Villa Colombo Toronto: Reviews & Inspection Reports

Villa Colombo Toronto (40 Playfair Avenue, Toronto) is managed by Extendicare, a for-profit operator of long-term care homes in Canada. There are approximately 390 beds.

Villa Colombo Toronto is owned by Villa Charities, a registered charity that supports the Italian-Canadian community.

Inspection Reports for Villa Colombo Toronto

Our research team carefully reviewed and summarized inspection reports for Villa Colombo Toronto. You can read the original copies of the reports in the Government of Ontario website.

🔍 December 22, 2023: Inspection

The inspection for Villa Colombo Toronto focused on several critical issues, including falls, allegations of abuse, skin and wound care, and the management of responsive behaviors. The inspection was led by Joy Ieraci.

Plan of Care and Falls Management: The facility failed to ensure collaboration among staff in implementing the plan of care related to falls. This lapse led to a resident falling and sustaining an injury because a crucial intervention wasn’t implemented due to it not being included in the resident’s care documentation.
Management of Responsive Behaviors: The home did not follow the plan of care for a resident with a history of responsive behaviors, putting both the resident and co-residents at risk. The necessary interventions were not in place during two separate observations.
Handling of Complaints: Villa Colombo Homes for the Aged did not forward a written complaint regarding alleged abuse towards a resident to the Director as required, indicating a potential lapse in managing complaints effectively.
Reporting Abuse: A PSW and an RN failed to report a resident’s allegation of abuse immediately to the Director, compromising the facility’s ability to investigate and respond appropriately to the allegation.
Skin and Wound Care: The licensee did not ensure that a resident with altered skin integrity was reassessed at least weekly by a member of the registered nursing staff, which could impede effective monitoring and healing of the skin condition.

The facility is required to address these non-compliances with detailed corrective actions, including ensuring that all aspects of a resident’s care plan are well-integrated and implemented consistently across staff functions, improving the management and reporting of abuse allegations, and ensuring consistent reassessment of residents with altered skin integrity.

🔍 December 14, 2023: Inspection

The inspection for Villa Colombo Toronto, led by Noreen Frederick and Chinonye Nwankpa, covered a range of issues from plan of care adjustments to medication management, resident care support, nutrition, and fall management. This comprehensive inspection aimed at addressing complaints, critical incidents, and follow-up actions from previous inspections.

Several non-compliances were identified, highlighting areas of concern in the facility’s operations and care provision.

Integration of Assessments and Care: Failures were noted in staff collaboration for developing and implementing care plans, particularly post-hospital discharge medication management and adherence to Substitute Decision Maker (SDM) directives on medication, posing risks of inappropriate care.
Plan of Care: The facility did not adhere to specified care plans, including the use of communication devices for fall risk residents and correct positioning aids, risking resident safety and well-being.
Review and Revision of Care Plans: There was a lack of timely reassessment and revision of care plans following changes in resident care needs or after specific incidents, risking inadequate care provision.
Reporting of Neglect to the Director: An alleged incident of neglect was not immediately reported, delaying potential intervention and resolution.
Fall Prevention and Management: Post-fall assessments were not conducted as per the facility’s policy, missing opportunities for evaluating fall risks and implementing preventive strategies.
Reporting of Disease Outbreaks: Delays were found in reporting COVID-19 outbreaks to the Director, potentially hampering timely response and containment efforts.
Notification Systems for Pharmacy Services: The facility failed to notify the pharmacy service provider within the required 24-hour window about changes in resident status, leading to unnecessary medication delivery.
Drug Record Maintenance: The facility did not maintain accurate and complete drug records for at least two years as required, risking medication management errors.
Drug Destruction and Disposal Practices: Non-compliance was noted in the procedures for drug destruction and disposal, including the lack of a team-based approach and failure to audit the system annually, raising concerns about medication safety and compliance with regulatory standards.

🔍 November 2023: Inspection

The inspection for Villa Colombo Toronto focused on key areas including resident care support, skin and wound management, medication management, and infection prevention. The inspection team included Henry Chong and Noreen Frederick.

Plan of Care: It was found that the specified care in a resident’s plan was not provided, particularly concerning toileting, transfers, and bathing, placing the resident at risk of potential injury.
Windows: The facility did not comply with regulations regarding window openings, exceeding the maximum allowable limit, which posed a risk for elopement.
Communication and Response System: Call bells were observed to be non-functional, risking resident safety due to delayed staff response.
Required Programs: The facility failed to implement a continence care and bowel management program according to their policy, risking inadequate continence support for residents.
Continence Care and Bowel Management: Specific residents did not receive appropriate assessments for their continence status changes, risking ineffective management of their conditions.
Infection Prevention and Control Program: Hand hygiene practices were not adequately followed by staff, increasing the risk of infectious disease transmission.
Continuous Quality Improvement Committee: The CQI committee lacked essential members, potentially omitting interdisciplinary feedback critical for quality improvement initiatives.
Continuous Quality Improvement Initiative Report: The CQI initiative report was not shared with the Residents’ Council, limiting residents’ awareness of quality improvement efforts.
Orientation Training Gaps: Newly hired staff did not receive comprehensive infection prevention and control training, covering all required topics, thus increasing the risk of non-compliance with IPAC practices.

🔍 September 2023: Inspection

The inspection for Villa Colombo Toronto, conducted by Britney Bartley and Lisa Mackay, focused on incidents including a resident missing for over 3 hours, a resident sustaining a fracture of unknown cause, a fall resulting in fracture, a respiratory outbreak, and an unexpected death of a resident.

Infection Prevention and Control Program: Failures in implementing a protocol issued by the Director with respect to infection prevention and control were noted, specifically in the use of personal protective equipment (PPE) by visitors to a COVID-19 positive resident’s room and ensuring hand hygiene agents were accessible at the point of care.
Plan of Care: A compliance order was issued regarding the plan of care, requiring re-training for a Personal Support Worker (PSW) on assistance requirements in a resident’s care plan, conducting audits for a resident’s safety device, and maintaining a record of these audits.

🔍 August 2023: Inspection

The inspection for Villa Colombo Toronto focused on various complaints and critical incidents relating to resident care, including issues of alleged neglect, falls, fractures of unknown causes, and an unexpected death. The inspection team included Rajwinder Sehgal, Reji Sivamangalam and Chinonye Nwankpa.

Resident’s Bill of Rights: The home failed to respect and promote a resident’s right to proper nutrition care and services consistent with their needs, as a resident was not taken to the dining room during mealtime as specified in their care plan.
Plan of Care: The facility did not provide fall prevention interventions to a resident as specified in their plan of care, leading to a fall incident that resulted in injury.
Reporting to the Director: The home did not report suspected improper or incompetent treatment or care of a resident, which led to a delay in necessary assessment and treatment.
Skin and Wound Care: Residents exhibited altered skin integrity but did not receive the necessary assessments or weekly reassessments by registered nursing staff, compromising their skin health and treatment effectiveness.
Pain Management: Strategies to manage a resident’s reported pain were not followed, resulting in discomfort and risk of further injury.
Infection Prevention and Control Program: Symptoms indicating the presence of infection in a resident were not monitored on every shift, failing to ensure effective surveillance and management of healthcare-acquired infections (HAIs).

🔍 June 2023: Inspection

The inspection for Villa Colombo Toronto addressed numerous complaints and critical incidents concerning resident care and safety. The inspection was conducted by inspectors Ryan Randhawa, Christine Francis and Cindy Ma.

Plan of Care – Device Use: The home did not have a written plan of care that provided clear directions for staff regarding the use of devices for pressure relief for a resident, compromising the resident’s care and treatment.
Plan of Care – Revisions: When residents’ care needs changed, their care plans were not revised accordingly, particularly regarding fall prevention interventions. This negligence increased the risk of falls and injuries among residents.
Plan of Care – ADL: The home failed to provide care as specified in residents’ care plans, particularly concerning two-person assistance with activities of daily living (ADL), putting residents at risk for falls or injuries.
Minister’s Directives: Staff were observed not adhering to masking requirements, posing a risk of communicable disease transmission within the facility.
Skin and Wound Care: The facility did not refer to the Registered Dietitian when residents exhibited altered skin integrity, nor did it ensure weekly skin and wound assessments by registered nursing staff, jeopardizing residents’ skin health.
Falls Prevention and Management Issues: After a resident fell, a clinically appropriate post-fall assessment was not conducted, missing a crucial step in providing timely treatment and preventing future falls.
Responsive Behaviours Management: Strategies to manage a resident’s responsive behaviours were not implemented, leading to an injury after a PSW continued to assist the resident despite their responsive behaviours.
Nutritional Care and Hydration Programs: The facility failed to refer a resident to a Registered Dietitian when they consumed 50% or less from all meals for three days, increasing the risk of further weight loss.

🔍 March 2023: Inspection

The inspection for Villa Colombo Toronto covered a range of issues, including abuse, neglect, improper care, and injuries of unknown causes. The results highlight multiple areas of non-compliance affecting resident care and safety. The inspection, led by Rodolfo Ramon, included Slavica Vucko, Noreen Frederick, Kirthiga Kavindran and Cindy Cao.

Plan of Care: The facility failed to involve a resident’s substitute decision-maker (SDM) in the development and implementation of the resident’s care plan, restricting the SDM’s participation in important care decisions.
Zero Tolerance Policy on Abuse and Neglect: The home did not comply with its own policy to promote zero tolerance of abuse and neglect, notably when staff failed to immediately report an allegation of physical abuse to a supervisor, delaying the response to the incident.
Complaints Procedure: The home was not prompt in forwarding complaints concerning resident care to the Director, contravening their procedure for handling complaints and potentially delaying resolution.
Transferring and Positioning Techniques: Safe transferring and positioning techniques were not used, resulting in injuries to residents. This included failures in assessing the appropriate transferring devices for residents and not following established protocols during transfers.
Pain Management: The facility did not reassess residents’ pain using clinically appropriate instruments when initial interventions were ineffective, potentially leading to inadequate pain management.
Infection Prevention and Control (IPAC): Staff failed to adhere to IPAC standards, particularly in assisting residents with hand hygiene before meals, raising the risk of infection transmission.
Response to Complaints: The facility did not respond to complaints within the required 10 business days, failing to address concerns regarding resident care in a timely manner.
Reporting Critical Incidents: The home did not provide a detailed written report to the Director following an incident where a resident sustained an injury during a transfer, missing an opportunity for investigation and prevention of future incidents.

🔍 January 31, 2023: Inspection

The inspection for Villa Colombo Toronto, led by Noreen Frederick and Irish Abecia, covered a comprehensive range of complaints and critical incidents. This inspection focused on issues related to abuse, neglect, complaints handling, resident care, and infection prevention and control, among other areas.

Reporting and Complaints: The facility did not investigate complaints concerning a resident’s care, particularly an allegation of harm, in violation of their “Complaints and Customer Service” policy. This failure posed a risk of continuing poor care for the affected resident.
Plan of Care: The inspection identified that the home did not provide clear directions to staff regarding a resident’s clinical procedure in the plan of care, leading to the resident’s refusal of the procedure due to the use of incorrect supplies.
Prevention of Abuse and Neglect: The facility was ordered to retrain Personal Support Workers (PSWs) on their responsibilities for monitoring a resident with high-risk responsive behaviours. This order was made following an incident where a 1:1 PSW was not present, resulting in the resident being found with a significant change in their health status.
Infection Prevention and Control (IPAC): The home failed to ensure adherence to IPAC standards, particularly in assisting residents with hand hygiene before meals, increasing the risk of infection transmission.
Pain Management: The facility did not reassess a resident’s pain using clinically appropriate assessment instruments when initial interventions were ineffective, leading to potential inadequate pain management.
Transferring and Positioning Techniques: Safe transferring and positioning techniques were not used, resulting in injuries to residents. The report highlighted a lack of assessment for appropriate transferring devices and a failure to follow protocols.

🔍 January 18, 2023: Inspection

The inspection report for Villa Colombo Toronto, led by Henry Chong, focused on a series of incidents related to falls with injury and aspects of infection prevention and control (IPAC).

Infection Prevention and Control Program: The facility failed to ensure full participation by all staff in the IPAC program. Violations included not following Routine Practices for wearing appropriate eye protection and an N95 mask during a suspected COVID-19 outbreak and when entering a resident’s room under droplet/contact precautions. These failures posed an increased risk of infection transmission among staff and residents.
Critical Incident Reporting: The licensee did not immediately report a disease outbreak to the director after normal business hours, contrary to regulations. This delay in reporting could impact the timely response and management of the outbreak, potentially increasing the risk of further transmission.