Linhaven (403 Ontario Street, St. Catherines) is a nursing home that is owned and operated by Niagara Region. There are approximately 250 beds.
Inspection Reports for Linhaven
Our research team at Caring Magazine carefully reviewed and summarized inspection reports for Linhaven. You can read the original copies of the reports in the Government of Ontario website.
November 2023: Inspection
The inspection, conducted by lead inspector Stephanie Smith along with Klarizze Rozal, was a comprehensive evaluation covering various aspects of care and facility operations.
This inspection included following up on previous compliance orders, addressing complaints, and investigating critical incidents. The inspection focused on key areas including infection prevention and control, responsive behaviours, prevention of abuse and neglect, staffing, training and care standards, and falls prevention and management.
- Responsive Behaviours: It was found that a resident’s triggers for their responsive behaviours were not documented in their care plan, contrary to the home’s policy. This non-compliance was rectified during the inspection when the Programs Manager (PM) updated the care plan with the identified behavioural triggers.
- Plan of Care: The licensee failed to review and revise a resident’s plan of care when their needs changed, particularly in relation to falls. This was highlighted by a resident experiencing multiple falls, with necessary interventions only included in the care plan after a fall resulted in injury.
- Reporting Matters to the Director: The licensee did not report suspected abuse incidents to the Director immediately. These incidents involved alleged sexual abuse by a resident towards co-residents, which were not reported despite being acknowledged by staff and management.
- Communication and Response System: There was a failure in ensuring that the home’s resident-staff communication and response system was effective. A resident was given a metal bell and a whistle as alternatives to the call bell system, which was not connected to the home’s main communication system.
Due to the failure to protect residents from sexual abuse by a resident, a Compliance Order was issued. The licensee is required to educate all relevant staff on the home’s policies regarding Abuse and Neglect- Zero Tolerance, with a focus on the definition of sexual abuse.
An Administrative Monetary Penalty of $5,500 was issued for the failure to comply with the requirement to protect residents from sexual abuse, marking the first such penalty issued to the licensee for this particular non-compliance.
August 2023: Inspection
The inspection, overseen by Stephanie Smith and Carla Meyer, was a critical incident inspection taking place from August 28 to September 5, 2023. This inspection addressed several intakes related to various incidents, including injuries of unknown causes, alleged improper care, and falls resulting in fractures.
- Unsafe Transferring Techniques: On a specific date in 2022, a resident fell from a mechanical lift during transfer due to a clip not being secured. This incident, resulting from operator error, led to the resident sustaining injuries and needing hospital treatment. The Associate Director of Resident Care (ADRC) acknowledged that safe transferring techniques were not used.
- Duty to Protect Compliance Order: The licensee was ordered to educate all registered staff on signs and symptoms of infections, including elevated blood sugar, and their role in monitoring and assessing residents showing signs of infection. This directive followed an incident in 2022 where a Personal Support Worker (PSW) reported a resident’s change in condition to a Registered Nurse (RN) who failed to respond. The charge RN neglected to assess the resident despite being informed of their declining condition.
February 2023: Complaints Inspection
The inspection, conducted by Emma Volpatti and Karlee Zwierschke, focused on various complaints related to admission refusals, prevention of abuse and neglect, maintenance services, medication management, and staffing.
- Infection Prevention and Control: The licensee failed to fully implement the IPAC Standard for Long-Term Care Homes. Specifically, personal protective equipment (PPE) was not adequately available in two resident rooms. However, this non-compliance was remedied before the inspection concluded.
- Refusal of Admission: Linhaven refused admission to applicants due to concerns about their smoking capabilities. However, it was acknowledged that this was not an acceptable reason for refusing admission, as the applicants were willing to engage in a smoking cessation program if they could not safely smoke in the facility.
- Water Temperature Monitoring: The licensee did not ensure that water temperature was monitored once per shift in random locations accessible to residents. This was identified from a complaint and corroborated by missing records over the past year. The DRC and Administrator acknowledged gaps in the process and confirmed that staff had not been routinely monitoring water temperatures.
December 2022: Follow-Up Inspection
The inspection, conducted by Yuliya Fedotova and Adiilah Heenaye, took place from November 28 to 30, 2022. This follow-up inspection focused on ensuring compliance with previous orders related to Infection Prevention and Control (IPAC) standards.
- IPAC Standard Implementation: The licensee had initially failed to fully implement the IPAC Standard for Long-Term Care Homes, specifically regarding the availability and accessibility of Personal Protective Equipment (PPE) for staff. It was observed that no gowns were available in the PPE bag for a specified room in the home. However, this was remedied on the same day by a Registered Practical Nurse (RPN) who refilled the PPE bag with gowns.
- Hand Hygiene Program: Another issue was with the hand hygiene program, particularly the alcohol content in hand sanitizers. The inspection found 60% Ethyl Alcohol Isagel brand hand sanitizers in use, whereas the standard requires 70-90% Alcohol-Based Hand Rub (ABHR). This issue was also addressed promptly. The Isagel brand hand sanitizers were removed from all home areas and replaced with sanitizers meeting the required alcohol content.
January 2022: Critical Incident Inspection
The inspection report, conducted by Gillian Hunter and others at Linhaven in St. Catharines, reveals several critical incidents and areas of non-compliance. The inspection, dated January 20, 2022, focused on multiple aspects including falls management and prevention, and medication administration.
- Medication Administration: The licensee failed to administer drugs as prescribed. In July 2021, a medication error occurred where a resident received an incorrect dose, leading to hospitalization. This incident highlighted a lack of understanding of medical abbreviations by the nursing staff, resulting in the administration of a dose that was significantly higher than prescribed.
- Plan of Care for Falls Prevention: There was a failure in implementing the care plan for falls prevention for a resident. In June 2021, a resident who was at risk of falls was found injured due to the safety device not being in place as specified in the care plan.
- Medication Management System: There was a lack of adequate written policies and protocols for the medication management system, specifically concerning the accurate acquisition of residents’ drugs. This was evident from the medication error incident in July 2021.
- Reporting Medication Incidents: The report also highlighted a failure in reporting medication incidents to the Medical Director, as required. This non-compliance was noted in two separate medication incident reports from June and August 2021.
A compliance order was issued to address these non-compliances. The licensee was required to ensure that all staff responsible for transcribing orders receive education on medical abbreviations and the College of Nurses of Ontario (CNO) Medication practice standard. Additionally, a listing of all medical abbreviations used in the transcription of orders must be posted and made available to staff responsible for transcribing orders.
January 2022: Complaints Inspection
The inspection, conducted by Gillian Hunter and Roseanne Western, highlights several areas of non-compliance related to resident care and administrative procedures. The inspection was a response to complaints and covered a range of protocols from falls prevention to infection prevention and control.
- Failure to Report Abuse Immediately: A student PSW, under the supervision of a PSW, allegedly witnessed abuse of residents by the supervising PSW in July 2021. However, the student failed to immediately report these concerns to the home, only doing so after their shift. This delay in reporting raised the risk of ongoing abuse. The Associate Director of Resident Care (ADRC) confirmed they were not immediately aware of the allegations. The report emphasizes the critical importance of immediate reporting of abuse to prevent ongoing harm to residents.
- Admission Approval Process: In June 2021, an applicant’s Substitute Decision Maker (SDM) received a letter from the home stating that the applicant was denied admission due to the home’s lack of nursing expertise to manage the applicant’s responsive behaviours. However, the grounds for withholding admission approval were not justified as per the required standards, indicating a failure in the admission approval process.
The report requested the licensee to prepare a voluntary plan of correction to ensure immediate reporting of suspected abuse to the Director.
January 2022: Follow-Up Inspection
During the course of this inspection, Non-Compliances were not issued.