Gilmore Lodge (50 Gilmore Road, Fort Erie) is a nursing home that is owned and operated by Niagara Region. There are approximately 80 beds.
Inspection Reports for Gilmore Lodge
Our research team at Caring Magazine carefully reviewed and summarized inspection reports for Gilmore Lodge You can read the original copies of the reports in the Government of Ontario website.
May 2023: Inspection
The inspection focused on several critical issues including abuse of a resident, whistleblowing protection, neglect of residents, and staff training and care standards. The primary issues identified during this inspection were related to transferring and positioning techniques used by staff.
In January 2023, a resident who required assistance for transfer reported an inability to use their usual assistive device. Despite this change in their ability to transfer safely, the Personal Support Worker (PSW) did not report the resident’s decline to registered staff and proceeded with the transfer. During this process, the resident experienced pain in their arm. This incident was not reported to the management team until the resident’s family informed them. The resident subsequently required medical attention at Urgent Care.
The Director of Resident Care (DRC) confirmed that staff were trained on policies and procedures for safe transferring of residents. The PSW was expected to assess the situation prior to the transfer and seek additional assistance if necessary. However, in this instance, these protocols were not followed.
The failure of the PSW to adhere to safe transferring techniques and report the incident led to the resident sustaining an injury. This was confirmed through post-hospital assessments.
The Clinical Documentation Informatics Lead (CDI Lead) confirmed that the incident was not reported to registered staff by the PSW. The management team only became aware of the incident through the resident’s family, indicating a lapse in communication and reporting within the facility.
November 2022: Inspection
This inspection report details a Critical Incident System inspection, led by Sydney Withers and Angela Finlay. The inspection focused on various aspects, including infection prevention and control, medication management, and falls prevention and management.
- Expired Hand Hygiene Products: The inspection found non-compliance regarding hand hygiene products. Specifically, on November 4 and 7, 2022, expired wall-mounted alcohol-based hand rub (ABHR) bags were observed in the resident home areas. The issue was addressed promptly after being identified, with expired ABHR bags replaced by November 7, 2022, minimizing the risk to residents.
- Non-Compliance with Minister’s Directive: On November 7, 2022, a staff member was observed providing care to a resident with suspected or confirmed COVID-19 while wearing two medical masks instead of the required N95 respirator. This was in violation of the Minister’s Directive, which mandates the use of N95 respirators in such scenarios. Although the staff member was working with only one resident, this non-compliance posed a potential risk.
- Administration of Unprescribed Drugs: The licensee was found non-compliant in ensuring that no drug was administered to a resident unless prescribed for that resident. In December 2021, a nurse administered medication to the wrong resident, who had no prescription for it. This incident could have posed significant health risks to the resident.
November 2021: Complaints Inspection
This inspection report focuses on a Complaint inspection, covering various aspects including end-of-life care, bathing, nutritional care, skin and wound care, medication use, physiotherapy services, and information provision to the Substitute Decision Maker (SDM). The inspection took place over several days in November 2021.
- Plan of Care: The licensee failed to ensure that a resident’s care plan was based on an identified assessment. This oversight meant that the care provided might not have been based on the resident’s specific needs. Additionally, the licensee did not ensure full participation of the resident’s SDM in the development and implementation of their plan of care. The resident’s condition and prognosis were not fully explained to the SDM, indicating a lack of adequate communication and involvement.
- Skin and Wound Care: There was a failure to conduct appropriate skin assessments using clinically appropriate instruments when wounds were identified in two residents. This non-compliance exposed the residents to risks of poor wound healing due to the lack of timely and adequate assessments.
The licensee was requested to prepare a Voluntary Plan of Correction (VPC) to achieve compliance in both areas. This includes ensuring that care plans are based on thorough assessments and that the SDM is fully involved in their development and implementation. Additionally, the licensee must ensure that residents with altered skin integrity receive timely and proper skin assessments by qualified nursing staff.
November 2021: Critical Incident Inspection
The report was made after a Critical Incident System inspection, focusing on incidents related to falls.
- Plan of Care: The licensee did not ensure that plans of care for three residents were based on interdisciplinary falls risk assessments. In each case, the residents were identified as being at high risk for falls, but subsequent fall incidents resulted in multiple injuries. It was found that other disciplines did not participate in the falls risk assessment process. This oversight potentially put these residents at risk of harm due to inadequate assessment and planning for fall prevention.
The licensee was requested to prepare a Voluntary Plan of Correction (VPC) to achieve compliance. This includes ensuring that plans of care are based on interdisciplinary assessments of health conditions, specifically regarding the risk of falls.
April 2021: Complaints Inspection
During the course of this inspection, Non-Compliances were not issued.