Lakeshore Lodge (3197 Lakeshore Boulevard West, Etobicoke) is owned and operated by the City of Toronto. There are approximately 150 beds.
Inspection Reports for Lakeshore Lodge
Our research team carefully reviewed and summarized inspection reports for Lakeshore Lodge. You can read the original copies of the reports in the Government of Ontario website.
October 2023
The inspection was a comprehensive evaluation addressing both complaints and critical incidents.
Led by Inspector Slavica Vucko and supported by additional inspectors, the inspection took place over several days in October 2023, focusing primarily on responsive behaviours, falls prevention and management, as well as reporting and complaints.
- Safety and Security Concerns: A critical incident involving resident #001 highlighted significant safety concerns. The resident experienced a fall resulting in hospital treatment, despite the presence of a private care sitter. Notably, this wasn’t an isolated incident, as previous falls had occurred under similar circumstances. The inspection revealed that the private care sitter repeatedly failed to adhere to the resident’s written plan of care. Furthermore, the facility lacked a process for training private caregivers, a gap that compromised resident safety.
- Responsive Behaviour Management: Resident #002 exhibited verbal and sexually inappropriate behaviours towards another resident, indicative of responsive behaviour issues. The inspection identified a lack of reassessment and intervention by the Behaviour Support Ontario (BSO) lead following these incidents. This oversight in managing and reassessing responsive behaviours of residents #002 and #004, as per the facility’s policies, posed risks of further incidents and harm to residents.
September 2023
A detailed inspection report highlights critical areas of non-compliance.
The report, led by Inspector Cindy Cao and supported by additional inspector Kehinde Sangill, encompasses several key elements of resident care, including falls prevention and management, responsive behaviours, and record maintenance.
- Falls Prevention: A resident, identified as high-risk for falls, was not provided with necessary interventions as specified in their care plan. The absence of these interventions was confirmed by nursing staff and put the resident at risk for potential injury.
- Responsive Behaviour Management: In another instance, a resident with a history of responsive behaviours was not adequately monitored according to their care plan. The assigned one-on-one support was not present at the time of an incident, leading to risk for other residents.
- Resident Records: A resident with a history of responsive behaviours had an incident where appropriate records were not maintained. Despite completion of a clinical monitoring tool to evaluate behaviour patterns, the staff could not produce this record when requested. This lapse in documentation signifies a gap in maintaining essential health records.
In a second inspection by Fiona Wong, there were no findings of non-compliance.
May 2023
The amended public report revises a previous inspection report for Lakeshore Lodge.
The amendment was necessitated by a Director’s Review, leading to the rescission of Compliance Order #001.
The initial inspection, led by Inspector Cindy Cao, with additional inspectors, was conducted over several dates in February and March 2023.
This comprehensive review focused on various aspects of resident care and facility operations, including falls prevention and management, resident-to-resident physical abuse, and staff to resident abuse.
- Plan of Care: Issues were identified with the implementation of care plans for residents, particularly regarding mobility devices and falls prevention interventions. The care plans were not updated or followed as required, leading to risks for the residents. Subsequently, care plans were updated to reflect current needs and interventions for the residents.
- Resident Records: There was a failure to maintain written records for a resident with a history of responsive behaviours. The lack of proper documentation posed a risk to the resident’s care and safety.
- Transferring and Positioning Techniques: Safe transferring techniques were not used when assisting a resident, leading to a risk of injury. The staff did not adhere to the specified methods in the resident’s care plan.
- Collaboration in Resident Assessment: Staff failed to collaborate effectively in assessing a resident, leading to missed vital signs and progress notes, which could have delayed necessary medical intervention.
- Duty to Protect: There was an incident of physical abuse between residents, with the facility failing to protect one resident from another.
June 2022
The first of two reports pertains to Lakeshore Lodge and provides a comprehensive overview of an inspection conducted from April 21 to May 4, 2022.
Led by Inspector Nital Sheth, this inspection encompassed several key areas of long-term care, including Continence Care, Falls Prevention and Management, Infection Prevention and Control (IPAC), Residents’ Rights and Choices, Responsive Behaviours, and Skin and Wound Prevention and Management.
This comprehensive review was held over several days in April and May 2022, scrutinizing a complaint intake and a Critical Incident System (CIS) intake related to duty to protect and skin and wound.
- Respect for Residents’ Rights: The inspection identified a violation of residents’ rights, specifically concerning respect and dignity. This non-compliance involved RPN #110 who reportedly used inappropriate language towards a resident during care provision. The resident, who exhibited responsive behaviours, required a specific approach for care as outlined in their plan. This included approaching slowly, minimizing noise, and providing reassurance. The incident was reported by the Resident’s Substitute Decision Maker (SDM). Following the report, RN #112 intervened, leading to changes in the staff assignments and the removal of the involved staff members from the resident’s care.
The second report was also led by Inspector Nital Sheth. This inspection focused primarily on a complaint regarding the duty to protect and maintenance at the long-term care home.
The issue centered around the care outlined in a resident’s plan, specifically relating to dressing assistance. The resident’s Substitute Decision Maker (SDM) reported to the Director of Care (DOC) that the resident was not appropriately dressed, which was contrary to the resident’s care plan. According to the plan, the resident needed extensive assistance from a staff member to ensure appropriate dressing. Nurse Manager #108 responded immediately to this concern, ensuring the resident received proper assistance to get appropriately dressed.
The non-compliance issue was effectively addressed by the licensee and was resolved prior to the conclusion of the inspection
June 2021
An inspection report, conducted by Inspector Nital Sheth, took place at Lakeshore Lodge in June 2021 . This critical incident system inspection occurred over several days and focused on various aspects of resident care and facility operations.
The inspection covered multiple intakes, including those related to falls resulting in injury, a breakdown of the major telecommunication system, controlled substance issues, and duty to protect.
- Failure to Report Abuse Immediately: An incident of alleged abuse reported by a resident was not immediately reported to the Director.
- Inadequate Pain Management: The facility failed to reassess a resident’s pain using a clinically appropriate assessment tool when initial pain interventions were ineffective.
Two Written Notifications (WNs) were issued for the non-compliances identified.
No Voluntary Plan of Correction (VPC), Compliance Order (CO), Director Referral (DR), or Work and Activity Order (WAO) were issued.
July 2020
An inspection was conducted by Inspector Babitha Shanmuganandapala. This inspection, focused on a critical incident system, took place over several days at the end of June and the beginning of July 2020.
The inspection was centered on log #010997-20, which related to an alleged neglect incident reported in the Critical Incident System.
Notably, no non-compliances were issued during this inspection.