Grace Villa Nursing Home

Grace Villa Nursing Home, located at 45 Lockton Crescent in Hamilton, is operated by Apans Health Services and has a capacity of approximately 180 beds.

December 2023 🚨

The inspection was completed by Meghan Redfearn, Yuliya Fedotova, and Stephanie Smith.

• Reporting Abuse and Neglect: The licensee did not ensure immediate reporting to the Director about a suspected abuse incident. This was in violation of the policy that mandates immediate reporting of any suspicion of abuse or neglect.
• Urinary Tract Infection Management Non-Compliance: The licensee failed to comply with the urinary tract infection management protocol. Despite documentation in the plan of care and lab reports showing microbiological organisms in a urine sample, there was no documented assessment of these results, confirmed by the Associate Director of IPAC.
• Transferring and Positioning Techniques: The home did not ensure the use of safe transferring and positioning techniques, leading to an injury of a resident during a transfer by an insufficient number of staff.
• Plan of Care Inconsistencies: The inspection revealed discrepancies in the resident’s plan of care regarding the number of staff required for transfers. This led to an incident where a resident was injured due to improper transfer assistance by an agency Personal Support Worker (PSW), highlighting the need for clear directions in care plans.
• Fall Prevention and Management: The facility did not implement a “falling leaf” intervention as part of its fall prevention strategy, despite it being a policy requirement. This oversight was confirmed by the Interim Executive Director and put high-risk residents at a greater risk of falls.
• 24-hour Admission Care Plan: A resident’s 24-hour admission care plan failed to include all necessary activities of daily living (ADLs), posing a risk to the resident. This oversight was later acknowledged and corrected by the Resident Assessment Instrument (RAI) Coordinator.
• Police Record Checks for Staff: The home failed to conduct police record checks within the required six-month period before hiring a staff member. This was highlighted by an incident involving an agency PSW whose police check was outdated, leading to their dismissal from the home.

October 2023 🚨

The inspection report was completed by Pauline Waldon and Betty Jean Hendricken.

• Plan of Care Non-Compliance: The home failed to ensure clear directions in the resident’s care plan, particularly regarding toileting and bathing, which did not match the resident’s actual care needs.
• Falls Prevention and Management Non-Compliance: The home did not adhere to its falls prevention and management program. After a resident’s fall, the required Head Injury Routine (HIR) monitoring was not fully completed, risking undetected adverse effects from the fall.
• Skin and Wound Care Non-Compliance: The facility failed to perform necessary skin and wound assessments for a resident with altered skin integrity. This lack of assessment meant the resident’s wounds were potentially not treated appropriately.
• Reporting of Critical Incidents: The home did not report a critical incident to the Ministry immediately as required.
• Emergency Plan for Missing Resident: The staff failed to follow the home’s Code Yellow plan when a resident was missing, leading to the resident’s fall and subsequent injury.

Additionally, two compliance orders were issued:

• Bathing Compliance Order: The home was ordered to ensure that two residents receive their preferred method of bathing at least twice a week, with proper documentation and daily audits of bathing records.
• Transferring and Positioning Techniques Compliance Order: The facility was directed to educate all staff on safe transferring techniques, maintain records of this training, and conduct regular audits related to transferring and bed mobility for certain residents.

June 2023 🚨

The inspection covered a period from March to May 2023. It was completed by Adiilah Heenaye, Lisa Vink, Sydney Withers, and Lesley Edwards.

• Plan of Care: There were instances where the written plans of care for residents did not provide clear directions for staff, leading to discrepancies with physician orders and assessments of fall risks. These were addressed and remedied during the inspection.
• Complaint Investigation: The report noted instances where alleged staff-to-resident abuse claims were not investigated promptly.
• Reporting of Suspected Abuse: The home was found to have delayed reporting suspected abuse to the Director.
• Residents’ Rights: Issues were identified concerning the treatment of residents, with some feeling their dignity was not fully respected. There were also delays in responding to residents’ service requests.
• Skin and Wound Care: The home showed lapses in conducting timely skin and wound assessments and subsequent reassessments.
• Falls Prevention and Management: The facility’s falls prevention program was not consistently followed, particularly in documenting interventions and monitoring after falls.
• Dining Services: The inspection found issues related to the communication of menu substitutions, maintenance of dining supplies, and cleanliness in dining service areas.
• Infection Prevention and Control: There were observations of staff not using appropriate personal protective equipment.
• Medication Administration: Delays in the administration of medication as per prescriber’s instructions were noted, which could impact resident health.

March 2022 🚨

The inspection was completed Parminder Ghuman, Angela Finlay, and Lisa Vink.

1. Plan of Care Non-Compliance: The licensee failed to provide specified care in residents’ plans, particularly concerning responsive behavior interventions and timely responses to assistance requests. This failure raised concerns about potential harm or increased fall risk for residents.
2. Documentation Lapses: There were instances where the provision of responsive behavior interventions was not adequately documented, contradicting the expectations set by Grace Villa’s administration.
3. Abuse Protection Failures: The home did not adequately protect a resident from abuse by another resident with a history of responsive behaviors, leading to a reported incident of abuse and subsequent hospitalization.
4. Infection Control Practices: Certain staff members did not adhere to IPAC program requirements, specifically in the use of Personal Protective Equipment (PPE), thus posing infection risks to residents.
5. Bathing Frequency: The facility did not meet the requirement to bathe residents at least twice a week, or as indicated by their medical condition, affecting residents’ hygiene.
6. Handling Complaints: The home failed to maintain documented records of complaints, particularly regarding alleged abuse, which contravened their own “Response to Complaints” policy.

In response to these findings, the inspectors issued Compliance Orders and a Voluntary Plan of Correction, requiring the licensee to address these issues promptly. The orders included re-training staff on IPAC practices, ensuring interventions for responsive behaviors, and improving the documentation process. The licensee was given specific deadlines to comply with these orders.

August 2021 🚨

The inspection report, conducted by Emmy Hartmann and Daria Trzos, focused on a critical incident system at Grace Villa Nursing Home in Hamilton, Ontario. The inspection, spanning from July 21 to August 10, 2021, involved a thorough examination of the facility and interactions with a wide range of staff members. Key protocols such as Falls Prevention, Infection Prevention and Control, and the Prevention of Abuse, Neglect, and Retaliation were used during the inspection.

The report highlights several areas of non-compliance. Firstly, the nursing home failed to use safe transferring and positioning devices when assisting a resident after a fall, contrary to its “Zero Lift and Transfer” program. This breach could lead to further injuries for residents.

Another major concern was the violation of the Residents’ Bill of Rights. An incident of physical abuse towards a resident by a Personal Support Worker (PSW) was reported. The PSW involved had not received training on the home’s prevention of abuse and neglect policy and the Resident’s Bill of Rights, reflecting a serious lapse in staff training and orientation.

Additionally, the report indicates that the nursing home did not ensure that all staff received orientation training on policies promoting zero tolerance of abuse and neglect of residents. This oversight was particularly critical during the COVID-19 pandemic, where rapid changes in regulations and staffing occurred. The lack of adequate training posed a risk to resident safety and well-being.

May 2020 🚨

The inspection, led by Daria Trzos and Yuliya Fedotova, was extensive, spanning multiple days and involved detailed examinations of various incidents and procedures at the facility.

• Frequent Falls with Injury: The inspection uncovered multiple incidents where residents suffered falls leading to injuries. These incidents indicate significant gaps in the facility’s fall prevention strategies, highlighting a need for more robust measures to protect the residents.
• Inadequate Care Plans: The inspectors noted that the written care plans for residents were often insufficient. These plans lacked clarity and detail, particularly in areas like fall prevention and management of responsive behaviors. The inadequacy of these plans was evident in their failure to prevent incidents and to provide clear guidance to staff.
• Failure in Documentation and Reassessment: The nursing home showed a consistent failure in properly documenting the care provided to residents. Furthermore, there was a lack of timely reassessment and revision of care plans in response to changing needs of residents or ineffective care strategies, which is crucial for ensuring continued appropriate care.
• Management of Responsive Behaviors: The facility was found lacking in effectively managing residents’ responsive behaviors. There were gaps in developing and implementing strategies to address these behaviors, which are critical for maintaining a safe and supportive environment for all residents.
• Inadequate Reporting of Incidents: The inspection highlighted instances where staff failed to report significant incidents in a timely and appropriate manner. This included cases of alleged abuse, where the reporting was either delayed or not conducted as per the required standards, which is a serious oversight in resident care and safety.
• Record Keeping Issues: The nursing home was not consistent in maintaining accurate and up-to-date records for each resident. This is a crucial aspect of resident care, as it ensures that all relevant information is readily available for making informed decisions about their care.

December 2019 🚨

The inspection, conducted by Jessica Paladino, primarily focused on a complaint inspection.

1. Non-Compliance with Bowel & Bladder Program Policy: The licensee did not comply with the Bowel & Bladder Program Implementation Policy. This policy mandates that residents should not be left unattended during certain care aspects, unless specified otherwise in the plan of care. However, it was found that two residents, #001 and #003, were left unattended, contrary to the requirements of their respective care plans. This resulted in an injury to resident #001.
2. Internal Investigation and Video Footage: The inspection team’s findings were supported by internal investigation notes, video footage, and interviews with the police, ED, and DOC. These sources confirmed that the residents were left unsupervised for an extended period.
3. Non-Compliance and Orders Issued: A Compliance Order was issued to the licensee. The order included specific directives to ensure that residents requiring monitoring during particular care aspects are not left unattended and to provide re-education to staff members involved.
4. Severity and Scope of the Issue: The severity of the issue was categorized as level 3 due to actual harm caused to a resident. The scope was determined to be level 2 as it affected two of the three residents reviewed. The home had a history of non-compliance in this area, as evidenced by previous Voluntary Plan of Correction and Written Notification.

April 2019 🚨

The inspection, conducted from April 11 to 18, 2019, by inspectors Jessica Paladino and Cathie Robitaille, was a comprehensive evaluation focusing on complaints related to food quality and medication administration.

1. Plan of Care Non-Compliance: The home failed to provide care as specified in the resident’s plan of care. This was particularly evident in a complaint about food quality by a resident’s family member. Despite being recognized and documented, the intervention specified in the resident’s diet record was not followed during meal services.
2. Non-Compliance with Food Policy: The home’s “Food Temperature Control” policy was not adhered to. A review of the food temperatures log revealed that no food temperatures were recorded at breakfast on several occasions.
3. Food Quality Issues: There were significant complaints regarding the quality of food, specifically the toast served at breakfast being soggy. Despite the home being aware of these concerns, observations during the inspection confirmed that the toast was indeed soggy. This issue was raised by multiple residents and acknowledged by staff, indicating a failure to prepare, store, and serve food in a manner that preserves its quality and appeal.