AgeCare Brant (1182 Northshore Boulevard East, Burlington, Ontario) is operated by AgeCare, a for-profit operator of long-term care homes in Canada. There are approximately 170 beds.
AgeCare Brant is formerly owned and operated by Chartwell, a for-profit operator of senior accommodations in Canada. The facility was previously known as Chartwell Brant Centre Long Term Care Residence.
Our research team at Caring Magazine carefully reviewed and summarized inspection reports for AgeCare Brant. You can read the original copies of the reports in the Government of Ontario website.
Inspection Reports for AgeCare Brant
Chartwell completed its sale of long-term care homes to AgeCare on September 6, 2023. Inspection results after this date should not be attributed to Chartwell operations.
🔍 September 2023: Inspection
The inspection for AgeCare Brant, conducted by Dusty Stevenson, focused on critical incidents related to abuse/neglect and resident care, particularly the administration of drugs.
A significant finding from the inspection was related to skin and wound care. Specifically, AgeCare Brant failed to ensure a resident received a timely skin assessment using a clinically appropriate instrument when a new skin issue was reported. The issue was observed and reported to a staff member who confirmed its presence but did not document an assessment immediately. It was not until the following day that another staff member completed the skin assessment.
Inspection Reports for Chartwell Brant Centre Long Term Care Residence
Chartwell completed its sale of long-term care homes to AgeCare on September 6, 2023. Inspection results before this date should not be attributed to AgeCare operations.
🔍 July 2023: Inspection
During an inspection at Chartwell Brant Centre Long Term Care Residence in Burlington, a significant issue was identified regarding the administration of drugs, particularly COVID-19 vaccinations.
The Director of Care disclosed to the inspector that a COVID-19 vaccination clinic held in July 2022 administered the Moderna vaccine to residents. However, an audit by Public Health later revealed that an incorrect dosage of 0.25 milliliters was administered to 45 residents, instead of the prescribed 0.5 milliliters.
By administering half the recommended dose of the COVID-19 vaccine, the residents were exposed to the risk of inadequate immunization protection and the associated consequences of COVID-19 exposure.
🔍 June 2023: Complaints Inspection
The inspection at Chartwell Brant Centre Long Term Care Residence addressed a complaint regarding personal support services. The inspection uncovered several areas of non-compliance, which were mostly remedied by the conclusion of the inspection or resulted in written notifications for action.
- Plan of Care Review and Revision: The facility initially failed to reassess and revise residents’ care plans as required, particularly when their care needs changed. This was observed in the usage of devices and physician’s orders not being updated in the care plans. Corrections were made, with the Director of Care (DOC) updating the necessary care plans.
- Reporting and Complaints: The facility did not immediately forward written complaints it received in 2022 regarding the care of a resident to the Director, as mandated. This failure was acknowledged during interviews with the Administrator and DOC.
- Care Conference Delays: The required annual care conference for a resident had not been held, which was confirmed during interviews with the DOC and Social Services Worker.
- Oral and Dental Care: The facility failed to offer annual dental assessments and other preventative dental services to a resident, as well as not providing assistance with inserting dentures as required by the resident’s care plan.
- Foot Care Services: A resident did not receive preventative and basic foot care services for several months, despite the need being identified and consent initially given then withdrawn for specialized services. The situation was later corrected, and routine follow-up was scheduled.
🔍 March 2023: Proactive Compliance Inspection
The Proactive Compliance Inspection at Chartwell Brant Centre Long Term Care Residence focused on various aspects of resident care and facility operations.
- Residents’ Bill of Rights and Policies Posting: The facility initially failed to post the revised Residents’ Bill of Rights and the home’s policy on zero tolerance of abuse and neglect. These issues were promptly corrected by posting the updated documents on March 1, 2023.
- Inspection Reports Posting: Inspection reports from the past two years were not displayed, an oversight that was rectified on March 1, 2023, by posting the required documents.
- Plan of Care for Dental and Oral Status: A resident’s care plan was found lacking details on dental status and oral hygiene. This was corrected by ensuring the care plan included this vital information by March 8, 2023.
- Visitor Policy Posting: The current visitor policy was not displayed, which was resolved on March 1, 2023.
- Nutrition Interventions: Two residents did not receive nutrition interventions as specified in their care plans, including the provision of adaptive devices during meals. This was acknowledged and corrected, with staff being reminded of the importance of following each resident’s care plan accurately.
- Compliance with Minister’s Directive on COVID-19: There was a failure to document COVID-19 testing for staff as required. This highlighted the need for rigorous documentation and adherence to testing protocols to prevent transmission.
- Resident-Staff Communication System: The facility’s call bell system had issues that prevented clear indication of the source of calls. Non-functioning pagers were identified and replaced to ensure staff could respond promptly to resident needs.
- Care Conference Participation: A resident reported not being invited to their care conference, an issue that was acknowledged, emphasizing the importance of involving residents in their care planning.
- Food and Fluid Temperature: Concerns were raised about food not being served at a palatable temperature. This issue was addressed by monitoring food temperatures more closely to ensure they met safety and quality standards.
- Cleaning and Maintenance of Resident Care Equipment: A commode chair was found not cleaned and disinfected after use, and a mechanical lift was used despite missing an emergency release button. These issues were addressed to prevent infection transmission and ensure resident safety.
- Infection Prevention and Control (IPAC) Practices: A staff member did not wear appropriate personal protective equipment (PPE) while providing care to a resident on droplet precautions. This was corrected, underscoring the importance of following IPAC standards to protect residents and staff from infection.
🔍 July 2022: Inspection
During the course of this inspection, the inspector(s) made relevant observations, reviewed records and conducted interviews, as applicable. There were no findings of non-compliance.
🔍 October 2021: Critical Incident Inspection
The Critical Incident System inspection at Chartwell Brant Centre Long Term Care Residence, conducted by inspectors Jobby James, Jessica Paladino, and Parminder Ghuman, focused on various critical incidents including falls with injury, abuse, and an unexpected death.
- Infection Prevention and Control (IPAC) Program Participation: Non-compliance was identified with the facility’s IPAC program, specifically regarding staff participation. An RPN and a PSW were observed not adhering to IPAC best practices, such as wearing appropriate Personal Protective Equipment (PPE) and hand hygiene. A Compliance Order was issued requiring re-training for specified staff on IPAC practices, completion of audits, and maintenance of training records.
- Responsive Behaviours: The facility failed to implement strategies for a resident displaying responsive behaviours, which resulted in the resident sustaining an injury. A Voluntary Plan of Correction was requested to ensure the development and implementation of strategies to address responsive behaviours effectively.
- Plan of Care: A resident’s plan of care lacked clear directions for staff, particularly regarding the handling of a care delivery item, leading to the resident’s injury. This indicated a need for clearer instructions in care plans to prevent future incidents.
The facility was ordered to address these non-compliances by enhancing training, ensuring adherence to IPAC practices, developing strategies for managing responsive behaviours, and providing clear instructions in residents’ care plans.
🔍 January 2021: Complaints Inspection
The complaint inspection conducted at Chartwell Brant Centre Long Term Care Residence by inspectors Emmy Hartmann and Meagan McGregor focused on resident care issues, including abuse, wound care, medication management, and documentation.
- Investigation and Action on Abuse: The licensee did not immediately investigate a reported abuse allegation from May 2020. The delay in investigation posed a risk to resident safety.
- Reporting to the Director: The licensee also failed to immediately report the abuse suspicion to the Director, violating mandatory reporting requirements.
- Skin and Wound Care: A resident with pressure ulcers did not receive weekly assessments by registered nursing staff, affecting the resident’s wound care and potentially contributing to harm.
- Medication Incidents and Adverse Drug Reactions: The inspection revealed a failure in documenting and reporting medication incidents involving a resident, leading to a lack of accountability and safety measures.
- Plan of Care Participation: The licensee did not ensure that a resident’s Power of Attorney was involved in the development and implementation of the resident’s plan of care regarding a new medication order.
The facility was issued written notifications and requested to prepare voluntary plans of correction for the identified non-compliances.
🔍 January 2021: Critical Incident Inspection
The critical incident system inspection at Chartwell Brant Centre Long Term Care Residence conducted by Inspector Meagan McGregor focused on several areas, including unexpected deaths, injury of unknown cause, falls prevention and management, and improper care.
- Plan of Care Compliance: A significant finding was the failure to adhere to a resident’s specified plan of care during a transfer between surfaces. This non-compliance led to a resident’s injury when a personal support worker (PSW) did not follow the outlined method for transferring, illustrating a breakdown in following established care protocols.
The licensee was requested to prepare a voluntary plan of correction to address the failure in providing care as specified in the resident’s plan.