Hillsdale Estates

Hillsdale Estates (590 Oshawa Boulevard North, Oshawa) is owned and operated by Durham Region. There are approximately 160 beds.

Inspection Reports for Hillsdale Estates

Our research team carefully reviewed and summarized inspection reports for Hillsdale Estates. You can read the original copies of the reports in the Government of Ontario website.

August 2023

• Plan of Care: There were instances where care was not provided to residents as per their plan of care, causing mistrust and frustration among residents and their families.
• Reporting and Complaints Issues: The licensee failed to forward certain written complaints to the Director, and did not maintain proper records of complaints, impacting the home’s ability to analyze and improve its complaints management process.
• Nutritional Care and Hydration Programs: The home did not follow its own “Provisions of Fluids” policy, leading to a resident being diagnosed with dehydration and sepsis.
• Accommodation Services: The process for locating lost resident clothing and personal items was not properly implemented, affecting the resident’s dignity.
• Infection Prevention and Control Program: Symptoms indicating the presence of infection in residents were not monitored every shift, putting residents at risk of not receiving timely interventions.
• Prevention of Abuse and Neglect: The licensee failed to protect residents from abuse and neglect. In one instance, staff failed to adhere to a resident’s plan of care requiring two people for certain care, and in another, a resident was not protected from abuse by another resident.
• Administration of Drugs: Pain medication was not administered to a resident as prescribed, potentially leading to unmanaged pain.

Two compliance orders were issued. The first order relates to the duty to protect residents from abuse and neglect. The second order requires the implementation of required programs, specifically education for staff on pain management and conducting post-fall audits.

March 2023

• Plan of Care Non-Compliance: There was a failure in staff collaboration, leading to a missed diagnostic test for a resident after an altercation. This lack of coordination among care staff could compromise the resident’s health and delay necessary medical interventions.
• Zero Tolerance Policy Non-Compliance: The home did not follow its own policy regarding zero tolerance of abuse and neglect, lacking summary documentation in their investigation files.
• Failure to Investigate Abuse Immediately: The home did not immediately investigate an alleged resident-to-resident abuse incident, increasing the risk of further abuse.
• Weight Changes Non-Compliance: The Registered Dietician failed to conduct nutritional assessments for a resident with significant weight changes.
• Responsive Behaviours Non-Compliance: The home did not have written approaches to care for residents with responsive behaviors, nor did it identify behavioral triggers for such residents.
• Infection Prevention and Control Non-Compliance: The home failed to implement standards for infection prevention and control, including proper use of PPE and outbreak management protocols.
• Failure to Notify Substitute Decision-Makers: The home did not notify the substitute decision-makers of residents about the results of abuse investigations immediately upon completion.
• Medication Incidents Non-Compliance: The home did not document, review, and analyze all medication incidents involving a resident.
• Pain Management Non-Compliance: When a resident’s pain was not relieved by initial interventions, the home failed to assess the resident using an appropriate instrument.
• Altercations and Interactions Between Residents Non-Compliance: The home failed to minimize the risk of altercations and harmful interactions between residents by not implementing effective interventions.

March 2022

In the first of two inspections, the inspection focused on a Critical Incident System inspection from March 14 to 18, 2022. The inspection was led by Sami Jarour, who, along with other team members, evaluated several critical incidents including allegations of neglect and abuse, as well as fall incidents.

• Non-Compliance with Use of Personal Assistance Services Devices (PASDs): The facility failed to include the use of PASDs in the care plans of residents #003, #006, and #007, even though they were being used for these residents. This oversight was acknowledged by various staff members, including a Personal Support Worker (PSW) and an Occupational Therapist (OT).
• Delayed Reporting of Neglect to the Director: An incident of alleged neglect was not reported to the Director immediately, as mandated. It was reported five days after the incident, highlighting a lapse in timely communication and potentially increasing the risk of harm to residents.
• Delayed Reporting of Critical Incident: There was a failure to inform the Director within one business day about a resident’s fall that resulted in a significant change in their health condition. The report to the Director was made six days after the incident, which was a deviation from the required protocol.

The facility was required to prepare a Voluntary Plan of Correction (VPC) to ensure compliance with the inclusion of PASDs in residents’ care plans.

In the second of two inspections, no compliance issues were found.

January 2022

The first inspection was led by inspectors Susan Semeredy, Julie Dunn, and Lynda Brown, which was a comprehensive Complaint inspection. This inspection covered multiple areas, including Infection Prevention and Control (IPAC) practices, dining and recreational services, prevention of abuse, responsive behaviors, fall prevention, pain management, and several other aspects crucial to the well-being of residents in long-term care homes.

• Non-Compliance in Monitoring Food Temperatures: The policy for monitoring food temperatures was not followed correctly. Staff were not recording temperatures properly, which could lead to serving food at unsafe or unpalatable temperatures.
• Failure in Drug Destruction Policy: There were instances where medication, including narcotics, was disposed of improperly by an RPN, contrary to the home’s drug destruction policy.
• Inadequate Protection from Abuse: The facility failed to protect residents from abuse by another resident who had a history of inappropriate comments and behaviors.
• Lack of Immediate Reporting of Abuse: There was a failure in promptly reporting incidents of abuse to the Director, increasing the risk of further abuse.
• Deficiencies in Responsive Behavior Management: The home did not adequately reassess or document interventions for a resident’s responsive behaviors, thereby failing to address the issue effectively.
• Recreational and Social Activities Program Lapses: The facility did not develop, implement, or communicate a comprehensive schedule of recreational and social activities, especially during evenings and weekends.
• Plan of Care Issues: There was a failure to reassess and revise a resident’s plan of care when their needs changed, particularly after a fall that resulted in a hip fracture.

The second inspection was a Critical Incident System inspection, conducted by Susan Semeredy, Julie Dunn, and Lynda Brown. This inspection focused on several critical areas including falls prevention, medication management, prevention of abuse, responsive behaviors, and the safe storage of drugs.

• Failure to Ensure a Safe Environment: The facility did not adequately ensure resident safety, especially in an incident involving a resident known for responsive behaviors who physically threatened another resident.
• Inadequate Measures to Prevent Resident Altercations: The home failed to take necessary steps to minimize the risk of altercations and potentially harmful interactions among residents.
• Unsafe Drug Storage Practices: There were instances where medication carts were left unattended and unlocked, posing a risk of unauthorized access to medications.
• Non-Compliance in Drug Administration: There were two cases where an RPN failed to administer medications as prescribed, resulting in disciplinary action.

The third inspection was a Director Order Follow-Up inspection, which took place from December 15 to 22, 2021. This inspection focused on two main areas: a Director’s Order for a safe and secure home, and a Compliance Order for Infection Prevention and Control (IPAC).

• Non-Compliance with Infection Prevention and Control Program: The facility failed to ensure staff participation in the IPAC program. This non-compliance was identified earlier and a Compliance Order was re-issued due to continued issues, such as inadequate availability of Personal Protective Equipment (PPE) and improper practices in donning and doffing PPE. This failing put residents at risk of cross-contamination and exposure to COVID-19.
• Non-Compliance with Safe and Secure Environment Requirements: The facility did not comply with a Director’s Order issued on October 18, 2021, regarding the safety and security of residents. Specifically, the order required that every individual entering the home should complete a COVID-19 screening assessment form, and this should be verified before allowing entry. However, the inspection observed that the screening process was not being adequately enforced, posing a risk of COVID-19 transmission.

December 2021

The Critical Incident System inspection revealed several areas of non-compliance7. The inspection was completed by Tammy Szymanowski.

• Safe and Secure Environment: The home failed to provide a safe and secure environment during a COVID-19 outbreak. Staff and residents were affected, and the home did not adhere to necessary precautions, leading to potential transmission risks.
• Infection Prevention and Control (IPAC) Practices: Staff failed to follow proper IPAC practices, including hand hygiene, correct use of Personal Protective Equipment (PPE), and maintaining cleanliness. This non-compliance posed a significant risk of infectious disease transmission within the facility.
• Resident Privacy: The home did not consistently maintain residents’ privacy during personal care, with instances of care being provided without ensuring doors or curtains were closed.
• Labeling of Personal Items: Personal items of residents were not appropriately labeled, posing risks of cross-use and sanitation issues.
• Dining and Snack Service: The home did not ensure safe positioning of residents who required assistance with eating, leading to risks of choking or aspiration. Meals were also served before assistance was available, impacting the quality and safety of resident meal times.