Trillium Manor (12 Grace Avenue, Orillia) is a nursing home that is owned and operated by Simcoe County. There are approximately 120 beds.
Inspection Reports for Trillium Manor
Our research team carefully reviewed and summarized inspection reports for Trillium Manor. You can read the original copies of the reports in the Government of Ontario website.
July 2023: Inspection
During the inspection at Trillium Manor, two key areas of non-compliance were identified. The inspection focused on various aspects, including Medication Management, Food, Nutrition and Hydration, Infection Prevention and Control, and Falls Prevention and Management.
- Plan of Care: The resident’s plan of care was not revised when care needs changed, specifically following a fall that resulted in an injury. A resident was found to require specific interventions for one of their Activities of Daily Living (ADLs). However, the care plan showed an inaccurate falls risk score and incorrect requirements for assisting with two ADLs. Both a Registered Practical Nurse (RPN) and the Director of Care (DOC) acknowledged that the resident’s care plan had not been updated to reflect the changed care needs. The failure to revise the care plan posed a minimal risk, as not all staff caring for the resident might be aware of the current care needs.
- Dining and Snack Service: The home’s dining service failed to include proper techniques to assist residents with eating, specifically staff standing while providing food and fluids. Staff were observed standing while feeding residents. The policy indicated that care should be provided as outlined in a specific textbook, which recommended that staff should sit facing the resident while feeding to create a relaxed setting. Standing could give residents a rushed feeling. A Personal Support Worker (PSW) was aware they should be seated while feeding residents but hadn’t been on a specified day. The administrator also confirmed that standing while feeding was not considered a proper technique.
February 2023: Inspection
The inspection report for Trillium Manor, conducted by Ryan Goodmurphy, Shannon Russell, and Samantha Fabiilli, took place from February 13 to 17, 2023.
This inspection included various intakes, including incidents of resident-to-resident responsive behaviors, issues with the resident-to-staff communication and response system, and complaints related to menu planning and the dietary department.
- Failure to Report Abuse: A critical incident report indicated a resident exhibited specific responsive behaviors towards another resident. The Director of Resident Care (DORC) noted that the incident should have been reported to the Registered Nurse (RN) or a manager on-call for direction on reporting requirements.
- Security of Drug Supply: A medication cart was found unlocked and unattended with medications on top and the electronic medication administration system (eMAR) left open. This posed a moderate risk to residents if they accessed drugs not prescribed to them.
- Failure in Managing Altercations: A resident who demonstrated responsive behaviors towards other residents did not receive their prescribed pharmacological intervention consistently when non-pharmacological interventions were ineffective.
- Menu Planning Issues: There were instances of menu items being substituted without informing the residents or updating the posted menu. This had a low impact and risk but indicated a lack of communication regarding meal services.
- Malfunctioning Communication and Response System: The resident-staff communication system was not functioning properly, leading to concerns for resident safety as staff might not be alerted to residents who required assistance.
- Failure to Report System Breakdown: The breakdown of the resident-staff communication system was not reported to the Director within one business day after the incident, as required.
September 2022: Inspection
The inspection at Trillium Manor Home, conducted by Tracy Muchmaker and Vernon Abellera, focused on various critical incidents, including an unexpected death, a missing resident, and follow-up on a previously issued Compliance Order related to the duty to protect residents.
There was an incident where a resident sustained minor injuries. During the inspection, a door leading to a patio area was found unlocked and unsupervised, with the gate to the parking lot also open. This indicated a lapse in security protocols.
A Personal Support Worker (PSW) and the Administrator confirmed that the patio doors were supposed to be locked unless supervised during family visits. It was suggested that the door might have been left unlocked after a family visit during the previous weekend. Additionally, the staff were reportedly unaware of their responsibility to conduct daily checks on these doors.
Another door leading to the front patio was also found unlocked and unsupervised. The Administrator thought the patio was secure due to a surrounding fence but acknowledged that the doors should be locked unless staff are present.
July 2022: Inspection
The inspection at Trillium Manor, conducted by Shannon Russell and Nira Khemraj, addressed several critical issues, including complaints and incidents related to resident-to-resident altercations, falls, and allegations of staff abuse.
- Failure to Report Abuse: The Interim Administrator received an email about alleged abuse towards a resident by a Personal Support Worker (PSW), which was not reported to the Director as required. This lack of reporting posed a risk to residents and violated the home’s policy on abuse and neglect.
- Duty to Protect: Physical and emotional abuse were not properly addressed. A resident expressed fear of a specific PSW, and allegations of abuse were not thoroughly investigated. The lack of investigation and continued employment of the PSW in question after the allegations posed a high risk to the resident. The home was ordered to re-educate staff on abuse and neglect, focusing on prevention and reporting requirements, and to develop a process for ensuring that all allegations of abuse and neglect are thoroughly investigated.
April 2022: Follow-Up Inspection
The inspection conducted at Trillium Manor involved inspectors Loviriza Caluza and Karen Hill. The inspection focused on two specific compliance issues: the provision of twice-a-week bathing and falls prevention management, both related to previous Compliance Orders. The inspection report confirmed compliance with previously issued orders.
April 2022: Critical Incident Inspection
The inspection conducted at Trillium Manor, by inspectors Loviriza Caluza and Karen Hill, revealed several non-compliances. The key issues identified included failures in care plan reviews, falls prevention and management, maintenance services, reporting critical incidents, and compliance with established policies and protocols.
- Care Plan Reviews: The home failed to ensure regular reviews and revisions of residents’ care plans, particularly in cases where care needs changed, resulting in inadequate care strategies for falls, continence care, and isolation measures.
- Falls Prevention and Management: There was a failure to conduct post-fall assessments using clinically appropriate instruments for falls prevention, resulting in missed opportunities for preventing recurrent falls.
- Maintenance Services: The home did not adequately maintain routine and preventive maintenance services, particularly in ensuring the safe use of electrical equipment in residents’ rooms.
- Critical Incident Reporting: The home failed to inform the Director within one business day about incidents that caused significant changes in residents’ health status. There were also lapses in reporting the outcomes and analysis of fall incidents.
- Compliance with Policies: There was a failure to comply with the home’s policies, specifically the “Head Injury” policy, which required staff to initiate post-fall Head Injury Routine (HIR) assessments.
- Reporting Investigations: The home did not include essential details, such as names of involved staff, in reports made to the Director about critical incidents.