The Woodlands of Sunset (920 Pelham Street, Welland) is a nursing home that is owned and operated by Niagara Region. There are approximately 120 beds.
Inspection Reports for the Woodlands of Sunset
Our research team at Caring Magazine carefully reviewed and summarized inspection reports for the Woodlands of Sunset. You can read the original copies of the reports in the Government of Ontario website.
August 2023: Inspection
The inspection report by Emily Robins focused on a Critical Incident System inspection. The report identified several non-compliance issues in relation to the Falls Prevention and Management Program and Prevention of Abuse and Neglect.
- Non-Compliance in Plan of Care: The licensee failed to ensure that care outlined in a resident’s plan was provided as specified. Specifically, the plan directed staff to use a certain lift for transfers to the toilet and to apply “Gentle Persuasive Approaches” for responsive behaviors. However, on a specified date in December 2022, Personal Support Workers (PSWs) used a different type of lift and did not utilize the “Gentle Persuasive Approaches” when the resident exhibited behaviors during care.
- Failure in Reporting Abuse: There was a failure to report suspected abuse of a resident immediately. A staff member alleged that another staff was verbally and physically abusive towards a resident while providing care, but did not report the incident until the following day via email. Consequently, the Director was not informed of the critical incident until two days after the alleged abuse. The Director of Resident Care (DRC) stated that the incident should have been reported immediately to the Registered Nurse in Charge (RN).
May 2022: Inspection
The inspection report, by Cathie Robitaille and additional inspectors Cathy Fediash and Yvonne Walton, addresses several critical incidents and complaints.
The licensee failed to ensure that appropriate strategies were implemented for Resident #001, who demonstrated responsive behaviours of resistance to care. Despite having a plan of care that identified strategies to respond to such behaviours, these were not effectively implemented by the staff.
The report detailed an incident where the resident refused care, and staff and students initially left the resident to settle before re-attempting care. However, when a Personal Support Worker (PSW) and a student later tried to assist the resident from bed using specified equipment, the resident exhibited responsive behaviours. The report alleges that the PSW staff was then physically abusive toward the resident.
The failure to implement the planned strategies for dealing with the resident’s responsive behaviours may have resulted in the resident becoming upset and agitated, thereby placing both the resident and staff at risk of harm.
April 2021: Complaints Inspection
The inspection conducted by Daria Trzos was a complaint-based inspection focusing on a bed refusal incident.
The licensee did not approve the admission of applicant #001 following a review of assessments and information provided. The refusal to admit the applicant was not based on any acceptable grounds as outlined in the Act. Acceptable grounds for refusal include the lack of physical facilities or nursing expertise necessary to meet the applicant’s care requirements, or other circumstances as provided in the regulations. However, in this case, the refusal was for a reason that was not a valid ground for withholding approval.
March 2021: Complaints Inspection
The inspection conducted by Cathy Fediash was a complaint inspection addressing multiple issues.
- Required Programs: The licensee failed to ensure the development and implementation of a comprehensive pain management program. This was highlighted by a case where a resident experienced pain in a limb, resulting in altered skin integrity and the development of new symptoms. Despite these signs, no further pain assessments were conducted as per the home’s pain policy, and no non-verbal signs of pain or symptoms were documented for the resident. This failure posed a risk to residents not having their pain fully assessed and effectively managed.
- Failure in Pain Management Program Development: The pain management program at the home lacked comprehensive directives for assessing a resident’s pain outside of specified times. There were also inadequacies in the electronic medication administration record (eMAR) and treatment administration record (eTAR) systems used, with no policy or written direction for their use.
- Plan of Care: The licensee failed to ensure that a resident’s substitute decision-maker (SDM) was given an opportunity to participate fully in the development and implementation of the resident’s plan of care. This was evident in the case where a resident’s SDM was not notified about a diagnostic test ordered for the resident.
March 2021: Critical Incident Inspection
The inspection conducted by Cathy Fediash was a Critical Incident System inspection.
- Plan of Care: The licensee failed to ensure clear directions to staff in a resident’s plan of care regarding fall prevention interventions. A critical incident report indicated a resident was injured due to a fall. The resident was at risk of falling, and their care plan included specific interventions for mobility and transfer. However, the interventions were not clear, leading to a risk of falls due to potential staff confusion about the most current directions.
- Failure in Providing Specified Care: The licensee did not ensure that the care outlined in a resident’s plan of care, specifically a safety intervention, was provided. This was observed when a resident was found injured, and the required safety device was not in place in their room. The safety intervention was part of the resident’s care plan, but staff, including a Personal Support Worker (PSW) and a Registered Practical Nurse (RPN), either were not aware of it or did not see it implemented.
- Lack of Review and Revision of Care Plan: The licensee did not ensure the resident’s care plan was reviewed and revised when a safety intervention was no longer necessary. Even though the safety device was removed as it was deemed unnecessary, the care plan was not updated to reflect this change.
June 2020: Critical Incident Inspection
The inspection conducted by Cathy Fediash focused on a Critical Incident System inspection related to medication management.
The licensee did not ensure that a medication incident involving a resident was documented properly, and immediate actions were taken to assess and maintain the resident’s health. Additionally, there was a failure to report the incident to the necessary parties, including the Medical Director, the prescriber of the drug, the resident’s attending physician or the registered nurse in the extended class attending the resident.
The incident involved a missing dose of a specified drug for resident #001. It was identified that doses of this drug were punched out of two blister cards on separate days. There was a possibility that two doses might have been administered to the resident, but this was not confirmed by the staff responsible for the medication administration.
The licensee failed to document the immediate actions taken to assess and maintain the resident’s health for 16 hours after the incident was discovered. Moreover, there was no documentation indicating that the Medical Director, the prescriber of the drug, the resident’s attending physician, or the registered nurse in the extended class attending the resident had been notified of this medication incident.