Georgian Manor (101 Thompsons Road, Penetanguishene) is a nursing home that is owned and operated by Simcoe County. There are approximately 150 beds.
Inspection Reports for Georgian Manor
Our research team at Caring Magazine carefully reviewed and summarized inspection reports for Georgian Manor. You can read the original copies of the reports in the Government of Ontario website.
🔍 July 2023: Inspection
The inspection report details an inspection conducted at the Georgian Manor. The focus was on two critical incidents: an instance of physical abuse between residents and a fall of a resident resulting in injury.
The facility was found non-compliant, failing to complete post-fall assessments in their entirety. This included missing out on several crucial User Defined Assessments (UDAs) triggered by the post-fall assessment tool, such as Post Fall Huddle, Comprehensive Pain Assessment, Fall Risk Assessment, and Skin Assessment.
🔍 December 2033: Inspection
The inspection report by lead Tracy Muchmaker and Eva Namysl addressed two primary concerns: a resident’s fall resulting in hospital transfer and a follow-up to a previously issued Compliance Order related to responsive behaviors.
- Non-Compliance Remedied: During the inspection, a non-compliance issue was identified but remedied by the licensee before the inspection concluded. The issue was related to the implementation of hand hygiene standards as per the Infection Prevention and Control Standard. Initially, during a lunch meal observation, inspectors noticed that residents were not encouraged or assisted in performing hand hygiene (HH). After addressing this with a Personal Support Worker (PSW), improvement was observed the following day with staff assisting all residents with HH before meals.
- Written Notification of Non-Compliance: Another non-compliance issue (NC #002) was noted regarding infection prevention and control. Specifically, the licensee failed to ensure symptom monitoring for a resident showing signs of infection on every shift. It was found that during the resident’s isolation period, 18 out of 30 shifts had no documentation of symptom monitoring. This was confirmed through reviews of the resident’s progress notes and interviews with staff, including a Registered Practical Nurse, the IPAC Lead, and the Administrator.
A compliance order, which deals with responsive behaviors, from a prior inspection was reviewed and found to be in compliance.
🔍 August 2022: Inspection
The inspection for Georgian Manor, led by Sylvie Byrnes, Shannon Russel and Amy Geauvreau, addressed a range of issues including resident abuse, falls, and verbal abuse.
- Plan of Care: The facility failed to provide a resident with specific equipment as outlined in their care plan when they were transferred rooms. This non-compliance was acknowledged by the Director of Care.
- Bed Rails Usage: The facility didn’t fully assess the safety issues related to the use of bed rails for a resident. This included an absence of assessment of entrapment zones and latch reliability.
- Reporting and Complaints: There was a delay in reporting an incident of a resident exhibiting responsive behaviors towards another resident. The incident was reported two days late, contrary to the facility’s policy.
- Prevention of Abuse and Neglect: A resident exhibited sexual responsive behaviors towards another resident, and the facility failed to protect the resident from this abuse.
The facility was ordered to prepare, submit, and implement a plan to ensure that interventions identified in residents’ care plans for responsive behavior are implemented. This order was due to the failure to minimize the risk of harmful interactions among residents.
🔍 October 2021: Follow-Up Inspection
The follow-up inspection at Georgian Manor Home for the Aged, conducted from October 18-20, 2021, by inspectors Shannon Russell and David Schaefer, focused on verifying compliance with a previous compliance order and assessing the home’s infection prevention and control program.
The home failed to ensure full participation of staff in implementing the infection prevention and control (IPAC) program. Specifically, there was an issue with signage indicating additional precautions for isolated residents. The inspectors observed two resident rooms that had isolation caddies but lacked proper signage to identify the type of isolation precautions required. This lack of signage could lead to improper precautions and an increased risk of infection spread.
The inspection issued a Written Notification (WN) for non-compliance related to the infection prevention and control program, particularly regarding the implementation of signage for additional precautions.
The inspection found that the home was compliant with the previously issued Compliance Order (CO #001) from inspection #2021_907692_0001. This order had addressed ensuring that staff used safe lifts and transfer devices for residents, with a compliance due date of September 30, 2021.
🔍 October 2021: Critical Incident Inspection
The Critical Incident System inspection conducted by Inspector David Schaefer at the Georgian Manor, focused on a resident fall resulting in injury and subsequent hospital transfer.
- Resident Care Plans: The licensee did not ensure that the care outlined in a resident’s plan was provided as specified. There were multiple incidents where safety interventions identified in the resident’s care plan were not implemented, creating potential risk of harm. Additionally, a physician-ordered safety device was not implemented, leading to potential injury risk.
- Failure to Implement Safety Device: A specific case involved a physician ordering a trial of a safety device for a resident, which was not implemented at the time of the inspection. Despite the order being received and transcribed by a Registered Nurse, the safety device was not incorporated into the resident’s care.
- Unlocked Doors to Non-Residential Areas: The inspection found that doors leading to non-residential areas, specifically two supply rooms, were unlocked and unsupervised. This was a breach of regulations requiring such doors to be locked when not in use or unsupervised, posing a safety risk.
The inspection resulted in two Written Notifications for non-compliance and requested a voluntary plan of correction to address the care plan issues.
🔍 August 2021: Critical Incident Inspection
The Critical Incident System inspection conducted at the Georgian Manor, by Inspector Shannon Russell, focused on various critical incidents including an unexpected death of a resident, abuse of a resident resulting in harm, and an incident causing significant change in a resident’s health status after a fall.
- Safe Transferring and Positioning Techniques: The licensee failed to ensure that staff used safe techniques when assisting residents. Specifically, a PSW assisted a resident alone with an activity of daily living (ADL) which should have required two-person assistance, resulting in a fall and significant change in health status. This non-compliance was observed in multiple instances over a 30-day period.
- Failure to Document Assessments and Responses: The licensee did not adequately document assessments and responses to a resident exhibiting responsive behaviors. This involved an incident where a resident was injured due to another resident’s responsive behavior, and the monitoring process documentation was incomplete.
- Non-Compliance with Cooling Requirements: The licensee failed to revise and implement the heat-related illness prevention and management plan during the period from May 15 to September 15 as per new regulations. This oversight was due to a misunderstanding of the requirements as the home was fully air-conditioned.
- Failure to Measure and Document Air Temperature: The licensee did not measure and document air temperatures in at least two resident bedrooms and one common area on every floor as required. This was only done once daily at the nursing station, which was not in compliance with the regulations.
The licensee was ordered to ensure staff used safe transferring and positioning devices or techniques when assisting residents. This included reviewing policies with nursing staff, providing hands-on re-training, maintaining records of training, and conducting weekly audits to ensure compliance.
🔍 May 2011: Critical Incident Inspection
The Critical Incident System inspection at Georgian Manor, conducted by Inspector Jennifer Nicholls, focused on several incidents, including injuries to residents leading to hospitalization and allegations of staff-to-resident abuse.
The licensee failed to ensure proper documentation of care for a resident who had sustained a fall. Specifically, there were missing entries in the resident’s assessment form, which were not recorded by staff. This non-compliance was acknowledged by the acting Director of Resident Care (DRC) during an interview with the inspector.
A Written Notification (WN) was issued for failing to comply with the requirements related to the documentation of care provision, outcomes, and the effectiveness of the care plan.