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- Duty To ProtectAbuse & neglectOrder$5,500 fine
Inspectors found that residents were subjected to physical abuse by other residents on several occasions, despite the home having interventions in place to prevent such incidents. The home has been ordered to conduct a comprehensive review of all historical incidents involving residents, ensure all future incidents are documented in detail in each resident's health record, and analyze the home's response to incidents including investigation, intervention, and effectiveness of those interventions.
- Altercations And Other Interactions Between ResidentsResponsive behavioursOrder
Inspectors found that the home did not adequately manage the risk of altercations between residents. A resident was involved in multiple physical and verbal altercations with other residents over several years. Although the home had documented the resident's history of behavioral concerns and known triggers, staff did not consistently use one-to-one monitoring, did not complete required assessments and referrals to specialized behavioral and mental health services, and did not update the resident's care plan with identified triggers and prevention strategies. The home has been ordered to revise its behavioral management policy, educate all nursing staff on the revised process, complete comprehensive assessments and referrals for the resident, conduct a medication review, and train all staff on the resident's specific triggers and required interventions.
- Resident CareEnvironment & safety
Inspectors found that a resident was left without access to their call bell for an extended period after a procedure, contrary to their care plan. The resident reported feeling unable to call for help because staff had not positioned the call bell within their reach.
- Responsive BehavioursResponsive behaviours
Inspectors found that a resident exhibited ongoing verbal and physical responsive behaviours toward others, but the home did not initiate or maintain the required behavioural monitoring and documentation in accordance with its policy following multiple incidents.