Garry J Armstrong Home: Reviews & Inspection Reports

Garry J Armstrong Home (200 Island Lodge Road, Ottawa) is a nursing home that is owned and operated by the City of Ottawa. There are approximately 180 beds.

Inspection Reports for Garry J Armstrong Home

Our research team carefully reviewed and summarized inspection reports for Garry J Armstrong Home. You can read the original copies of the reports in the Government of Ontario website.

November 2023: Inspection

The inspection at Garry J Armstrong Home covered a range of issues, from alleged staff abuse to problems with meal service and fall incidents. The inspection, led by Margaret Beamish and Julienne NgoNloga, revealed several areas of non-compliance.

Plan of Care: There were issues with the execution and documentation of residents’ care plans. One resident was observed receiving meals that did not align with their prescribed diet, indicating a failure to reassess dietary needs. Another resident experienced physical abuse during care, revealing a lack of collaboration in developing and implementing care plans, especially regarding managing responsive behaviors.
Duty to Protect: The facility failed to protect a resident from physical abuse by a staff member, who acknowledged hitting the resident during care. This incident underlines the necessity for better staff training and adherence to abuse prevention protocols.
Licensee Consideration and Approval: The home withheld an applicant’s admission citing insufficient nursing expertise, which was not adequately justified or explained in writing as required by legislation.
Behaviours and Altercations: The home did not develop or implement adequate procedures to address a resident’s increasing physically responsive behaviors, increasing the risk of harm.
Safe Storage and Administration of Drugs: There were lapses in the safe storage and administration of drugs. Medications were left unattended in a resident’s room, and there was an incident of a resident self-administering medication without proper approval or oversight, which could potentially allow access to medications by other residents.

September 2023: Inspection

The inspection report for the Garry J. Armstrong Home, by Saba Wardak, Pamela Finnikin and Gabriella Kuilder, focused on several critical incidents. These incidents included verbal and sexual abuse between residents, alleged physical and verbal abuse by staff towards residents, and a fall resulting in injury and significant change in a resident’s condition.

A significant finding was under the category of Plan of Care, where the licensee failed to ensure that the care specified in the resident’s plan was provided. Specifically, a resident attempted to self-transfer, resulting in a fall. This incident occurred despite having instructions in their care plan to reduce the risk of injury related to falls. It was confirmed by registered staff and the Director of Care (DOC) that direct care staff did not follow these instructions, especially after the resident was transferred to bed prior to the incident. This lapse in following the care plan led to the resident sustaining an injury and increased their risk of injury.

July 2023: Inspection

The inspection report for the Garry J Armstrong Home, by Marko Punzalan and additional inspectors, covered various intakes including complaints about resident care and services, falls resulting in significant changes in health status, improper care, alleged financial abuse, and physical abuse.

Plan of Care: A resident who should have been transferred by two staff members using a mechanical lift was instead transferred by a single staff member, resulting in the resident sustaining a left ankle fracture. This incident occurred due to the failure to adhere to the resident’s transfer plan of care, which explicitly required two staff members for transferring and positioning.
Plan of Care Documentation: The resident’s plan of care stated that staff should conduct and document hourly monitoring of the resident. However, a review of the resident’s health records revealed missing documentation for these hourly checks. Interviews with the Registered Practical Nurse (RPN) and the Program Manager for Personal Care (PMPC) confirmed that this monitoring was not documented as required.
Delayed Reporting: A Critical Incident System (CIS) report related to improper transfer or positioning of a resident by a Personal Support Worker (PSW) was submitted four days late to the Director. The PMPC acknowledged the failure to report the incident immediately, violating the protocol that mandates timely reporting of such incidents.

March 2023: Inspection

The inspection report for the Garry J Armstrong Home, by lead inspector Lisa Cummings and Severn Brown, covered various intakes, including allegations of improper care, injury and personal care and services complaints, financial abuse, follow-up on a compliance order regarding falls prevention and management, and a written complaint about verbal abuse and personal care and services.

The inspection revealed non-compliance with respect to safe transferring techniques. A resident suffered an injury, which an investigation suggested could have been caused by the use of a mechanical lift.

Two Personal Support Workers (PSWs) admitted to using a specific type of mechanical lift for the resident but stated it had been used months prior to the injury. However, a Registered Nurse (RN) noted that residents should be assessed by a physiotherapist before using this type of lift, and the resident in question had not received such an assessment. The Program Manager of Personal Care found that the mechanical lift had been used more recently than the PSWs claimed. It was concluded that the injury pattern was consistent with the type of mechanical lift sling used, suggesting it could have caused the injury.

December 2022: Inspection

The inspection report for the Garry J Armstrong Home covers various critical incidents and complaints. The inspection was led by Lisa Cummings, with Sarah Stephens and Severn Brown.

Plan of Care: The home failed to provide clear directions in a resident’s plan of care regarding fall risk and mobility requirements. Despite the resident’s high risk of falls and subsequent falls leading to hospital transfer, the plan of care and Kardex lacked specific guidance on the level of assistance and the use of mobility devices.
Responsive Behaviours: There was a failure to implement the strategy of one-to-one supervision for a resident who required constant close supervision due to unpredictable behaviors. Incidents of the resident not being closely monitored led to altercations with other residents.
Falls Prevention and Management: The home was ordered to perform weekly audits and take corrective actions regarding their Falls Prevention Program. This order was issued because the home had not complied with its falls prevention policy for a resident who experienced multiple falls.

May 2022: Complaints Inspection

The inspection report for Garry J Armstrong Home, conducted by Anandraj Natarajan, outlines the findings from a Complaint inspection.

Meal Provision: The home did not comply with the requirement to offer each resident a minimum of three meals daily. A complaint was received alleging that a resident was not offered a lunch meal. Video footage review contradicted a Personal Support Worker’s (PSW) claim of delivering the meal.
Complaint Handling: The licensee did not adequately address verbal and written complaints regarding resident care. In one instance, a complaint about residents being rushed during meals and receiving cold or soggy food was not responded to. In another instance, a complaint about resident care was not addressed within the required 10 business days.
Plan of Care: The home failed to provide care as specified in a resident’s plan of care. Specifically, a PSW did not apply the resident’s dentures as per the instructions detailed in the care plan.

May 2022: Follow-Up Inspection

During the course of this inspection, Non-Compliances were not issued.

May 2022: Critical Inspection Inspection

The inspection report for the Garry J Armstrong Home, conducted by Anandraj Natarajan and Janet McParland, focuses on a Critical Incident System inspection.

The inspection covered various incidents, including injuries to residents with unknown causes, alleged emotional abuse by staff to a resident, improper resident care resulting in harm, a medication incident, and alleged physical abuse between residents.

The home failed to ensure that medication was administered to a resident as prescribed. In December 2021, a resident’s request for pain medication was delayed by approximately one hour, contrary to the prescription’s specified frequency.

January 2022: Critical Inspection Inspection

The inspection conducted at Garry J Armstrong Home, under the supervision of Inspector Anandraj Natarajan, focused on a Critical Incident System inspection. This inspection scrutinized critical incidents involving allegations of staff to resident abuse.

Failure to Protect Residents: The licensee did not protect resident #001 from sexual abuse by a staff member. This non-compliance was identified based on a Critical Incident Report and video footage showing the abuse.
Infection Prevention and Control: The inspection found that staff did not adhere to hand hygiene practices during meal services, raising concerns about infection control.
Plan of Care: The inspection noted a failure in adhering to a resident’s plan of care regarding two-person assistance for transfers.
Policy to Promote Zero Tolerance of Abuse and Neglect: The report highlighted a failure in immediate reporting of witnessed or suspected abuse by a Long-Term Care helper.
Investigation and Response to Incidents: There was a failure to immediately investigate incidents of abuse and to report suspicions to the Director, as required.
Notification About Investigation Results: The licensee did not notify the Substitute Decision Maker of resident #004 about the results of an abuse investigation immediately upon its completion.