Mon Sheong Home for the Aged (36 D’Arcy Street, Toronto) is operated by Mon Sheong Foundation (孟嘗會), a Canadian charity to support the Chinese-Canadian community. There are approximately 100 beds.
In this review, we refer to this facility as “Mon Sheong Toronto” or “Mon Sheong Toronto Long Term Care Centre” to avoid confusion with other facilities that are named after the municipalities in which they are located.
Inspection Reports for Mon Sheong Toronto
Our research team carefully reviewed and summarized inspection reports for Mon Sheong Toronto Long Term Care Centre. You can read the original copies of the reports in the Government of Ontario website.
June 2023
The inspection took place on May 29-31 and June 1-2, 2023. The lead inspector for this inspection was Adelfa Robles. The inspection was conducted in response to specific complaints and critical incidents related to resident care.
During the inspection, several intake cases were examined, including a critical incident related to a fall with injury, a complaint regarding nutrition and hydration, and another critical incident concerning an improper transfer of a resident.
The inspection covered various aspects of care, including Falls Prevention and Management, Food, Nutrition, and Hydration, Infection Prevention and Control, Resident Care and Support Services, and Skin and Wound Prevention and Management.
One notable finding from the inspection is a non-compliance issue related to skin and wound care. Specifically, the report states that Mon Sheong Foundation failed to ensure that when a resident exhibited altered skin integrity, the resident was assessed using a clinically appropriate assessment instrument specifically designed for skin and wound assessment. This non-compliance poses a risk for inappropriate and delayed treatment of residents with skin injuries.
February 2023
The inspection was conducted from January 23 to 27, 2023. The purpose of the inspection was to assess the facility’s compliance with relevant regulations and protocols related to resident care.
Two specific intakes were inspected during this critical incident system inspection, which included cases of injury of unknown cause and a fall resulting in injuries.
The inspection results indicated that a non-compliance issue was identified during the inspection, but it was promptly remedied by Mon Sheong Foundation before the inspection concluded.
The specific non-compliance issue involved the failure of the licensee to ensure compliance with the Minister’s Directive regarding COVID-19 response measures for Long-Term Care Homes (LTCHs). The directive required enhanced environmental cleaning and disinfection for surfaces, following Provincial Infectious Diseases Advisory Committee (PIDAC) best practices. It was noted that expired disinfectant wipes were found in one resident home area, which reduced the efficacy of environmental cleaning and infection prevention and control practices.
The issue was promptly addressed by removing the expired disinfectant wipes. This incident highlighted the importance of adhering to infection control protocols, especially during the COVID-19 pandemic.
February 2022
Two inspections occurred in February 2022. The first of two inspections was categorized as a Complaint inspection and took place over several days from January 19 to 28, 2022.
During the inspection, three intakes related to essential caregiver and visitors’ restrictions, concerns related to staff assisting residents with eating, and the duty to protect were investigated.
- Dining and snack service: The licensee failed to ensure that staff used proper techniques to assist residents with eating, including safe positioning of residents who required assistance. Unsafe feeding and positioning techniques were observed during the inspection, potentially placing residents at risk.
- Minister’s Directive #3: The licensee failed to comply with a Minister-issued operational or policy directive regarding long-term care homes. Directive #3 required that essential caregivers include those providing direct care to residents. However, the home restricted essential caregiver visits, particularly during outbreaks, limiting their roles to feeding assistance and end-of-life care.
- Infection Prevention and Control: The licensee failed to ensure that all staff participated in the implementation of the IPAC program. During observations, staff members were observed not using appropriate Personal Protective Equipment (PPE) when providing care to residents in rooms with COVID-19 precautions.
- Failure to report alleged staff-to-resident abuse: The licensee failed to report an alleged incident of staff-to-resident abuse to the Director, as required by the Long-Term Care Homes Act, 2007. Despite receiving a complaint related to alleged abuse, the home did not inform the Director as they did not substantiate the abuse through their investigation.
The inspection report includes recommendations and required actions for each non-compliance issue, such as preparing a written plan of correction for achieving compliance.
The second of two inspections was conducted as part of a Critical Incident System inspection. Three intakes related to falls resulting in injury were inspected in this Critical Incident System (CIS) inspection. During the course of this inspection, Non-Compliances were not issued.
September 2021
The inspection was categorized as a Complaint inspection and took place from September 1 to 3, 2021.
During the inspection, a complaint intake was investigated, which related to alleged neglect of a resident.
A single non-compliance issue was identified during this inspection. The licensee failed to ensure that all staff participated in the implementation of the IPAC program. Observations revealed instances where staff did not follow proper IPAC protocols, including the sequence of personal protective equipment (PPE) application and hand hygiene duration.
The inspector issued a Written Notification (WN) to address this non-compliance, requesting the licensee to prepare a written plan of correction to ensure that all staff participate in the implementation of the IPAC program, to be implemented voluntarily.
December 2020
The first of two inspections was categorized as a Complaint inspection and took place from November 20 to 26, 30, and December 1-3, 2020. The complaint intake for this inspection was related to the care given to residents.
- Administration of drugs: The licensee failed to ensure that a drug was administered to a resident in accordance with the directions for use specified by the prescriber. The resident’s prescribed medication for symptom management was not administered as required on two separate days, leading to an unfortunate outcome.
- Infection prevention and control program: The licensee failed to ensure that on every shift, a resident’s symptoms indicating the presence of infection were recorded. This lapse in adherence to the infection prevention and control program resulted in symptoms going unrecorded for eight separate days, ultimately leading to adverse consequences.
A Voluntary Plan of Correction (VPC) was requested to address this non-compliance and ensure that drugs are administered to residents in accordance with prescriber directions. Another Voluntary Plan of Correction (VPC) was requested to address this non-compliance and ensure that resident symptoms indicating infection presence are recorded on every shift, with immediate action taken as required.
In the second of two inspections, a Critical Incident System inspection was conducted in response to three intakes.
- Plan of care: The licensee did not ensure that resident #002’s written plan of care included the planned care for the resident, and the care set out in resident #001’s plan of care was not provided to the resident as specified in the plan.
The licensee was requested to prepare a written plan of correction voluntarily to address these non-compliance issues and ensure that each resident has a written plan of care specifying the planned care and that the care specified in the plan is provided to the resident as required.