delay in identifying and addressing the medication error.
The licensee was ordered to ensure proper medication administration as per prescriber’s instructions and adhere to best practices for medication management, including conducting audits.
A voluntary plan of correction was requested to address non-compliances, specifically regarding medication management and infection control measures.
March 2021
- The inspection aimed to follow up on previous Compliance Orders issued in inspection #2020_832604_0017.
- Additionally, it included a Critical Incident System inspection focused on an allegation of staff to resident abuse and neglect.
- The inspector engaged in discussions with various staff members, including the Director of Care, IPAC Coordinator, RNs, RPNs, PSWs, Recreation Aides, and Housekeepers, and also interacted with residents.
- The inspection involved a review of the home’s internal records, resident healthcare records, applicable policies, and observed the delivery of resident care and services. The home’s Infection Prevention and Control Program was also reviewed.
The previously issued Compliance Orders from inspection #2020_832604_0017 were found to be in compliance at the time of this follow-up inspection.
No new non-compliances were issued during this inspection.