Main Street Terrace: Reviews & Inspection Reports

Main Street Terrace (77 Main Street, Toronto) is operated by Extendicare, a for-profit operator of long-term care homes in Canada. There are approximately 150 beds in private, semi-private and shared rooms.

Main Street Terrace is formerly owned and operated by Revera.

Inspection Reports for Main Street Terrace

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

🔍 December 2023: Inspection

This report for Main Street Terrace provides details of a critical incident inspection. The inspection was carried out by Trudy Rojas-Silva and Cindy Cao.

Plan of Care: The licensee failed to ensure that the care specified in the plan of care was provided to a resident as specified in the plan. This non-compliance led to a resident having an unwitnessed fall and sustaining an injury. The staff did not follow the intervention specified in the resident’s plan of care, which resulted in the fall and injury.
Required Programs: The licensee failed to ensure that Head Injury Routine (HIR) monitoring was completed for a resident as required by the falls prevention and management program. Specifically, registered nursing staff did not comply with the home’s Post-Fall Management Policy to conduct HIR monitoring for a specified period of time after a resident sustained an unwitnessed fall. This failure put the resident at risk of unidentified injury.

🔍 July 2023: Inspection

This report for Main Street Terrace provides details of a critical incident system inspection. The inspection was carried out by Oraldeen Brown.

Plan of Care: The licensee failed to ensure that the care specified in the plan of care was provided to resident #001 as specified in the plan. A resident who was at risk for falls had interventions in place that required staff assistance. However, a Personal Support Worker (PSW) left the resident unattended while assisting another resident, leading to a fall and a significant change in the resident’s health status. The PSW acknowledged the error, and the Director of Care (DOC) stated that staff were expected to follow resident care plans.
Reporting and Complaints: The licensee failed to ensure that the Director was informed of an incident that caused an injury to resident #001 in a timely manner. The resident’s fall resulted in a significant change in their health status, but the Critical Incident Report (CIR) was submitted days later, exceeding the required timeframes. The Administrator acknowledged this non-compliance with the legislation.

🔍 October 2022: Inspection

This report for Main Street Terrace provides details of a critical incident system inspection. The inspection was carried out by Ivy Lam, Maya Kuzmin and Goldie Acai.

Plan of Care: The licensee had failed to ensure that a resident was reassessed and the plan of care reviewed and revised when the resident’s care needs changed. A resident at risk for falls did not have a specific intervention included in their written plan of care. The intervention was added to the care plan, after the inspection, addressing the non-compliance.
Medication Management: The licensee failed to comply with the home’s medication management policy for administering medication as per the policy. Specifically, staff did not administer a treatment as required by the policy when a resident refused it. This resulted in an increased risk to the resident’s health.
Surveillance Protocols: The licensee failed to implement surveillance protocols issued by the Director for proper use of COVID-19 testing kits. Staff were observed not following the manufacturer’s instructions for administering rapid antigen tests (RAT), which posed an increased risk of infection transmission.
Personal Protective Equipment: Staff did not follow routine precautions according to the Infection Prevention and Control Standard for Long Term Care Homes in terms of appropriate use of Personal Protective Equipment (PPE). Secondly, staff did not follow additional precautions for residents requiring specific PPE, increasing the risk of infection transmission. Thirdly, staff did not support residents with hand hygiene prior to meals, as required, increasing the risk of infection transmission.

🔍 June 2021: Complaints Inspection

During the course of this inspection, Non-Compliances were not issued.

🔍 June 2021: Critical Incident Inspection

The inspection for Main Street Terrace revealed several instances of non-compliance. The inspection focused on Critical Incident System inspection, falls prevention and management, abuse prevention, and infection prevention and control.

Safety Checks: The licensee failed to ensure that safety checks for three residents were documented as specified in their falls management plans of care. This documentation deficiency was observed for residents #003, #004, and #005, increasing the risk to their safety.
Documentation of Skin and Wound Care Interventions: The licensee failed to ensure that interventions related to skin and wound care for two residents were documented as required. This deficiency was observed for residents #002 and #006, which increased the risk of skin integrity issues.
Continence Care and Bowel Management: The licensee failed to ensure that interventions related to continence care and bowel management for three residents were documented. This documentation deficiency was observed for residents #001, #002, and #006, potentially impacting their quality of care.
Skin Assessments: The licensee failed to ensure that altered skin integrity of two residents was assessed by a member of the registered nursing staff using a clinically appropriate assessment instrument. This deficiency was observed for residents #002 and #006, potentially affecting their skin and wound care.
Responsive Behaviors: The licensee failed to ensure that strategies were developed and implemented to respond to responsive behaviors exhibited by resident #001. This deficiency could have increased the risk of incidents involving responsive behaviors.
Infection Prevention and Control (IPAC) Procedures: The licensee failed to ensure that staff followed IPAC procedures, particularly regarding the usage of Personal Protective Equipment (PPE). Staff were observed not properly doffing and disinfecting PPE, potentially increasing the risk of infectious disease transmission.

🔍 March 2020: Critical Incident Inspection

The inspection for Main Street Terrace pertains to a critical incident.

Plan of Care: The licensee, Revera Long Term Care Inc., failed to ensure that care specified in the plan of care for resident #001 was provided as specified. This non-compliance was related to a choking incident during an excursion outside of the home. The resident’s dietary intervention was not properly communicated, leading to a diet-related incident.
Staff Communications: The licensee also failed to ensure that staff and others providing direct care to residents were aware of the contents of the plan of care and had convenient and immediate access to it. This lack of communication contributed to the incident involving resident #001.
Monitoring During Meals: Residents, including those eating in locations other than dining areas, were not adequately monitored during meals. This was evident in the case of resident #003, who was left unsupervised during a meal in a tilted position.
Techniques in Meal Assistance: Proper techniques for assisting residents with eating, including safe positioning, were not consistently followed for residents #002, #003, and #004. This posed a risk of aspiration or choking.

As a result of these findings, the licensee was requested to prepare a written plan of correction to achieve compliance voluntarily.

🔍 January 2020: Complaints Inspection

The inspection for Main Street Terrace, conducted by inspectors Praveena Sittampalam and Babitha Shanmuganandapala, addressed issues related to staffing, continence care, and the skin and wound care program.

Policies, Protocols, and Records Compliance: The inspection found that the care home failed to comply with its own policies and procedures as required by regulation, specifically in areas related to skin and wound care. This failure led to practices that did not meet the standard care protocols, affecting resident wellbeing.
Skin and Wound Care Program: Staff at the care home did not adhere to the established Prevention of Skin Breakdown policy. This lack of compliance directly impacted the care for residents, notably for one identified as having skin and wound care issues, suggesting that the necessary preventive measures and care strategies were not properly implemented.
Staffing Sufficiency: The report points out that the care home did not adequately evaluate and update its staffing plan to ensure it met the residents’ assessed care and safety needs. This shortfall in staffing planning contributed to the overall inability to provide consistent and comprehensive care to residents.
General Program Requirements: There was a failure to annually evaluate and update essential programs such as the continence care and bowel management program and the skin and wound care program. Without these evaluations and updates, the programs could not be assured to be based on the latest evidence-based practices, potentially compromising the quality of care.
Nursing and Personal Support Services: The care home did not perform annual evaluations and updates of its staffing plan according to evidence-based practices. This neglect resulted in a shortage of personal care staffing, adversely affecting services like resident showers.
Bathing Practices: The care home did not ensure that each resident received baths at least twice a week, as preferred by the resident or as required by their hygiene needs. Specific instances were noted where residents missed their scheduled showers due to staffing shortages, indicating a significant oversight in meeting basic care and hygiene standards.

Each of these non-compliance issues prompted the inspectors to request Voluntary Plans of Correction (VPCs) from the licensee to rectify these shortcomings and improve the standard of care provided to residents.

🔍 January 2020: Critical Incident Inspection

The Critical Incident System inspection conducted at Main Street Terrace by inspectors Praveena Sittampalam and Babitha Shanmuganandapala focused on falls, prevention of abuse and neglect, and responsive behaviors.

Plan of Care: The care home did not ensure collaborative and integrated development and implementation of care plans among staff, leading to inconsistencies in resident care, notably in fall risk assessments and interventions.
Duty to Protect Residents: The licensee failed to protect residents from abuse, as evidenced by a physical altercation between two residents, indicating shortcomings in addressing responsive behaviors and ensuring resident safety.
Zero Tolerance Policy on Abuse and Neglect: The home did not comply with its written policy promoting zero tolerance of abuse and neglect. This was highlighted by a physical altercation that was not adequately investigated or followed up according to policy requirements.
General Program Requirements: The falls prevention and management program lacked annual evaluation and updates based on evidence-based practices, and records of such evaluations were not adequately maintained.
Responsive Behaviours Program: The home failed to annually evaluate and update its responsive behaviors program to reflect evidence-based or prevailing practices, and no written record of such an evaluation was kept.
Risk of Altercations: Steps were not taken to minimize the risk of altercations between residents. Despite known triggers and responsive behaviors, effective interventions were not identified or implemented.
Posting of Information: The policy promoting zero tolerance of abuse and neglect was not posted in the home, failing to meet the requirement to make such information readily available.
Evaluation of Abuse and Neglect Policies: There was a failure to annually evaluate the effectiveness of policies against abuse and neglect, and to consider the analysis of every incident in such evaluations. Additionally, the home did not maintain detailed records of evaluations, changes, and improvements.

For each area of non-compliance, the inspectors issued Written Notifications (WNs) and requested Voluntary Plans of Correction (VPCs) from the licensee to address and rectify the identified issues.