Extendicare York (333 York Street, Sudbury) is operated by Extendicare, a for-profit operator of long-term care homes in Canada. There are approximately 290 beds in private, semi-private and shared rooms.
Inspection Reports for Extendicare York
Our research team at Caring Magazine carefully reviewed and summarized inspection reports for Extendicare York. You can read the original copies of the reports in the Government of Ontario website.
🔍 December 2023: Inspection
The inspection report for Extendicare York addresses several compliance issues. The inspection, led by Karen Hill, focused on a range of protocols including Skin and Wound Prevention and Management, Infection Prevention and Control, Prevention of Abuse and Neglect, and Falls Prevention and Management.
- Plan of Care: The licensee did not revise the care plan of a resident when their care needs related to toileting changed. However, this was remedied after discussion with the inspector.
- Plan of Care: Issues were identified with the resident’s written plan of care, including missing care interventions and lack of clear directions for falls prevention needs.
- Investigation of Alleged Neglect: The licensee did not immediately investigate an alleged incident of neglect of a resident.
- Reporting to the Director: Failure to report a suspicion of neglect of a resident to the Director.
- Directives by Minister: Non-compliance with masking requirements as per the Minister’s Directive.
- Skin and Wound Care: The licensee failed to reassess a resident with altered skin integrity at least weekly as required.
- Continence Care: The licensee did not provide requested assistance for toileting to a resident, using continence care products instead.
- Infection Prevention and Control Program: The licensee was ordered to conduct weekly documented audits on the monitoring process of residents with symptoms indicating the presence of infection.
🔍 August 2023: Inspection
The inspection report for Extendicare York focuses on a follow-up and critical incident system inspection. Amy Geauvreau and Chad Camps assessed various aspects, such as medication administration, alleged improper or incompetent care, alleged abuse, and compliance with previously issued orders.
- Reassessment and Revision of Care Plan: The licensee failed to reassess and revise a resident’s care plan when the current plan was ineffective. This was evident in the resident’s behavior towards another resident, where the required focused intervention was not provided in a specific area. Personal support and registered staff expressed their inability to provide the needed intervention, necessitating changes to the resident’s care plan.
- Responsive Behaviours: The licensee did not document actions, assessments, reassessments, interventions, and responses to interventions for a resident’s responsive behaviors. This included a lack of documentation by an RPN following an incident between two residents, and an RN’s removal of a resident’s plan of care intervention without proper documentation. The failure to document these actions posed a moderate risk of harm to other residents.
🔍 May 2023: Inspection
The inspection report for Extendicare York details an inspection by Jennifer Lauricella. This inspection focused on various critical incidents and complaints including a resident’s death, medication incidents with adverse reactions, alleged abuse, and incidents causing injuries to a resident.
- Critical Incident Reporting: The licensee did not inform the Director within one business day after the occurrence of an incident that caused significant injury to a resident, resulting in hospitalization.
- Medication Administration: The home failed to comply with prescribed medication protocols, leading to a resident receiving two incorrect medications and requiring hospital transfer.
- Safe and Secure Home: The licensee was ordered to develop and implement an auditing process to ensure the safe positioning of bed systems in resident rooms and to prevent unauthorized adjustments to specific devices in resident rooms. This was in response to an incident where a resident was unsafely positioned in their room, leading to injury.
🔍 January 2023: Inspection
The inspection report for Extendicare York provides an analysis of various issues at the facility. Conducted by Lisa Moore, the inspection addressed allegations of abuse, neglect, improper medication management, and a medication error leading to a hospital transfer.
- Prevention of Abuse and Neglect: A resident did not receive required care from a Personal Support Worker (PSW). This neglect was confirmed by the home’s investigation, and it was noted that there was no documentation of care provided. The neglect led to a moderate impact and risk to the resident.
- Reporting and Complaints: A Registered Practical Nurse (RPN) discovered that a resident had not received care but did not immediately notify the Manager or the Director, which was a failure in protocol.
- Administration of Drugs: A medication error occurred when a Registered Nurse (RN) failed to update the electronic medication administration record (eMAR), leading a RPN to administer medication on an incorrect date. This error posed a moderate risk to the resident.
- Plan of Care: A PSW attempted to provide care to a resident without the assistance of another staff member, contrary to the resident’s care plan, which required two staff members. This failure led to a low impact and risk to the resident.
🔍 August 2022: Inspection
The inspection report for Extendicare York was issued by Steven Naccarato. The inspection focused on various critical incidents and compliance orders.
- COVID-19 Self-Assessment Audits: There was a failure to comply with the Minister’s Directive regarding COVID-19 response measures, specifically the development and implementation of a COVID-19 Outbreak Preparedness Plan which included regular Infection Prevention and Control (IPAC) audits. The required COVID-19 Self-Assessment Audit Tool was not completed by the home before the inspection. However, this was remedied during the inspection, with no significant impact or risk to residents noted.
- Residents’ Bill of Rights: There was an incident where a staff member did not treat a resident with courtesy and respect, recognizing the resident’s individuality and respecting their dignity. This non-compliance resulted in moderate harm to the resident.
A previously issued Compliance Order, related to care not provided as specified in the plan of care, was found to be in compliance.
🔍 June 2022: Inspection
The inspection for Extendicare York, led by Sylvie Byrnes and Loviriza Caluza, covered several critical incidents, complaints, and compliance-related aspects.
- Plan of Care: There were multiple instances where the licensee failed to document outcomes in the plan of care, reassess resident care needs, and include the resident or designated persons in the care planning process.
- Maintenance Services: Issues were noted with the maintenance of the home, specifically regarding the safety of the residents’ smoking area, where posts and ruts posed a moderate risk of falls.
- Fall Prevention and Management: The inspection revealed failures in conducting post-fall assessments, especially when residents were away on leave.
- Dining and Snack Service: The licensee did not provide necessary eating aids and assistive devices to a resident, posing a moderate risk.
- Reporting and Complaints: There was a failure to address and respond to a written complaint concerning a resident’s care needs within the required timeframe.
- Safe Storage of Drugs: Drugs were not securely stored, as a medication room was left unlocked, posing a moderate risk to residents.
- Infection Prevention and Control: Hand hygiene assistance before meals was not adequately provided, creating a moderate risk.
The licensee was ordered to prepare, submit, and implement a plan to ensure the implementation of fall prevention interventions as specified in the residents’ care plans.
🔍 February 2022: Complaints Inspection
The inspection report for Extendicare York in Sudbury, conducted by Steven Naccarato, focused on a complaint inspection. The primary objective was to address a complaint, including investigating a resident’s fall resulting in injury and concerns related to resident care and building maintenance.
The licensee failed to ensure that staff used safe transferring devices and techniques when assisting a resident. Specifically, after an unwitnessed fall of a resident, the staff manually assisted the resident to stand without an assessment by a registered staff member. It was highlighted that using a mechanical lift was required for safe lifting after the assessment.
A Voluntary Plan of Correction (VPC) was requested to ensure compliance with safe transferring devices and techniques for resident assistance.