Hillsdale Terraces (600 Oshawa Boulevard North, Oshawa) is owned and operated by Durham Region. There are approximately 200 beds.
Inspection Reports for Hillsdale Terraces
Our research team carefully reviewed and summarized inspection reports for Hillsdale Terraces. You can read the original copies of the reports in the Government of Ontario website.
September 2023
The inspection, conducted between August 23 and September 1, 2023, revealed several areas of non-compliance in the management of resident care, specifically in handling medication and addressing responsive behaviors.
- Behaviors and Altercations: The facility failed to properly implement procedures and interventions for residents at risk of harm due to responsive behaviors. A critical incident involving physical assault between two residents with cognitive impairment and known responsive behaviors was reported. Both residents were left unsupervised at the time of the incident. The care plan lacked details about triggers for the aggressor’s responsive behaviors, although staff were aware of these triggers. Continued altercations between the two residents indicated a lack of effective intervention.
- Medication Management System: There were significant gaps in the medication management system, particularly in the documentation of administered drugs and narcotic count during shift changes. The facility’s policies required detailed documentation for narcotics and controlled substances, but reviews revealed missing information in the records for several residents. Additionally, there were lapses in the narcotics count procedure, compromising the accuracy of medication tracking.
- Medication Incidents and Adverse Drug Reactions: The facility failed to document a medication incident involving a resident properly and did not report the incident to the resident’s attending physician. It was unclear if a resident had received a second dose of medication, and no immediate assessment was documented to check for any adverse effects. The lack of communication with the resident’s physician further compromised the resident’s safety and care.
June 2022
The inspection focused on several critical areas including falls prevention, allegations of neglect, infection prevention and control, and residents’ rights and choices. This inspection also included follow-ups to previous compliance orders.
- Infection Prevention and Control: Expired hand hygiene agents were observed on two resident units, compromising the effectiveness of infection prevention and control measures. The issue was remedied by replacing expired products with valid ones and implementing a process to monitor expiration dates.
- Resident Privacy: A resident’s privacy was not fully protected during personal care due to improperly closed curtains. This was addressed by ensuring curtains were properly closed and referring maintenance issues for repair.
- Critical Incidents: The facility failed to include full names of staff members responding to a critical incident in a report submitted to the Director. This was identified as a breach of the regulation requiring detailed documentation of incident responses.
February 2022
The inspection report, conducted by inspectors Jennifer Batten and Catherine Ochnik, highlighted several compliance issues. The inspection was carried out during the Omicron COVID-19 outbreak, which necessitated the implementation of contact/droplet isolation precautions and affected the usual operations of the home.
- Meal Service: The home failed to offer a minimum of three meals daily to residents #011, #024, and #025. This was due to the transition to tray service for all meals served in resident bedrooms during the outbreak. The inspection noted instances of residents not receiving the correct meal or any meal at all, and others being offered inappropriate meal replacements.
- Dining and Snack Service: The home did not adhere to regulations regarding proper techniques and safe positioning for residents requiring eating assistance. Meals were not served at safe and palatable temperatures, and residents were placed in unsafe positions during intake, increasing the risk of choking or aspiration. There were also deficiencies in the availability of appropriate furnishings and equipment for meal services.
- Infection Prevention and Control: There were numerous lapses in infection prevention and control practices. This included inconsistent hand hygiene practices among staff, improper use of PPE, and poor management of contaminated items. These issues posed actual risks of harm to residents due to potential transmission of infectious agents.
March 2021
Complaints Inspection
The inspection report outlines several areas of non-compliance. The inspection, primarily a complaint inspection, was carried out over several dates in February and March 2021.
- Pain Management: The licensee failed to ensure comprehensive pain assessments using clinically appropriate instruments for residents whose pain was not relieved by initial interventions. This non-compliance was widespread, affecting multiple residents. The pain management program lacked clear directions for staff on the necessity of comprehensive assessments in certain situations.
- Program Development: The licensee was found non-compliant with ensuring the development and implementation of interdisciplinary programs such as falls prevention, skin and wound care, continence care, and pain management. Specifically, the pain management program did not adequately include procedures for assessing pain unrelieved by initial interventions.
- Authorization for Admission: The home failed to demonstrate adequate reasons for refusing admission to certain applicants, suggesting a lack of evidence that the home lacked the necessary facilities or nursing expertise to meet the applicants’ care requirements.
Critical Incident Inspection
The inspection report conducted by Inspector Denise Brown details the findings of a Critical Incident System inspection carried out over several days in February and March 2021. The inspection focused on resident falls and infection prevention and control practices.
- Infection Prevention and Control: The facility was found non-compliant with the implementation of its infection prevention and control program. Staff members were observed not performing hand hygiene during critical moments, such as before assisting residents with meals and before medication administration, which could potentially lead to the spread of infection. This issue was identified across multiple staff members, indicating a broader issue with adherence to infection control protocols.
- Inadequate Signage for Additional Precautions: The inspection also found that the facility failed to post correct and necessary signage for isolation precautions outside residents’ rooms, as required by the Provincial Infectious Diseases Advisory Committee (PIDAC) guidelines. This lack of proper signage could increase the risk of infection transmission within the facility.
The licensee was requested to prepare a written plan of correction voluntarily to ensure that all staff participate effectively in the infection prevention and control program.