Montford Long Term Care Home (705 Montreal Road, Ottawa) is operated by Extendicare, a for-profit operator of long-term care homes in Canada. There are approximately 130 beds in private, semi-private and shared rooms.
Montford is formerly owned and operated by Revera.
Inspection Reports for Montfort
Our research team carefully reviewed and summarized inspection reports for Montfort. You can read the original copies of the reports in the Government of Ontario website.
🔍 October 2023: Inspection
The inspection for Montfort Long Term Care Home, led by Julienne Nloga and Joelle Taillefer, addressed three main incidents: an injury of unknown cause, alleged resident-to-resident abuse resulting in injury, and alleged neglect by staff.
- Plan of Care: The inspection identified failures in ensuring clear, consistent directions in the residents’ written plans of care, particularly regarding mobility and transfer methods. These inconsistencies posed risks for falls and injuries due to improper assistance and transfer techniques.
- Falls Prevention and Management: Failures were noted in assessing residents post-fall and conducting post-fall assessments using clinically appropriate instruments, leading to potential risks of unaddressed injuries or conditions.
- Transferring and Positioning Techniques: The facility was ordered to provide training for all registered nursing staff and PSWs on safe transferring and positioning devices or techniques, based on the home’s Safe in Ambulation, Lift, and Transfer (SALT) assessment and other relevant assessments.
🔍 July 2023: Inspection
The inspection for Montfort Long Term Care Home, spearheaded by Linda Harkins with assistance from Lisa Kluke, covered multiple intakes, including resident falls, various care concerns, alleged staff to resident abuse, and resident to resident abuse.
- Police Notification: The facility failed to notify the appropriate police service immediately about alleged, suspected, or witnessed incidents of abuse or neglect that could constitute criminal offences. This non-compliance was identified in two separate instances: resident to resident abuse was reported without police notification; and alleged staff to resident abuse was reported with “N/A” for additional authorities informed, indicating a failure to notify the police as required.
🔍 March 2022: Complaints Inspection
The inspection for Montfort Long Term Care Home, led by inspector Manon Neighbor, was initiated in response to a complaint about a resident’s pain control and care issues.
- Policy and Procedure Compliance: The facility failed to follow its pain management policy and procedure. Despite a resident showing new onset of pain, the prescribed pain assessment tool was not initiated as required, leading to a lack of proper pain reassessment and management.
- Plan of Care Review and Revision: The licensee did not reassess the resident’s care plan or revise it when the resident’s care needs changed and when the care provided was not effective. This oversight occurred even as the resident exhibited new symptoms and their health status changed, ultimately resulting in the resident’s hospitalization and subsequent death.
- Administration of Drugs: There was a failure to administer medication as prescribed by the doctor. A necessary medication was not given until the day after it was supposed to start, contributing to the deterioration of the resident’s condition and their eventual death.
For each area of non-compliance, the licensee is requested to prepare a Voluntary Plan of Correction (VPC) to ensure policies, procedures, and pain management systems are adhered to; residents’ plans of care are promptly reassessed and revised as needed; and medications are administered in accordance with prescriber directions.
🔍 March 2022: Critical Incident Inspection
The inspection for Montfort Long Term Care Home, led by inspector Manon Neighbor, was prompted by a critical incident involving resident-to-resident physical responsive behavior,.
- Documentation of Care: The facility failed to properly document pain, behaviors, and neurological assessments as outlined in the resident’s care plan. This failure occurred after a resident was involved in a physical altercation with another resident, leading to injuries. Despite initiating various assessment tools to monitor the resident post-incident, numerous entries were missed or incomplete. This lack of thorough documentation posed a risk of not identifying changes in the resident’s condition following the incident.
The licensee is required to prepare a Voluntary Plan of Correction (VPC) to ensure compliance with the Long-Term Care Homes Act, specifically to document the provision, outcomes, and effectiveness of care as outlined in residents’ care plans thoroughly and accurately.