True Davidson Acres (200 Dawes Road, Toronto) is owned and operated by the City of Toronto. There are approximately 190 beds.
Inspection Reports for True Davidson Acres
Our research team carefully reviewed and summarized inspection reports for True Davidson Acres. You can read the original copies of the reports in the Government of Ontario website.
November 2023
The inspection, led by Susan Semeredy, was a follow-up to a previously issued compliance order and also addressed critical incidents.
The inspection spanned several days, from October 24 to November 1, 2023. It focused on a follow-up to Compliance Order #001 from an earlier inspection (2023-1590-0007) related to safety risks and falls prevention. Additionally, critical incidents including the unexpected death of a resident (Intake #00092941) and responsive behaviours of another resident (Intake #00093061) were examined.
- Plan of Care: The home failed to reassess and revise a resident’s plan of care following a change in their care needs due to disease progression. The resident’s personal assistive service devices (PASDs) had not been reevaluated since admission, despite changes in their condition. This oversight was acknowledged by the nursing staff and posed a risk for injury to the resident.
- Reporting and Complaints: The home did not immediately inform the Director about the unexpected death of a resident, a requirement under the Long-Term Care Act. The delay in reporting was acknowledged by the Director of Nursing (DON).
The previously issued Compliance Order #001 was found to be in compliance, indicating improvements or corrective measures were successfully implemented.
July 2023
The inspection took place over several days, from June 26 to July 7, 2023. It covered various complaints and critical incidents including issues related to pest control, housekeeping, resident falls, hypoglycemia episodes, physical abuse allegations, and suicide attempts among residents.
- Plan of Care: The facility failed to provide clear directions in the plan of care, resulting in inadequate care for a resident who no longer required certain equipment due to a change in fall risk. Staff collaboration in developing and implementing care plans was lacking, leading to inconsistencies in care provision and increased risk of harm. In another instance, a resident required close monitoring for responsive behaviours, but the necessary supervision was not provided, leading to the resident harming themselves.
- Administration: The home did not comply with the Minister’s Directive regarding the administration of glucagon and failed to inform the Director about a resident who was administered glucagon and subsequently hospitalized.
The facility was ordered to conduct an interdisciplinary review of high-risk residents for falls, ensuring comprehensive and updated care plans, and to develop a method to communicate safety risks to the staff.
May 2023
The inspection, led by Inspector JulieAnn Hing and assisted by Arther Chandramohan, took place over several days in March and May 2023.
The inspection focused on two critical incidents related to allegations of resident-to-resident sexual abuse, identified as intake numbers #00022365 and #00022403.
The inspection found a non-compliance issue regarding the execution of a resident’s care plan. According to the resident’s progress notes, there was a directive to keep them a certain distance away from another co-resident. However, during an event at the home, it was observed that both residents were in close proximity to each other. Staff interviews confirmed this observation.
The failure to adhere to the specified care plan, particularly in maintaining the distance between the two residents, exposed one of the residents to potential further harm.
January 2023
The inspection, led by April Chan with additional inspector Arther Chandramohan, took place over several days in December 2022 and January 2023.
The inspection was in response to a complaint and examined various aspects of the care provided at the facility.
- Infection Prevention and Control: A non-compliance issue was noted where a Registered Practical Nurse (RPN) failed to adhere to the required Personal Protective Equipment (PPE) protocol for droplet contact precautions. After being educated on personal risk assessment and proper PPE use, the RPN rectified their practices.
- Medication Management System: There was a failure to document consent for new medication or changes in medication directions, as well as a failure to maintain drug records for the required period of three years.
- Nutritional Care and Hydration Programs: The inspection found that policies related to referrals to a dietitian for nutritional care and hydration were not followed. This non-compliance was identified when a resident’s declining food and fluid intake did not trigger a referral to the dietitian as per the home’s policy.
During the inspection, non-compliance issues were identified but were rectified by the licensee before the conclusion of the inspection.
November 2022
This inspection, led by Fiona Wong with assistance from April Chan, took place at True Davidson Acres, a long-term care home in Toronto. The inspection occurred over several days in November 2022.
The inspection focused on follow-up and critical incident protocols. It included the examination of specific incidents related to falls, recreation, and social activities.
- Infection Prevention and Control (IPAC): A compliance issue was noted where a resident’s room labeled with contact precautions did not have the required isolation gowns in the PPE caddy. This was corrected on the same day after being identified.
- Plan of Care for Falls Prevention: There was a failure in implementing the specified intervention in the care plan for a resident at risk of falling. This non-compliance resulted in the resident sustaining an injury due to a fall.
- Revision of Care Plan: The care plan for a resident at risk of falls was not revised effectively despite the resident experiencing multiple falls. This oversight was acknowledged by the staff, indicating a risk for further falls and injuries.
Some non-compliance issues were identified but were rectified by the licensee before the end of the inspection.
September 2022
In the first of two inspections, Slavica Vucko, with the assistance of Goldie Acai and Manish Patel, conducted an investigation which occurred over several days in August 2022.
The inspection involved a detailed review of incidents concerning hospitalization, significant changes in residents’ health status, allegations of accidents resulting in injury and hospitalization, and overall management of falls, infection control, and recreational activities.
- Infection Prevention and Control (IPAC): The home failed initially to follow the IPAC Standard for rapid antigen testing, specifically regarding the swab collection procedure. After the issue was identified, staff received education on correct procedures and implemented them correctly.
- Personal Protective Equipment (PPE) Usage: Staff were observed not using PPE according to the guidelines during a COVID-19 outbreak. Following the inspection, education was provided, and correct usage was observed.
Non-compliance was identified and rectified by the licensee before the conclusion of the inspection.
However, a compliance order was issued due to a failure in adhering to the home’s policy for community outings. This resulted in a serious incident where a resident suffered harm during an outing due to improper route assessment. The home was directed to review its policy on community outings with relevant staff and maintain records of such reviews.
The second of two inspections, led by Babitha Shanmuganandapala, took place over several days in August 2022, focusing on a complaint related to safe transfers, abuse, neglect, infection prevention, and control, as well as resident care and support services.
- Non-Compliance with Safe Transferring Techniques: The inspection revealed that the facility did not ensure staff used safe transferring and positioning devices when assisting a resident, specifically resident #007, who required a lift and assistance from two staff members for transfers. However, it was reported and confirmed that on multiple occasions, the resident was transferred independently by staff members without using a lift, contravening the resident’s plan of care.
- Staff Awareness and Training Issues: Personal Support Workers (PSW #100 and #101) involved in these incidents acknowledged that they were not aware of the resident’s care plan regarding transfer procedures at the time of these transfers. This lack of awareness and adherence to the care plan posed significant risks to the resident, including potential falls and injuries.
The findings were supported by various sources, including the home’s investigation notes, the resident’s clinical health records, and Closed Circuit Television footage.
July 2022
The inspection was led by April Chan, with additional inspectors Wing-Yee Sun, Fiona Wong, and Rajwinder Sehgal.
The inspection, taking place over several dates in June 2022, covered various complaints and critical incidents including allegations of resident-to-resident abuse, staff-to-resident abuse, multiple care concerns, and issues related to infection prevention, abuse and neglect prevention, reporting and complaints, resident care and support services, and responsive behaviors.
- Non-Compliance in Skin and Wound Care: The facility failed to document actions related to a resident’s skin and wound care program, including assessments and responses to interventions, which is vital for proper wound management and recovery.
- Inadequate Collaboration in Resident Assessments: There was a failure in ensuring staff collaboration in assessing a resident’s pain, leading to inconsistent and uncoordinated care.
- Neglected Participation in Care Plans: The facility did not fully involve a resident and their substitute decision-maker in developing and implementing the resident’s care plan, particularly in pain management scenarios.
- Failure in Providing Care as Specified in Care Plans: There were instances where care was not provided as specified in the resident’s plan, including irregular times for morning care and dressing.
- Lack of Protection from Sexual Abuse: The facility failed to protect five residents from sexual abuse by another resident, highlighting a significant breach in safety and well-being protocols.
- Ineffective Responsive Behaviour Strategies: Strategies to manage a resident’s sexually inappropriate behavior were not effectively developed or implemented, leading to multiple incidents of sexual abuse towards other residents.
- Failure to Review and Revise Care Plans: The facility did not reassess and revise a resident’s care plan when their care needs changed, particularly in regard to inappropriate sexual behavior.
- Non-Compliance in Reporting Suspected Abuse: There was a failure to immediately report the suspicion of sexual abuse of a resident to the Director, as required by law.
December 2021
The inspection conducted at True Davidson Acres was a Critical Incident System inspection led by Matthew Chiu. This inspection, which occurred on various dates in December 2021, was focused on evaluating aspects of falls prevention, change in health condition, and infection prevention and control.
- Infection Prevention and Control Program Non-Compliance: The facility did not fully comply with its infection prevention and control program. Specifically, it was noted that two residents who were capable of eating on their own were not assisted with hand hygiene before their meals, as directed by the home’s guidelines for dining room services. This lack of assistance in hand hygiene poses a risk of infection transmission among residents.
A Written Notification was issued to the licensee for failing to ensure that all staff participated in the implementation of the infection prevention and control program.
The facility was requested to prepare a written plan of correction to achieve compliance, ensuring that all staff participate in the infection prevention and control program implementation. This plan aims to address the observed lapses and enhance overall infection control measures in the facility.