Extendicare Scarborough

Extendicare Scarborough (3830 Lawrence Avenue East, Toronto) is operated by Extendicare, a for-profit operator of long-term care homes in Canada.

Inspection Reports for Extendicare Scarborough

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

November 2023 🔎

A Proactive Compliance Inspection was conducted by Ryan Randhawa and Ramesh Purushothaman.

• Visitor Policy Posting: The current version of the visitor policy was not posted in the home, remedied on October 12, 2023.
• Fall Prevention Strategy: A failure to implement a required fall prevention strategy for a resident as specified in their care plan.
• Documentation Errors: Incorrect documentation of care provided to two residents, in contrast to their care plans.
• Window Safety : Windows in three resident rooms could open more than 15 centimeters.
• Food Temperature: Inadequate temperature control of served food, posing a risk for food-borne illnesses.
• Infection Prevention and Control: Non-compliance in implementing routine practices for hand hygiene and personal protective equipment usage.
• Continuous Quality Improvement Reports: The licensee failed to include necessary written records in the Continuous Quality Improvement initiative report and did not provide a copy to the residents’ council.

September 2023 🚨

Complaint and Critical Incident inspections were conducted by Arther Chandramohan and Slavica Vucko.

Extendicare Scarborough was reported to have failed to protect resident #002 from physical abuse by resident #001. This incident involved a physical altercation between the two residents, where resident #002 sustained injuries. Evidence of the abuse was confirmed through interviews with staff and progress notes of resident #001.

April 2023 🚨

This amended report, issued by Goldie Acai and aided by additional inspectors Parimah Oormazdi, Irish Abecia, and Dorothy Afriyie, was completed on April 21, 2023, with the amended issue date being April 27, 2023.

• Plan of Care: Non-compliance was noted in ensuring clear directions for staff related to transfers in a resident’s care plan. A resident fell and sustained an injury due to unclear instructions in the care plan and Kardex about the level of assistance required for transfers. This lack of clarity increased the risk of falls and injury for the resident.
• Protection from Certain Restraining: The licensee failed to comply with regulations to ensure a resident was not restrained for staff convenience. A resident was inappropriately restrained by a PSW, later discovered and released by an RPN. This incident violated the home’s policy on physical restraints and increased the risk of injury to the resident.
• Responsive Behaviours: There was a failure to implement a strategy for a resident exhibiting certain behaviors. Despite an intervention being ordered by the Behavioral Support Ontario (BSO) lead, it was not implemented promptly, causing the resident to continue exhibiting behaviors. This lack of timely intervention put the resident at an increased risk of further injuries.

June 2022 🔎

A Follow-Up Inspection was conducted by Amandeep Bhela, Ana Best and Fatemah Heydarimoghari.

All the previously issued Compliance Orders were found to be in compliance.

However, a Personal Support Worker (PSW) was observed not wearing a surgical mask correctly, as it was below their nose. This PSW indicated they had been informed that they could wear the mask this way if they had breathing difficulties. However, the IPAC manager confirmed that this was not the correct direction for staff and that masks should cover both nose and mouth to reduce the risk of transmission.

March 2022 🚨

A Critical Incident System inspection was conducted by Jennifer Batten, Ama Agyemang, and Catherine Ochnik.

• Resident Abuse: Extendicare Scarborough failed to protect residents from abuse, specifically residents #001 and #002. Resident #001 was involved in an incident with PSW #100, leading to physical and emotional injuries. Resident #002 was abused by PSW #134, causing physical pain. The incidents were substantiated, and it was noted that the police were not notified as required in such cases.
• Failure to Notify Police: Extendicare Scarborough did not notify the police immediately regarding the abuse incidents, which was a failure to comply with regulations.
• Plan of Care: There was a failure to provide clear directions in the plan of care for resident #016, leading to a fall and injury.
• Reporting of Abuse Investigation: Extendicare Scarborough did not report the results of the abuse investigation related to resident #002 and PSW #134 to the Director as required.

As a result of these findings, several Written Notifications (WN) and Voluntary Plans of Correction (VPC) were issued, along with Compliance Orders (CO). Extendicare Scarborough was required to create and implement plans to protect residents from abuse, report incidents to the police, ensure clear directions in care plans, and report investigation results to the Director. The facility was given specific deadlines to comply with these orders.

In the same month, a Compliant Inspection was completed by Jennifer Batten. An amendment was made following Extendicare Scarborough’s request for a four-week extension to comply with the initial orders.

• Dining and Snack Service: Extendicare Scarborough failed to ensure that residents who required assistance with eating were positioned safely and appropriately during meals.
• Meal Service to Residents Needing Assistance: Meals were served to residents requiring assistance with eating before someone was available to help them.
• Infection Prevention and Control Program: There were several lapses in infection prevention and control practices observed throughout the home.
• Bathing: Extendicare Scarborough failed to ensure that residents were bathed at least twice weekly by their preferred method. The licensee is requested to prepare a plan to ensure compliance with residents’ bathing preferences.
• Personal Items and Aids: Personal items were found unlabeled and not cleaned as required.
• Safe Storage of Drugs: Medications were not stored securely or exclusively in designated areas.

March 2021 🚨

A Complaint Inspection was conducted by Moses Neelam.

• Plan of Care: There was a failure to ensure clear direction in the plans of care for residents #001 and #009, specifically concerning the use of a certain care item. This lack of clarity put the residents at minimal risk of injury.
• Forwarding Complaints: Extendicare Scarborough did not forward all written complaints about resident care and operation of the home to the Director immediately.
• Infection Prevention and Control Program: The licensee failed to ensure all staff participated in the infection prevention and control program, particularly noted when a PSW did not wear a gown while attending to a resident under droplet precaution.

Non-compliances issued included written notifications and voluntary plans of correction, but no compliance orders, director referrals, or work and activity orders were issued.

In the same month, This report details a Critical Incident System inspection conducted at Extendicare Scarborough by Moses Neelam. The inspection occurred over several dates in March 2021 and focused on specific incidents that led to injuries and a case of physical abuse.

Key Findings:

1. Plan of Care (WN #1): Non-compliance was noted in the implementation of the plan of care for resident #013. Specifically, the plan indicated that the resident’s limbs were to be protected during movement, which was not followed, leading to an injury. This non-compliance was identified through progress notes and interviews with the staff involved.
2. Duty to Protect (WN #2): The licensee failed to protect resident #011 from being physically abused by resident #012. The incident was reviewed, and it was noted that resident #011 did not feel threatened by resident #012 despite the incident. This was a one-off incident, and the harm to resident #011 was minimal.

The inspection protocols used included Falls Prevention, Personal Support Services, Prevention of Abuse, Neglect and Retaliation, and Responsive Behaviours. The non-compliances resulted in written notifications and voluntary plans of correction, with no compliance orders, director referrals, or work and activity orders issued.

This inspection highlighted the need for proper implementation of care plans and measures to prevent resident abuse, ensuring the safety and well-being of all residents in the care home.