Ina Grafton Gage Home (40 Bell Estate Road, Scarborough) is managed by Responsive Health Management. There are approximately 130 beds.
Responsive Health Management is the operating partner of Rykka Care Centres, and currently operates a portfolio that includes 12 long term care homes and one retirement home in southern Ontario.
Inspection Reports for Ina Grafton Gage Home
Our research team carefully reviewed and summarized inspection reports for Ina Grafton Gage Home. You can read the original copies of the reports in the Government of Ontario website.
November 2023
The inspection, conducted from November 6-15, 2023, was a combination of a Complaint and Critical Incident inspection.
The Critical Incident intakes inspected were related to a disease outbreak and several instances of falls prevention and management. Complaint intakes involved alleged improper/incompetent care resulting in injury, general care concerns, and issues related to a resident plan of care.
The inspection resulted in four written notifications of non-compliance:
- Falls Prevention and Management: There was non-compliance with the home’s falls prevention and management program policies, specifically regarding monitoring residents after a fall. A Registered Practical Nurse (RPN) failed to initiate Head Injury Routine (HIR) monitoring for a resident after an unwitnessed fall. This oversight was not reported by the morning Unit Supervisor RPN, and the Head Injury Routine was initiated later by another RPN. This failure to follow policy could lead to delays in identifying head injury and treatment.
- Falls Prevention and Management: The licensee did not ensure a post-fall assessment using an appropriate instrument for a resident who had an unwitnessed fall. The failure to document a post-fall assessment resulted in delayed identification of any injuries and treatment.
- Infection Prevention and Control: There was a failure to ensure staff participation in the Infection Prevention and Control (IPAC) program. A resident was not offered or assisted with hand hygiene before meals by the RN and PSW, which could increase the risk of infection.
- Dealing with Complaints: The licensee did not respond within 10 business days to verbal complaints made by a resident’s Substitute Decision Maker (SDM) regarding the resident’s care. The home acknowledged the complaints and submitted Critical Incident Reports but did not provide a response to the SDM. This failure to respond prevented the SDM from fully participating in the development and implementation of the resident’s care plan.
September 2023
The inspection, conducted from September 18-26, 2023, was a combination of a Complaint and Critical Incident inspection.
The Critical Incident intakes related to falls prevention and management, while the complaint intake focused on resident care, including aspects like continence care, skin and wound prevention, infection control, responsive behaviors, and falls management.
- Falls Prevention and Management: There was a failure to conduct a post-fall assessment in an accurate and timely manner as required by the home’s “Fall Prevention Program.” A Critical Incident report for a resident’s fall indicated that the registered staff delayed documenting the assessment immediately post-fall. The failure to complete this assessment in a timely manner posed a risk of missing accurate information to prevent, manage, and reduce future falls and related injuries.
- Safe Transfer: The licensee failed to ensure safe transferring techniques when assisting a resident who had fallen. Documentation and staff interviews confirmed that two staff members transferred a resident from the floor post-fall without an assessment by registered staff. This contravened the “Fall Prevention Program,” which stipulates that a fall must be assessed immediately by registered staff before moving the resident. This failure increased the risk of further injury to the resident.
Both instances of non-compliance highlighted issues with following established procedures for falls management, specifically regarding timely assessment and safe transfer protocols.
August 2023
The inspection, conducted from August 15-22, 2023, focused on a combination of Complaint and Critical Incident types.
- Falls Prevention and Management: After a resident experienced a fall resulting in injury and hospitalization, the Physiotherapist (PT) assessed them upon return and recommended a fall prevention equipment. However, the resident’s care plan was not updated with this recommendation until during the inspection, which posed a risk for subsequent falls and injuries.
- Prevention of Abuse and Neglect: A complaint was raised about physical abuse by a Personal Support Worker (PSW). The Nurse Practitioner (NP) assessed the resident but failed to document this assessment in the Point Click Care system. The lack of documentation created inconsistencies in monitoring the resident and violated the home’s Abuse and Neglect Policy.
- Housekeeping: A strong and lingering urine odor was observed in a resident’s room, indicating a failure in addressing this issue. The Environmental Service Manager (ESM) admitted that a special chemical required for eliminating such odors hadn’t been used. This left the resident in an undignified living condition.
The report highlights issues with falls management, response to abuse allegations, and housekeeping standards at the facility. Remedial actions were taken for the falls prevention issue during the inspection, while the other two non-compliances required further action.
July 2023
The proactive compliance inspection of Ina Grafton Gage Home in Scarborough, conducted from June 16 to June 28, 2023, addressed several areas, including food, nutrition and hydration, medication management, safe and secure home, quality improvement, pain management, recreational and social activities, falls prevention and management, skin and wound prevention and management, resident care and support services, residents’ and family councils, infection prevention and control, prevention of abuse and neglect, and residents’ rights and choices.
- Plan of Care: The home failed to revise the plan of care for resident #011, who was at high risk for falls, as their condition changed. This posed an increased risk of injury. There was a failure in staff collaboration regarding resident #010’s care. The resident’s pain was not communicated to the nurses, delaying potential treatment.
- Safe and Secure Home: Doors leading to non-residential areas were left unlocked or open, posing a risk of injury to residents.
- Recreation and Social Activities: The home did not adequately involve residents or their families in developing and scheduling recreation and social activities, particularly for resident #013 who had specific medical needs.
- Nutritional Care and Hydration Programs: There was a failure to communicate menu substitutions to residents and staff, as observed with the serving of mango mousse cake.
These findings highlight issues in care plan management, staff communication, safety protocols, resident engagement in activities, and food service management at the facility.
January 2023
The follow-up inspection, conducted from December 15 to December 20, 2022, reviewed compliance orders related to prevention of abuse and neglect, general requirements for the skin and wound program, falls prevention program, and plan of care.
All previously issued compliance orders from inspection #2022_1528_0002 were found to be in compliance.
There was a failure to ensure an adequate hand hygiene program, as per the “Infection Prevention and Control (IPAC) Standard for Long Term Care Homes April 2022.” Specifically, the IPAC Lead did not ensure access to 70-90% Alcohol-Based Hand Rub (ABHR), and there was a usage of expired ABHR in the home. This non-compliance was remedied during the inspection after an expired bottle of ABHR was found and removed. The risk to residents was considered low, as other non-expired ABHR options were available.
The inspection concluded that the licensee had remedied the identified non-compliance regarding hand hygiene by removing the expired ABHR and ensuring compliance with the IPAC Standard.
October 2022
The inspection conducted on October 3-6, 2022 focused on a complaint related to medication management.
There were multiple instances of staff failing to perform hand hygiene as per the IPAC Standard. This included Staff #103 not performing hand hygiene before and after handling soiled linen and waste, and Staff #102 failing to perform hand hygiene after contact with the resident’s environment and between assisting different residents. The home’s policy on hand hygiene was not followed, which increased the risk of infection transmission. The IPAC Lead acknowledged the importance of hand hygiene in preventing the transmission of infection.
The licensee initially failed to place additional precaution signage for a resident on additional precautions as required by the “Infection Prevention and Control (IPAC) Standard for Long-Term Care Homes, April 2022.” This was observed when a resident’s room had a Personal Protective Equipment (PPE) cart and soiled linen cart outside but lacked the necessary signage. Staff #100 rectified this by placing the appropriate signage on the resident’s bedroom door. The non-compliance was resolved on October 3, 2022.
Overall, the inspection addressed the issue of non-compliance regarding infection prevention and control, specifically related to hand hygiene and signage for additional precautions. The licensee took immediate action to remedy these issues during the inspection.
August 2022
This amended public report for Ina Grafton Gage Home relates to an inspection conducted over several dates between May and July 2022.
The inspection involved a complaint related to skin and wound and falls prevention and management, and a follow-up related to the plan of care.
- Residents’ Bill of Rights: The home failed to keep a resident’s electronic-medication administration record (e-MAR) confidential, as it was left unattended and visible. This could have allowed unauthorized access to personal health information, violating the Personal Health Information Act, 2004.
- Skin and Wound Care: The home did not refer a resident with altered skin integrity to a registered dietitian for assessment, nor were changes to the resident’s nutrition and hydration plan implemented as required.
- Safe Storage of Drugs: An unlocked medication cart was left unattended, making residents’ medications accessible, which posed a risk of residents ingesting medications not prescribed for them.
- Prevention of Abuse and Neglect: The home was ordered to implement a plan to ensure residents are not neglected by the licensee or staff, including audit processes, timely transcription of treatment orders, and staff training in related areas.
- General Requirements for Programs: The home was instructed to ensure documentation of interventions and residents’ responses under the skin and wound care program, including procedures for rounds, assessment, and staff education on documentation standards.
- Fall Prevention Program: The home was ordered to conduct audits of its fall prevention program and retrain staff, due to gaps in implementing the program when a resident experienced falls.
- Pressure Ulcers: The home failed to ensure weekly assessments by a registered nurse for a resident with pressure ulcers. The licensee was ordered to conduct weekly skin assessments and initiate separate orders for each treatment.
- Plan of Care: The home was required to ensure collaboration between staff in assessing residents, particularly for those with altered skin integrity. This includes defined roles, communication processes, and refresher training for registered staff.