02 - June 10, 2025 Homes Committee of Management Agenda PackageOZ5
ElgmCounty
Homes Committee of Management
Orders of the Day
Tuesday, June 10, 2025, 10:30 a.m.
Council Chambers
450 Sunset Drive
St. Thomas ON
Note for Members of the Public:
Please click the link below to watch the Committee Meeting:
https://www.facebook.com/ElginCounty
Accessible formats available upon request.
1. Call to Order
2. Approval of Agenda
3. Adoption of Minutes
4. Disclosure of Pecuniary Interest and the General Nature Thereof
5. Delegations
6. Reports/Briefings
6.1 Director of Homes and Seniors Services - Homes — Committee of
Management — Long -Term Care Director's Update January 1, 2025 —
March 31, 2025
6.2 Director of Homes and Seniors Services - Homes — Committee of
Management — Long -Term Care Operational Report January 1, 2025 —
March 31, 2025
7. Other Business
8. Correspondence
9. Closed Meeting Items
10. Motion to Rise and Report
11. Date of Next Meeting
12. Adjournment
Pages
2
5
12
Homes Committee of Management
Minutes
February 11, 2025, 11:00 a.m.
Council Chambers
450 Sunset Drive
St. Thomas ON
Members Present: Warden Grant Jones
Deputy Warden Ed Ketchabaw
Councillor Dominique Giguere
Councillor Mark Widner
Councillor Jack Couckuyt
Councillor Todd Noble
Councillor Mike Hentz
Councillor Richard Leatham
Members Absent: Councillor Andrew Sloan
Staff Present: Blaine Parkin, Chief Administrative Officer/Clerk
Michele Harris, Director of Homes and Seniors Services
Nicholas Loeb, Director of Legal Services
Katherine Thompson, Manager of Administrative
Services/Deputy Clerk
Jenna Fentie, Legislative Services Coordinator
Stefanie Heide, Legislative Services Coordinator
1. Call to Order
The meeting was called to order at 11.00 a.m. with Warden Jones in the chair.
2. Approval of Agenda
Moved by: Councillor Hentz
Seconded by: Councillor Leatham
RESOLVED THAT the agenda for the February 11, 2025 Homes Committee of
Management meeting be approved as presented.
Motion Carried.
Page 2 of 25
3. Adoption of Minutes
Moved by: Councillor Widner
Seconded by: Deputy Warden Ketchabaw
RESOLVED THAT the minutes of the meeting held on November 12, 2024 be
adopted.
Motion Carried.
4. Disclosure of Pecuniary Interest and the General Nature Thereof
None.
5. Delegations
None.
6. Reports/Briefings
6.1 Homes — Committee of Management — Long -Term Care Director's
Update October 1, 2024 — December 31, 2024
The Director of Homes and Seniors Services presented the report that
provides an overview of recent updates, and Ontario Health, Ministry of
Health, and Ministry of Long -Term Care announcements which impact the
three (3) County of Elgin Long -Term Care Homes services and operations
for the period of October 1, 2024 — December 31, 2024.
Moved by: Councillor Giguere
Seconded by: Councillor Leatham
RESOLVED THAT the report titled "Homes — Committee of Management
— Long -Term Care Director's update October 1, 2024 — December 31,
2024" from the Director of Homes and Seniors Services dated February
11, 2025 be received and filed.
Motion Carried.
6.2 Homes — Committee of Management — Long -Term Care Operational
Report October 1, 2024 — December 31, 2024
The Director of Homes and Seniors Services presented the report that
provides an overview of the day-to-day operations of the three (3) County
of Elgin Homes along with pertinent departmental and committee updates
and inspections for the period of October 1, 2024 — December 31, 2024.
Moved by: Councillor Hentz
Seconded by: Councillor Couckuyt
RESOLVED THAT the report titled "Homes — Committee of Management
— Long -Term Care Operational Report October 1, 2024 — December 31,
2
Page 3 of 25
2024" from the Director of Homes and Seniors Services dated February
11, 2025 be received and filed.
Motion Carried.
7. Other Business
None.
8. Correspondence
None.
9. Closed Meeting Items
None.
10. Motion to Rise and Report
None.
11. Date of Next Meeting
The Homes Committee of Management will meet again at the call of the Chair.
12. Adjournment
Moved by: Deputy Warden Ketchabaw
Seconded by: Councillor Noble
RESOLVED THAT we do now adjourn at 11.26 a.m. to meet again at the call of
the Chair.
Motion Carried.
Blaine Parkin, Warden Grant Jones,
Chief Administrative Officer/Clerk. Chair.
3
Page 4 of 25
ElginCounty
Report to Homes Committee of Management
From: Michele Harris, Director of Homes and Seniors Services
Date: June 10, 2025
Subject: Homes — Committee of Management — Long -Term Care Director's Update
January 1, 2025 — March 31, 2025
Recommendation(s):
THAT the report titlted "Homes — Committee of Management — Long -Term Care
Director's Update January 1, 2025 — March 31, 2025" dated June 10, 2025 be received
and filed.
Introduction:
This report provides an overview of recent updates, and Ontario Health, Ministry of
Health, and Ministry of Long -Term Care announcements which impact the three (3)
County of Elgin Long -Term Care Homes services and operations for the period of
January 1, 2025 — March 31, 2025.
Background and Discussion:
Ministry Updates
On January 2, 2025, the Ministry of Long -Term Care (MLTC) releaserd a memo and
Fact Sheet related to policy guidance to support implementation of amendments to
Section 80 of the Ontario Regulation 246/22 undder the Fixing Long -Term Care Act,
2021. The amendments came into force on January 1, 2025 and included:
• Onsite requirements for registered dietitians in long-term care homes including
provisions for a back-up plan (remote care via telephone or video conferencing)
to ensure continuous dietary management and support; and, written records of
actions and strategies taken related to a back- up plan.
On January 6, 2025, the Ontario Centres for Learning, Research and Innovation (CLRI)
announced that they are launching a new ministry funded program "Dementia Care
Sector Preparedness Initiative" in January 2025. This initiative aims to enhance
dementia care across Ontario's long-term care homes by providing homes with the
opportunity to get support in evaluating their current demntia care approaches and
Page 5 of 25
models and in assessing opportunities for the adoption and delivery of new or enhanced
dementia care approaches and models. This data, at the home and sector level, will
help homes prepare for the proposed new legislative amendments to the Fixing Long -
Term Care Act, 2021 (FLTCA) that if approved, will require all LTCHs to have an
organized program for dementia, as part of a broader effort to improve dementia care
and supports in Ontario. This initiative aims to advance dementia care practices,
improve the quality of life for residents and equip front line staff with the neccessary
skills and judgement. Homes that participate in this initiative will be provided with a
stipend to cover participation costs. All three (3) Elgin County Homes participated in
the initiative and received a stipend.
On January 13, 2025, the MLTC released a memo reminding LTCHs about the French
Translation Services available for LTCHs. Under the FLTCA all homes must post the
Fundamental Principle and the Residents' Bill of Rights in both English and French,
and, have strategies in place to support the needs of residents who cannot
communicate in the language used within the Home. The Regional Translation Network
Program (RTNP) supports translation of eligible materials intended for LTCH residents
and their caregivers/families into French. All LTCHs are eligible to request translation
services with no charge to the Home. All three (3) Elgin County Homes have met this
requirement.
On February 13, 2025, the MLTC released a memo clarifying the reporting requirements
for C. auris advising that only C. auris infections, versus C. auris colonization, are
reportable.
On February 24, 2025, the MLTC released a memo regarding the provincial election
that was held on February 27. The memo outlined the legislative mandate to ensure
that all eligible Ontarians, including those living in LTCHs, had the opportunity to vote.
Each of the three (3) Elgin County Homes had a polling station that was accessible to
all residents.
On March 20, 2025, the MLTC released a memo regarding the 2023 Long -Term Care
Home Annual Report (LTCHAR) and Long -Term Care Home Subsidy Calculation
Worksheet with instructions providing financial staff members with information for
completing the LTCHAR by June 18, 2025.
Ministry of Long -Term Care, Ontario Health and Health Quality Ontario Reporting
Long -Term Care Homes continue to have weekly, quarterly, annual and other one-time
sensitive reporting and document extension/submission obligations and requirements
which are completed within the authority of the delegation bylaw.
Reporting and documents submitted for the three County of Elgin Homes during the
timeframe of January 1, 2025 — March 31, 2025, within the delegation bylaw include the
following:
• Each home continues to complete the LTCH data submission (L9 Form) weekly
to provide details regarding bed vacancies, bed rate changes, etc.
Page 6 of 25
Each home continues to submit, in consultation with finance and human resource
department staff, quarterly staffing reports to the MLTC.
Completion of integrated technology solutions (ITS) funding survey.
Continuous Quality Improvement Requirements
The FLTCA requires long-term care homes to:
• Establish an interdisciplinary quality improvement committee.
• Ensure the home's continuous quality improvement initiative is coordinated by a
designated lead.
• Annually prepare a report on the continuous quality improvement for the home
and publish on their website.
• Maintain a record of the names of the people who participated in the evaluations
of improvements in the continuous quality improvement report.
All three homes prepared and published the annual report on the Homes website as
required and have submitted a quality improvement plan (QIP) to Health Quality Ontario
for the 2025 — 2026 timeframe, prior to the deadline of March 31, 2025.
The Continuous Quality Improvement Committee at each Home meets monthly to work
on the QIP and other key performance indicators all of which is discussed quarterly at
Professional Advisory Committee Meetings.
Bobier Villa Annual Report for 2024-2025, and, 2025-2026 Quality Improvement Plan
(QIP) Progress Report, Narrative Report and Workplan Report
II R y� R R y) R (� ;u
II....e �,(,,.� IIIIIn.Ilelin.... � IIIIf��«,IIu'..... ��pu �.�II�� (.Y. (Y:..
II ,e,pP�ll„1�` (,,,)2t�:i�u ��(���„�'li� a� 1II„
iilllle.� a i,ll III II�Re.�u Ir.:.e �� II �.... �p.�5 �.()�."'...0 ()26
.....
4 p 11 e.� 1� a 11 p� �.iC�S U
p NN yy�� R R.P 2()26
Elgin Manor Annual Report for 2024-2025, and, 2025-2026 Quality Improvement Plan
(QIP) Progress Report, Narrative Report and Workplan Report
� ln \41anoi Cd;;i,ll Il n�fiiatn ve Ann« uaII �' � �V �u �5` 2(,,,)2(,,,)2 5
In \41e �.� i�: o ll d i, ll...11 a II a � ..�� l u ° �...., II , "Il � �� �.p„ �5` (,,,) 2 5 (,,,) � �� 1��
'iiln \4le�.�i�: oll d i�ll...l a II�Re.�u:pe�nu���'....II �'��II �..11�5` 2()2.�5 (,,,)26.
11a \41a1[:uo11 d� i�ll...11 �u Wo'llC-ll pll20........... 2()2.5 2(,,,)26�.
Page 7 of 25
Terrace Lodge Annual Report for 2024-2025, and, 2025-2026 Quality Improvement
Plan (QIP) Progress Report, Narrative Report and Workplan Report
I eii "I a ((� II o ....� d i, 11 Il „u u n u e �� n u /� � , i��� a i� ai « u e �� 11 II �`� Il � � u �5` ..2 (,,,) � � :�2 (,,,)25 �.
I eii"Ia((� II o�N¢i�"....� ill II �u��¢iu II �'�".11" ��u-t ° (,,,)2�u � (,,,)�))'��''.
e iii":�ii a! (,D,d....�� ill II � �����ue���u a e���)�iiv � II �'� �".11����u �5` (,,,)� 5 (,,,) 2)��;1��.
::od¢i�"....d ill II WoiII��II�.II„go 2M 2O26.
Agreements and Documents Executed
The following agreements and documents have been developed and executed in
consultation with legal services, the procurement team, and, as required, the Chief
Administrative Officer (CAO), and align with the authority of the delegeation bylaw.
• January 3, 2025, agreement with Vitalis for one-year extension as outlined in
original agreement for provision of foot care services.
• January 19, 2025, agreement with Medline Canada for one-year extension as
outlined in original agreement for provision of incontinence supplies.
• January 27, 2025, agreement with Point Click Care (PCC) for skin and wound
application.
• January 27, 2025, CAO and Director of Homes and Seniors Services signed and
submitted extension of respite bed, one/home, for January 1, 2025 - December
31, 2025.
• January 27, 2025, Schedule A, Description of Home and Services for each of the
three LTCHs.
• February 2025, agreement signed with Anderson College for nursing clinical
student placements.
• February 4, 2025, updated fire plan, sign off by local fire department for Terrace
Lodge inclusive of Phase 3 of the Terrace Lodge redevelopment project.
• February 20, 2025, signed extension letter for Long-term Care Service
Accountability Agreement (LSAA) for each of the three (3) LTCHs.
• February 21, 2025, agreement with Mohawk College for clinical student
placements.
• February 27, 2025, Medical Director Agreement with Dr. Eric Wong for Terrace
Lodge Medical Director services.
• February 27, 2025, Attending Physician Agreement with Dr. Eric Wong for
Terrace Lodge resident medical services.
• February 27, 2025, Medical Director Agreement with Dr. Derek Vaughan for
Bobier Villa and Elgin Manor Medical Director services.
• February 27, 2025, Attending Physician Agreement with Dr. Brendan Boyd for
Elgin Manor resident medical services.
• February 27, 2025, Attending Physician Agreement with Dr. Derek Vaughan for
Bobier Villa and Elgin Manor resident medical services.
• February 27, 2025, Terrace Lodge Redevelopment, Phase 3, Part A, Building
Readiness Pre -Occupancy Inspection Checklist submitted to MLTC.
Page 8 of 25
• February 27, 2025, Terrace Lodge Redevelopment, Phase 3, Part B, Nursing
Pre -Occupancy Inspection Checklist submitted to MLTC.
• February 27, 2025, Terrace Lodge Redevelopment, Phase 3, Part B, Dietary Pre -
Occupancy Inspection Checklist submitted to MLTC.
• February 27, 2025, Terrace Lodge Redevelopment, Phase 3, Part B,
Environmental Pre -Occupancy Inspection Checklist submitted to MLTC.
• February 2025, Memorandum of Understanding between County of Elgin (Elgin
Manor) and Thames Valley District School Board (Southwold Public School)
regarding emergency evacuation plans.
• March 11, 2025, agreement with Westminster Mobile Imaging for one-year
extension as outlined in original agreement for provision of xray and ultrasound
services.
• March 19, 2025, Schedule E, Declaration of Compliance for Long-term Care
Service Accountability Agreement (LSAA) submitted with one exception related
to ongoing DEI and Indigenous Training and implementation work (training and
work is in progress and ongoing).
• March 19, 2025 letter signed by CAO for one-time funding received for diagnostic
equipment for skin and wound app, vital signs machines/softwareto integrate with
PCC, submitted to Ontario Health West.
• March 28, 2025, Terrace Lodge Redevelopment Phase 3, Confirmation of First
Resident Form submitted to MLTC.
• Clinical placement Stipend Master Agreement with the MLTC as part of the
Personal Support Worker Stipends and Incentives Program submitted by Elgin
County Homes, awaiting final sign off by Ministry.
Project Updates
Registered Nurses Association of Ontario (RNAO) Clinical Pathways, Year 1,
implementation go live date set for April 1, 2025.
o Year 1 focus includes Admission Assessment, Delirium Assessment, and
Resident and Family Centred Care.
o Front-line staff training continued throughout January — March 2025 and
funded through ministry one-time funding.
o Policy and procedures and assessments reviewed to streamline
processes, reduce duplication, standardize assessments and align with
legislative requirements.
o The Clinical Pathways project aligns with the RNAO Best Practice
Spotlight Organization (BPSO) project work.
InterRAI LTCF
o Management staff of the Home and MDS RAI coordinator staff continue tc
attend/participate in webinars and educational opportunities to prepare for
implementation, and to minimize any potential financial impact.
o MLTC has notified LTCHs that our three (3) Homes will receive training
June — September 2025 and go live implementation is October 1, 2025.
Skin and Wound Application (PCC)
o Funding received related to diagnostic equipment application approval.
o Training scheduled for registerd staff and management April 2025.
o Implementation of skin and wound application May 2025.
Page 9 of 25
o Skin and wound champions to implement first and "train the trainer" model
to train all front line registered staff.
o Streamline process and accuracy in skin and wound assessments,
treatment and outcomes.
o Real time data and photos for skin and wound team meetings,
professional advisory committees, care conferences, team huddles to
support quality improvement goals and positive wound and skin care
outcomes.
VitalLink implementation
o Funding received related to diagnostic equipment application approval.
o Training scheduled for April 2025.
o Implementation May 2025.
o Streamline resident care and services, provide registered staff with
additional opportunities for direct resident care and services
Policy and Procedure Updates
While policy work was undertaken by the management team during January — March
2025, education and policy changes will be implemented in April — June 2025.
Financial Implications:
On January 2, 2025, the MLTC released a memo regarding the 2024-2025 LTC Staffing
Increase Top -Up and Resident Health and Well -Being Program Consolidation. Effective
January 1, 2205, eligible LTCHs will receive an adjustment to the monthly funding
provided for staffing investments to help increase direct hours of resident care. The
ministry also communicated an investment to enhance access to social support services
provided by registered social workers (RSWs), social service workers (SSWs) and other
allied health professionals (AHPs) to increase overall health, well-being and quality of
life in LTCHs through the Resident Health and Well -Being (RHWB) program. The
County of Elgin Homes have achieved the direct care hours target of 4
hours/resident/day within the required timelines.
On January 6, 2025, the MLTC announced one-time funding specific to the Skin and
Wound Professional Growth Fund, in addition to the Supporting Professional Growth
Fund. This change was effective January 1, 2025 for the 2024-2025 year. All three (3)
Elgin County Homes received, utilized and reported on the one-time funding
($4.39/bed/month for January 1 — March 31, 2025) as per the criteria — prioritized for
skin and wound care education and training, and additional funding for education
unrelated to skin and wound care.
On March 21, 2025, the MTLC released a memo regarding Funding for LTC Infection
Prevention and Control (IPAC) Leads. The MLTC advised that they would be providing
up to $4,411,100 of remaining reserve funds to support the salary and benefits for IPAC
leads in LTC Homes. All three (3) Elgin County Homes receive IPAC funding to support
the IPAC lead roles in the Homes.
Page 10 of 25
Advancement of the Strategic Plan:
The long-term care director's update report aligns with the following Corporate Strategic
Plan priorities:
Strategy 2: Organizational Culture and Workforce Development
Strategy 3: Service Excellence and Efficiency
Local Municipal Partner Impact:
The announcements from the Ministry of Long -Term Care and Ontario Health West
support the quality of care and support positive outcomes for the three (3) County of
Elgin Long -Term Care Homes as staff and managers work collaboratively to provide
care and services to the residents of our Homes and community clients.
Communication Requirements:
Information has been communicated to the appropriate departments, resident council,
family council, residents, staff and visitors as required.
Conclusion:
The long-term care homes management team continues to be thankful for the support
from Council, the Chief Administrative Officer, the Senior Management Team, and staff
in all departments as we work collaboratively to maintain and improved the quality of
services and care for our residents, families, staff and communities.
All of which is Respectfully Submitted
Michele Harris
Director of Homes and Seniors Services
Approved for Submission
Blaine Parkin
Chief Administrative Officer/Clerk
Page 11 of 25
ElginCounty
Report to Homes Committee of Management
From: Michele Harris, Director of Homes and Seniors Services
Date: June 10, 2025
Subject: Homes — Committee of Management — Long -Term Care Operational Report
January 1, 2025 — March 31, 2025
Recommendation(s):
THAT, the report titled "Homes — Committee of Management — Long -Term Care
Operational Report January 1, 2025 — March 31, 2025" dated June 10, 2025 be
received and filed.
Introduction:
This report provides an overview of the day -to day operations of the three (3) County of
Elgin Homes along with pertinent departmental and committee updates and inspections
for the period of January 1, 2025 to March 31, 2025.
Background and Discussion:
Ministry of Long -Term Care (MLTC) Compliance Inspection Reports Summary
MLTC inspections are unannounced and last from 1 day to 2 weeks depending on the
purpose of the inspection. There are several types of inspections of long-term care
homes as follows:
Reactive Inspections which are done in response to complaints or critical incident
submissions and generally focus on the substance of the complaint or incident;
and follow-up inspections conducted to ensure that any compliance orders have
been addressed.
Proactive Inspections which are broad -based inspections carried out on a regular
basis to ensure that a home is in ongoing compliance with the Act and
Regulation.
Other types of inspections include pre -occupancy and post -occupancy inspection
visits to a home undergoing the development/redevelopment of beds.
Page 12 of 25
Ministry inspectors visited the Home on March 19, 20, and 21, 2025 to conduct a critical
incident inspection regarding an outbreak at the Home. Inspection protocols utilized
during the inspection included Infection Prevention and Control.
During the course of the inspection the inspector made relevant observations, reviewed
records and conducted interviews. A written notification was issued related to the
debrief requirement following an outbreak.
iilllle�� IIIru��i.�p� ��nu�°I�u II �'� �V��u �5`\le:��uIlu 2()25.
Elgin Manor
Ministry inspectors visited the home on Feburary 11, 12, 13, 14, 18, 19, 20, and 21,
2025 to conduct a proactive compliance inspection. Inspection protocols utilized during
the inspection included Resident Care and Support Services, Skin and Wound
Prevention and Management, Residents' and Family Councils, Food, Nutrition and
Hydration, Medication Management, Infection Prevention and Control, Safe and Secure
Home, Prevention of Abuse and Neglect, Quality Improvement, Staffing, Training and
Care Standards, Residents' Rights and Choices, and Pain Management.
During the course of the inspection the inspectors made relevant observations,
reviewed records and conducted interviews. Two written notifications were issued. One
written notification which was related to safe storage of drugs during medication pass;
and one written notification related to medication destruction and disposal.
airoll n°�,�2I �g nuon II�'���p, ��u�5` II ��II�II«ue�M.p 2M.
Terrace Lodge
Ministry inspectors visited the Home on February 3 and 4, 2025 to conduct a critical
incident inspection. Inspection protocols utilized included Infection Prevention and
Control and Falls Prevention and Management.
During the course of the inspection the inspectors made relevant observations,
reviewed records and conducted interviews. There were no findings of non-compliance.
eIIIIa!(" �I��� QV� �� �"� nIIP�IPII �L�Y�koll" �Y,�IPll,llu��ll ° ��()�B5
Critical Incident Systems Report Summary for all Three (3) Homes
Types of Critical Incidents — January 1, 2025 — March 31, 2025
Total
Number
— Three
Homes
Abuse & Neglect — Any alleged, suspected or witnessed abuse of a resident
10
by anyone or neglect of a resident by the licensee or staff that resulted in
Page 13 of 25
harm or risk of harm to the resident, misuse or misappropriation of
residents' money, misuse or misappropriation of funds provided to licensee.
Unlawful or Improper or Incompetent Treatment or Care — Includes care of
5
a resident that resulted in harm or risk of harm to resident.
Unexpected death — Including a death resulting from an accident or suicide.
1
Medication Incident — Includes a medication incident or adverse drug
0
reaction in respect of which a resident is taken to hospital.
Environmental Hazard — Includes breakdown or failure of the security
2
system or major equipment or a system in the Home that affects the
provision of care or the safety, security or well-being of residents for a
period greater than six hours.
Disease Outbreak
6
Contamination of Drinking Water Supply
0
Incident that Causes Injury and Transfer to Hospital — includes injury in
5
respect of which a person is taken to hospital resulting in signficant change
in status.
Controlled Substance Missing/Unaccounted — Includes missing or
0
unaccounted for controlled substance.
Written Complaint
2
The above noted critical incidents have been reviewed and internally investigated. It is
important to note that the abuse and neglect critical incident reporting includes "harm or
risk of harm". Each of the three Homes has a memory care resident home area
supporting mild to severe cognitively impaired residents that may, at times, and despite
interventions, exhibit responsive behaviours resulting in "risk of harm". The Homes are
diligent in reporting responsive behaviours in the "risk of harm" category with 8 of the 10
reports falling into this category. Follow up to each incident is conducted by the
management team in collaboration with both the internal and external Behavioural
Support Ontario (BSO) teams and is ongoing to develop interventions and update plans
of care to support all residents on the memory care resident home areas and throughout
the Homes.
Two (2) written complaints were received in this quarter across the Homes and were
responded to as per legislative requirements.
The management team and continuous quality improvement teams have developed and
implemented a plan of action to address each of the critical incident related areas and
written complaints, including, but not limited to, providing additional training and
education as required.
Outbreaks
Home
Number of
Timeframe of
Number of
Outbreaks and
Outbreak
Resident Cases
Agents
Bobier Villa
1 Suspect
January 10 -22,
1 Resident Home
Outbreak — COVID
2025
Area, 3 residents
19
Page 14 of 25
Elgin Manor
2 Confirmed
Outbreaks
#1 — Rhinovirus
#1 January 9 — 17,
#1 Entire home — 6
(Common Cold)
2025
residents
#2 — Coronavirus
#2 March 17 — April
#2 One Resident
7, 2025
Home Area — 12
residents
Terrace Lodge
3 Confirmed
Outbreaks
#1 — Influenza A,
#1 — Dec. 30, 2024
#1 — Entire Home,
COVID 19
— January 21, 2025
37 residents
#2 — Norovirus
#2 — February 6 —
#2 — Entire Home,
March 6, 2025
51 residents
#3 — Influenza A
#3 — February 21 —
#3 — Two Resident
and COVID 19
March 13, 2025
Home Areas, 10
residents
Elgin and Oxford communities experienced increased infections/illnesses during the
January — March quarter cold and flu season which did result in an increased number of
outbreaks across the three LTCHs. The IPAC teams across the Homes continue to
provide education to staff, residents and families and promote the recommended
vaccinations (RSV, COVID, influenza, pneumococcal, etc.). Staff vaccination promotion
continues across the Homes.
Infection Prevention and Control (IPAC) managers continue to participate in the IPAC
Hub and Community of Practice meetings/opportunities. Ongoing collaboration with
Southwestern Public Heaath continues to support accuracy in decision -making and
planning regarding updated circulating pathogens, guidance documents and policy and
procedures.
Each Homes IPAC team conducts biweekly IPAC audits and provides staff, residents
and visitors with education to support IPAC measures including, but not limited to, hand
hygiene, personal protective equipment, passive screening for symptoms, etc. IPAC
audits are conducted weekly during suspect/confirmed disease outbreaks.
In response to the updated IPAC policy and procedures in December 2024, this quarter
has seen the implementation of a revised Antibiotic Resistant Organism (ARO)
screening tool which includes C. Auris, as required by the MLTC and Public Health
Ontario. Additionally, the recommended changes to the Tuberculosis (TB) screening
tool has resulted in a decreased number of chest xrays (CXR) being required upon
admission. CXRs are now only required as per criteria within the TB screening tool.
Bobier Villa has implemented a closed hand sanitizing system in the common areas,
hallways and resident rooms at the point of care. Additionally an electronic hand
hygiene audit has been rolled out and is available for all staff to utilize via a QR code
and on all desktop computers and is being utilized by all staff across all departements.
Both of these initiatives support hand hygiene compliance, effectiveness, awareness
and minimize transmission risk.
Page 15 of 25
Mandatory Masking continued for staff, students and volunteers during this quarter due
to the increased outbreak activity within the Homes and throughout the community.
Mandatory masking continues to be evaluated and adjusted based on local activity and
guidance documents.
Occupancy Data
A 97% occupancy rate is required to support full ministry funding. All 3 Homes continue
to work diligently to support >97% occupancy rates, despite outbreak(s).
Home Name
Occupancy
Admissions
Discharges
Data excluding
respite bed
January 1 —
March 31,
2025
Bobier Villa
99
6
4
Elgin Manor
99.9
10
10
Terrace Lodge
97.67
10
14
Health System Partners (i.e. Fire, Public Health, Ministry of Labour)
• Monthly fire drills and health and safety inspections are conducted each month
on all shifts at all three Homes.
• The annual 2024 fire inspection report at Bobier Villa was received in January
and compliance was achieved. One fire extinguisher was replaced in the main
kitchen.
Bobier Villa received a visit from the Ministry of Labour (MOL) on December 27,
2024 in regard to Personal Protective Equipment (PPE) and a follow-up visit on
January 3, 2025. Orders were received on January 3, 2025, in regard to an
obstruction in the basement related to a delivery of supplies; and, in regard to
expired PPE with an extended expiry date. The orders were complied with prior
to the MOL compliance date and the MOL confirmed that the Home was in
compliance on January 27, 2025.
Terrace Lodge fire plan was updated to reflect the final Phase, Phase 3 of the
Redevelopment project and was approved by Malahide Fire Department in
February.
There were no public health inspections for the dietary departments across the 3
Homes, however, Public Health was involved in the pre -occupancy inspection for
Phase 3 of the Terrace Lodge Redevelopment Project to support occupancy
approval.
Dietary and Housekeeping/Laundry Departmental Updates
Department
Bobier Villa
Elgin Manor
Terrace Lodge
Dietary
St. Patrick's Day
traditional Irish
The dietary staff
and kitchen were
Terrace Lodge
main kitchen
Page 16 of 25
meal was prepared
creative delivering
renovations were
and enjoyed with
theme meals with
complete and the
entertainers in
January
kitchen in full use.
Whitelock to
celebrating
Staff were excited
complete the Irish
Chinese New Year
to participate in
celebration.
and February
the Phase 3 move
Valentine's
into the Pine and
The new winter
Events.
Chestnut
menu was
serveries, dining
launched in
The dietary team
rooms and home
January with the
successfully
kitchen spaces
addition of new
managed
which are being
menu items
providing services
enjoyed by
requested by
during a boil water
residents and
residents including
advisory in the
staff.
Meat Lovers Pizza,
month of
Sauteed Shrimp
February.
Terrace Lodge
Scampi, Colossal
An efficient way to
provides Meals on
Carrot
test the Boil Water
Wheels services
Cheesecake and
Code policy!
through a
Baked Salmon with
partnership with
a Lemon Dill
Elgin Manor
VON. Our staff
Sauce!
provides Meals on
participated in the
Wheels services
March 4 Meals
The purchase of a
through a
promotion event
new conveyer
partnership with
along with staff
toaster to help
VON. Our staff
from VON and
improve the
participated in the
volunteer drivers.
preparation of
March 4 Meals
toast for breakfast
promotion event
was very well
along with the
received by
County Warden,
residents.
staff from VON
and volunteer
drivers.
Food Committee
Theme meal
Theme meal
Finalization of the
planning continued
planning continues
new menu was
with February
— Chinese New
completed.
enjoyment of tacos
Year and
Residents
and nachos and a
Valentine's Day.
suggested a new
70's themed
idea — "Chefs
entertainment; and
Choice" meal
March focusing on
which involves the
Irish celebrations.
cook of the month
Families were
creating a menu 1
invited to join their
day/month — this
loved ones for the
will begin in May.
festivities.
Page 17 of 25
The reopening of
the tuck shop in
the new event &
tuck shop space
occurred and the
space is extremely
well utilized and
enjoyed 7
days/week!
The Auxiliary
members should
be congratulated
for successfully
providing tuck
shop opportunities
for residents and
visitors during
Phase 3 of the
project temporarily
in the library
space.
Events supported
by the dietary
department
included
Valentines and St.
Patrick's Day
celebrations with
an authentic Irish
menu, special
snacks and green
beer.
Housekeeping/laundry
The Manager of
The housekeeping
Housekeeping
Support Services
team was kept
staff have
completed the
busy with outbreak
experienced
Public Health
IPAC
significant change
Ontario Infection
management, and,
in job routines
Prevention and
supporting the
throughout the
Control
dining room floor
project and should
Environmental
replacement
be commended for
Best Practices
project in each
their ability to
modules for long-
RHA.
adjust and
term care.
Throughout the
accommodate to
month of March
support both
the team prepared
operational needs
the chapel to
and the needs of
become a
the residents.
Page 18 of 25
temporary dining
Housekeeping
room each week
staff completed
while working
training as part of
through the 4
the Public Health
dining room
Ontario Infection
replacement
Prevention and
project. Dietary
Control
and housekeeping
Environmental
staff made this
Best Practices
timeframe special
modules for long -
for residents with
term care.
many feeling as
though they were
"going out for
meals to a
restaurant" —
kudos to all staff,
all departments for
supporting this
work and resident
experience!
Joint Health & Safety
Code Drill Reviews
Code Drill reviews
Monthly Code
included Code
included
Drills with team
White, Code Blue
Code Yellow and
members with an
and Code Red.
Code White drill
enhanced focus
this quarter on
Additional eye
Active drills —
Code Red related
wash stations and
Code Orange,
to the building
fire extinguishers
Loss of Essential
updates as part of
were installed as a
Service (water),
the redevelopment
proactive measure.
and Boil water.
project.
Regular
Workplace
Code Brown drill.
inspections and
Violence Risk
fire drills.
Assessment
Regular
finalized.
inspections and
fire drills.
Regular
inspections and
fire drills.
Resident & Family Council Updates
Resident Council
Bobier Villa
Elgin Manor
Terrace Lodge
January 2025
Average of 8
Average of 10
Meeting delayed
residents attend the
residents attend the
due to outbreak.
monthly meetings.
monthly meetings.
Information shared
Topic highlights for
Topic highlights —
with residents from
Page 19 of 25
January, February
satisfaction survey
Ontario Association
and March —
results 2024,
of Residents
Resident and family
special events and
Council. 11
satisfaction survey
outings, Ontario
residents attended
results, CQI update
Association of
January 30
including review of
Resident Council
meeting. Topic
and opportunity to
membership
highlights -
participate in 2025-
renewal.
redevelopment
2026 QIP,
project, water
Recreation
temperatures, front
programs.
door, HVAC
system, IPAC,
February 2025
Topic highlights for
Topic highlights —
Meeting cancelled
January, February
CQI updates,
due to outbreak
and March —
review and
status.
Resident and family
opportunity to
satisfaction survey
provide input into
results, CQI update
proposed 2025-
including review of
2026 QIP, car show
and opportunity to
in June
participate in 2025-
2026 QIP,
Recreation
programs.
March 2025
Topic highlights for
Meeting cancelled
4 residents
January, February
due to outbreak.
attended the March
and March —
13 meeting. Topic
Resident and family
highlights -
satisfaction survey
redevelopment
results, CQI update
project, front door,
including review of
TSN sports
and opportunity to
coverage, IPAC,
participate in 2025-
2024 resident and
2026 QIP,
family satisfaction
Recreation
survey results, CQI
programs.
update including
review of and
opportunity to
participate in 2025-
2026 QIP.
Family Council
January 2025
5 members part of
8 members part of
Meeting postponed
Family Council
Family Council.
due to outbreak.
which is an
Continue to meet
increase by one
monthly in person
member. Continue
and virtually to
to meet monthly in
support attendance.
person and virtually
Page 20 of 25
to support
attendance.
February 2025
Topic highlights for
Topic highlights for
6 members
January, February
February and
attended the
and March include
March — CQI
February 5, 2025
CQI updates,
updates, Resident
meeting. Topic
proposed QIP
and family
highlights — 2024
2025- 2026 review
satisfaction survey
Satisfaction survey
and opportunity to
results, CQI update
results, IPAC and
provide input,
including review of
outbreak updates,
Diners Committee,
and opportunity to
referrals,
Recreational
participate in 2025-
redevelopment
Programs.
2026 QIP,
project, Public
Recreation
Health Inspection,
programs.
new and special
event menus,
program and
leisure.
March 2025
Topic highlights for
Topic highlights for
4 members
January, February
February and
attended the March
and March include
March — CQI
12 meeting. Topic
CQI updates,
updates, Resident
highlights included
proposed QIP
and family
clothing labels,
2025- 2026 review
satisfaction survey
redevelopment
and opportunity to
results, CQI update
update, election
provide input,
including review of
polls, CQI update,
Diners Committee,
and opportunity to
review and
Recreational
participate in 2025-
opportunity to
Programs.
2026 QIP,
provide input on
Recreation
proposed QIP for
programs.
2025 -2026, dental
services, recreation
programing and
upcoming events.
Program and Therapy Department Updates
Item
Bobier Villa
Elgin Manor
Terrace
Lodge
Special Programs &
Chinese New Year
Subway Lunch
Shiloh
Event Highlights
Lunch Outing
Club
Mennonite
Choir
Muffins & Movies
Shiloh Mennonite
Choir
Catfish
70's Show and
Creek
Dinner Music
Visit from Animal
Conservation
Aide
Authority
Art Classes
Presentation
Page 21 of 25
Sunday Tea with
Chinese New Year
— Blue Bird
Entertainment
Habitats
Art Therapy
Irish Day Party
Crafting with
Celebration of Life
Helen
Pizza and Trivia
Night
Pottery Class
Sensory
Visits
Spring Luncheon
Waffle Breakfast
Wheel of
Easter Bunny Visit
Celtic Dancers
Fortune &
(Auxiliary
Family Feud
Sponsored)
& Jeopardy
Challenge
St. Patrick's Day
Party (live music)
Puppy Visits
Tai-Chi
Little Hobby
Hill Animal
Visits
St. Patrick's
Day Party
Spring
Cookie
Decorating
Travelling
Goats
Volunteer Services
9 active, 15
13 active and
4 new
registered
registered
volunteers
volunteers
volunteers
(Gift Shop)
2 new applicants to
4 new applicants
Recruitment
start April 2025
ongoing for
portering,
1 exceptionally
horticulture,
dedicated volunteer
lending
who visits every
library
Tuesday morning
management
for 1:1 visits with
residents
Education &
Alzheimer's
Alzheimer's
Ongoing
Training
Socieity — healthy
Socieity — healthy
annual
brains, dementia in
brains, dementia in
education
the younger
the younger
population
population
Page 22 of 25
No student
No student
No student
placements this
placements this
placements
quarter
quarter
this quarter
Nursing Department Updates
Item
Bobier Villa
Elgin Manor
Terrace Lodge
Education
Clinical Pathways —
Clinical Pathways —
Clinical Pathways —
admission
admission
admission
assessment,
assessment,
assessment,
delirium
delirium
delirium
assessment
assessment
assessment
registered staff
registered staff
registered staff
Wound Care
Phase 3 Move Day
Bobier Villa
The Education
Significant planning
Manager of
Lead/Quality
and collaboration
Resident Care
Improvement
across all
provided support to
Coordinator
departments to
the Terrace Lodge
dedicated
support residents
readiness for
additional time to
and families for 2
Phase 3 Move Day.
support Phase 3
Phase 3 move
move day
days!
education.
Continuous Quality Improvement
Indicators reported within the Homes — Committee of Management — Directors Report
through the Quality Improvement Plan (QIP) progress report, narrative, workplan and
annual report for each Home.
Administrative Updates
Item
Bobier Villa
Elgin Manor
Terrace Lodge
Clinical Connect
Training and
Training and
Training and
implementation in
implementation in
implementation in
progress as
progress as
progress as
connectivity issue
connectivity issue
connectivity issue
resolved.
resolved.
resolved.
Staffing Updates
No changes
No changes
Manager of
Resident Care
Recruitment of the
Recruitment of the
position
Education
Education
Recruitment of the
Coordinator
Coordinator
Education
Position across the
Position across the
Coordinator
3 Homes
3 Homes
Page 23 of 25
Position across the
3 Homes
Education
Management and
Management and
Management and
MDSRAI staff
MDSRAI staff
MDSRAI staff
attending
attending
attending
educational
educational
educational
opportunities for
opportunities for
opportunities for
inter-RAI LTCF and
inter-RAI LTCF and
inter-RAI LTCF and
Clinical Pathways
Clinical Pathways
Clinical Pathways
Individual Home
Bobier Villa worked
Elgin Manor team
Terrace Lodge
Highlights
collaboratively with
was well prepared
management and
the continence care
for, and celebrated
staff worked
provider to achieve
an excellent
diligently to
budgetary targets
proactive
successfully
and positive
compliance
prepare for pre -
resident outcomes
inspection,
occupancy Phase 3
— well done!
congratulations to
inspection and two
all staff, all
(2) move days into
departments!
the Pine and
Chestnut Resident
Home Areas. We
could not have
done this without
the valued support
from all 3 Homes,
library, facilities,
and administration!
Financial Implications:
Advancement of the Strategic Plan:
The long-term care operational report aligns with the following Corporate Strategic Plan
priorities:
• Strategy 2: Organizational Culture and Workforce Development
• Strategy 3: Service Excellence and Efficiency
Local Municipal Partner Impact:
Communication Requirements:
Information has been communicated to the appropriate departments, resident council,
family council, residents, staff and visitors as required.
Page 24 of 25
Conclusion:
The long-term care homes management team continues to be thankful for the support
from Council, the Chief Administrative Officer, the Senior Management team, and the
staff in all departments as we work collaboratively to maintain and improve services and
care for our residents, families, staff and communities.
All of which is Respectfully Submitted
Michele Harris
Director of Homes and Seniors Services
Approved for Submission
Blaine Parkin
Chief Administrative Officer/Clerk
Page 25 of 25