Thornton View (329 Eagle Street, Newmarket) 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.
Thornton View is formerly owned and operated by Revera.
Inspection Reports for Thornton View
Our research team carefully reviewed and summarized inspection reports for Thornton View. You can read the original copies of the reports in the Government of Ontario website.
🔍 December 2023: Inspection
The inspection for Thornton View, conducted by Susan Semeredy and other inspectors, focused on a range of issues, including complaints, critical incidents, prevention of abuse and neglect, medication management, and falls prevention.
- Plan of Care: The licensee failed to reassess and revise the care plan of a resident who exhibited inappropriate behaviors. Despite the initial intervention being reduced and later discontinued, there was no reassessment before a second incident occurred, placing other residents at risk.
- Prevention of Abuse and Neglect: Residents were not protected from abuse by another resident, which included inappropriate behavior. The Director of Care acknowledged these incidents.
- Fall Prevention Device: A Personal Support Worker disabled a resident’s fall prevention device, contrary to the resident’s care plan. This action increased the risk of falls for the resident.
- Plan of Care Documentation: The licensee did not document the care provided to certain residents, as required by their plans of care. This inconsistency posed a risk for inaccurate reassessments.
- Failure to Protect from Abuse by Staff: A resident was not protected from emotional abuse by a staff member. The staff member’s behavior was not in line with person-centered care and was considered abuse.
- Bathing Preferences: A resident’s preference for tub baths was not honored due to a broken bathtub. This failure did not meet the resident’s bathing preference.
- Skin Assessment: A resident with altered skin integrity did not receive the necessary skin assessment by nursing staff, potentially compromising wound monitoring and management.
- Responsive Behaviour Policy: The licensee did not comply with its own responsive behaviour policy when a resident exhibited self-harm behavior, increasing the risk of harm.
- Medication Administration: The licensee failed to comply with medication administration policies, leading to missed or late administrations, which in turn increased resident behaviors.
- Documenting Medication Incidents: Medication incidents and adverse drug reactions were not adequately documented, reviewed, or analyzed, increasing the risk of medication errors.
🔍 June 2023: Inspection
The inspection for Thornton View, led by Diane Brown, focused on a complaint related to managing a resident’s responsive behaviors and two critical incidents of alleged resident-to-resident physical abuse.
- Zero Tolerance Policy: The home failed to comply with its Resident Non-Abuse policy. A resident exhibiting physical aggression was not adequately assessed, leading to ongoing altercations. This failure increased the risk of further incidents.
- Physical Abuse Allegation: The licensee did not immediately investigate an allegation of physical abuse reported by a resident. This lack of investigation placed residents at continued risk of physical abuse and fear.
- Report Abuse to the Director: The licensee did not report suspected abuse by a resident, which resulted in harm, to the Director as required.
- Responsive Behaviors: The licensee did not develop or implement effective strategies for a resident who demonstrated harmful physical interactions. This lack of intervention resulted in injuries to other residents and an environment of fear.
- Risk of Altercations: The licensee failed to take steps to minimize the risk of altercations between residents, particularly by not providing continuous monitoring for a resident who repeatedly entered other residents’ rooms and was physically aggressive.
- Notifying Substitute Decision-Maker: The licensee did not notify the substitute decision-maker of a resident about the results of an investigation into physical abuse immediately upon completion.
🔍 April 2022: Complaints Inspection
The inspection for Thornton View, led by Darlene Murphy, focused on a complaint inspection and investigating critical incidents.
- Plan of Care: The licensee did not ensure clear directions for staff providing direct care to a resident who became agitated during continence care. The resident’s plan of care lacked specific instructions regarding the provision of care during responsive behaviors.
- Zero Tolerance Policy: The licensee failed to comply with the zero tolerance of abuse policy. An allegation of resident abuse was not immediately reported or investigated, contrary to the policy.
- Air Temperature Regulation: The home did not maintain the minimum required air temperature of 22 degrees Celsius, and temperatures in resident bedrooms were not appropriately documented. There were also gaps in measuring air temperature as required.
🔍 November 2021: Follow-Up Inspection
During the course of this inspection, Non-Compliances were not issued.
🔍 September 2021: Complaints Inspection
The inspection for Thornton View, conducted by Karyn Wood, took place over several days between May and June 2021.
- Infection Prevention and Control Program (IPAC): The licensee failed to ensure all staff participated in the IPAC program. Specific issues included staff not adhering to appropriate practices for donning and doffing personal protective equipment (PPE) and the absence of precaution signage for residents in isolation due to respiratory symptoms or COVID-19 screening.
- Providing On-the-Spot Education and Training: When infection control practice deficiencies were identified during audits, there was no consistent evidence of on-the-spot education and training for staff.
- Safe and Secure Environment for Residents: The home did not ensure proper COVID-19 screening on entrance, as required by Directive #3 issued on May 4, 2021.
- Air Temperature Monitoring: The licensee did not ensure that the temperature was measured and documented in at least two resident bedrooms in different parts of the home.
- Bathing: Resident #002 was not bathed a minimum of twice a week as required, with no alternate arrangements documented when refusals occurred.
- Nutrition Care and Hydration Programs: The licensee failed to measure and record resident #003’s monthly weight, leading to concerns about nutritional care and weight changes.
🔍 August 2021: Critical Incident Inspection
During the course of this inspection, Non-Compliances were not issued.
🔍 March 2021: Complaints Inspection
The inspection for Thornton View was part of a complaint inspection carried out between February 1 and 4, 2021. The inspection was overseen by Lynda Brown, an inspector with the Central East Service Area Office.
- Plan of Care: The licensee failed to ensure that the care specified in a resident’s plan of care, particularly related to dressing, was provided. Despite the plan indicating the resident could dress themselves but required intermittent supervision, review of records showed inadequate documentation of proper dressing and supervision.
- Bathing Requirements: The licensee did not ensure that a resident was bathed twice a week as per their preference. There was a lack of evidence that the resident received their baths twice weekly during a specific two-month period. This non-compliance could impact the resident’s health and well-being.
🔍 February 2021: Critical Incident Inspection
The inspection for Thornton View, conducted by Lynda Brown, was a Critical Incident System inspection, involving a disease outbreak, an unexpected death, and a fall resulting in injury.
- Infection Prevention and Control (IPAC) Program: The home failed to ensure staff participation in the IPAC program. This included instances of improper use or absence of personal protective equipment (PPE) and isolation precautions, as well as gaps in daily surveillance for infections. This non-compliance posed a risk of infection spread, especially concerning COVID-19.
- Safe Environment: The home did not maintain a safe environment in adherence to Directive #3, which includes cohorting staff, daily active resident screening, universal mask use, and physical distancing. The failure to follow these measures, especially during COVID-19 outbreaks, put residents at risk of infection and transmission.
- Duty to Protect: The licensee failed to protect residents from neglect. A specific case involved Resident #002, who was found not breathing with no CPR performed despite having full CPR directives. The investigation into this unexpected death was inadequate, and there were significant staffing issues on the shift prior to the resident’s death.
🔍 February 2021: Other Inspection
The inspection for Thornton View, conducted by Asal Fouladgar, focuses on infection prevention and control.
- Minister’s Directive: The home failed to comply with the Minister’s Directive titled “COVID-19: Long-term care home surveillance testing and access to homes,” effective January 8, 2021, and updated on February 16, 2021. A staff member who had not been tested for COVID-19 entered the home multiple times, leading to a COVID-19 outbreak. Fortunately, no residents were affected during this outbreak. This non-compliance presented a risk of virus transmission within the home.
The licensee was requested to prepare a written plan of correction voluntarily. This plan should ensure that all staff working in the home undergo Antigen Tests or PCR Tests as prescribed in the Minister’s Directive, to prevent future breaches of testing protocols.