Meadows of Dorchester (6623 Kalar Road, Niagara Falls) is a nursing home that is owned and operated by Niagara Region. There are approximately 120 beds.
Inspection Reports for Meadows of Dorchester
Our research team carefully reviewed and summarized inspection reports for Meadows of Dorchester. You can read the original copies of the reports in the Government of Ontario website.
October 2023: Inspection
The inspection, conducted by Jonathan Conti, focused on a complaint regarding alleged abuse, continence care, and recreational and social activities. The inspection examined several aspects of resident care and facility operations.
- Continence Care and Bowel Management: The inspection identified a failure in implementing a resident’s individualized plan of care related to continence management. The plan specified different continence products for different times of the day, based on an assessment conducted in March 2023. However, it was noted in April 2023 that the resident was wearing the incorrect product at a certain time of day, contrary to the care plan. This discrepancy was raised as a concern by the substitute decision maker (SDM).
August 2023: Inspection
The inspection, conducted by Waseema Khan with additional input from Brittany Wood, focuses on various issues including resident care, prevention of abuse and neglect, and safety and security.
- Plan of Care: The inspection revealed failures in the implementation and updating of the plan of care for residents. A resident’s Substitute Decision Maker (SDM) was providing daily personal care, which was not reflected in the plan of care. The Assistant Director of Care (ADOC) acknowledged that the plan should have been updated to include this information. In another instance, the resident’s plan of care included the use of a yellow wander strip across their doorway for safety and security. However, it was observed that the strip was not put up while the resident was in their room, a lapse acknowledged by the staff.
- Skin and Wound Care: The facility failed to ensure that a resident who was dependent on staff for repositioning was repositioned every two hours as required. The resident was observed in their bed for over two hours without being repositioned, contrary to their care plan. This neglect increased the resident’s risk of developing pressure ulcers.
January 2023: Inspection
There were no findings of non-compliance.
September 2023: Inspection
The inspection report, by inspectors Phyllis Hiltz-Bontje and Aileen Graba, reveals several areas of non-compliance in the care and management of residents. The inspection was conducted over several days in July 2022 and involved critical incidents, including a complaint related to falls prevention, pain management, and an unexpected death.
- Failure to Notify Director of Suspected Resident Injury: The licensee didn’t notify the Director immediately when there were reasonable grounds to suspect a resident may have sustained injuries during an interaction with staff, resulting in a change in the resident’s health status.
- Failure to Report Unexpected Death: The licensee did not inform the Director immediately about the unexpected death of a resident, as required by regulations.
- Inadequate Post-Fall Assessment: The facility failed to complete a post-fall assessment using a clinically appropriate instrument specifically designed for falls.
- Inadequate Handling of Complaints: Complaints made to the Administrator and DRC about a resident’s care were not adequately investigated, nor was a response provided to the complainant. Additionally, a documented record of the complaint was not maintained as required.
- Non-Compliance with Policies and Procedures: Staff did not comply with the licensee’s written procedure related to the complaint process when a resident’s family raised concerns about the care of the resident.
- Failure in Falls Prevention and Management Program: The program was not fully implemented, and staff did not comply with the program directions and procedures following a resident’s fall.
- Failure in Pain Management Program: The required Pain Management Program was not fully implemented, and staff failed to comply with the policy related to the assessment and monitoring of a resident experiencing pain.
- Inadequate Infection Prevention and Control: The infection prevention and control lead did not work regularly on-site for the required hours per week.
- Inadequate Temperature Monitoring: Temperature measurements in different parts of the home were not documented as required on several occasions.
Various compliance orders were issued, including ensuring proper care plans based on assessments, reassessing and revising care plans when care needs change, and respecting residents’ rights to proper care.
April 2022: Complaints Inspection
The inspection report, conducted by Roseanne Western, identified several non-compliance issues during an inspection. This inspection focused on a range of areas including continence care, bowel management, neglect, food quality, medication administration, and response to complaints.
- Failure to Provide Care as Specified in the Plan: The licensee did not ensure that care set out in a resident’s plan was provided as specified. In one instance, a resident required assistance to use the toilet but was not provided timely help due to the unavailability of a second staff member needed for the transfer. This issue demonstrates a failure to adhere to the specified care plan.
- Failure to Report Neglect: There was a failure to report an allegation of neglect to the Director immediately after it was brought to the Director of Resident Care (DRC) by a family member. This neglect reportedly had a negative outcome on the resident, yet the Director was not notified following the initiation of an internal investigation.
- Failure to Respond to Complaints Within Required Time: The licensee did not investigate, resolve, or respond to a written complaint within 10 business days of its receipt. This complaint concerned staff behavior and care concerns raised by a family member. The absence of a timely response signifies non-compliance with the standards for handling complaints.
May 2021: Other Inspection
The inspection report by Michelle Warrener identified a significant non-compliance issue concerning the implementation of the Minister’s Directive related to COVID-19 long-term care home surveillance testing and access to homes.
- Non-Compliance with Minister’s Directive: The licensee did not ensure compliance with the Minister’s Directive effective from March 15, 2021, regarding COVID-19 Long-Term Care Home Surveillance Testing and Access to Homes. This directive required all Support Workers to either demonstrate a negative COVID-19 test result from an Antigen Test on the day of the visit or from the previous day before granting entry to the home. The home was also expected to maintain a log of such proofs.
- Failure in Rapid Antigen Testing Protocol: Upon review, it was found that the Rapid Antigen Testing log for specified dates was not available. Two Support Workers confirmed that they had not received a rapid antigen test at the home nor had they been asked to provide proof of testing before entering the home.
- Confusion in Implementation: The Administrator acknowledged there was confusion about who should be tested under the Rapid Antigen Testing Program, particularly regarding Support Workers. This led to a situation where Support Workers entered the home without undergoing the required Rapid Antigen Screening.
The licensee was requested to prepare a written plan of correction to ensure compliance with the operational or policy directives applicable to the long-term care home.
January 2021: Critical Incident
During the course of this inspection, Non-Compliances were not issued.