AgeCare London

AgeCare London (1750 Division Road North, Kingsville, Ontario) is operated by AgeCare, a for-profit operator of long-term care homes in Canada. There are approximately 90 beds.

AgeCare London is formerly owned and operated by Chartwell, a for-profit operator of senior accommodations in Canada. The facility was previously known as Chartwell London Long Term Care Residence.

Our research team carefully reviewed and summarized inspection reports for AgeCare London. You can read the original copies of the reports in the Government of Ontario website.

Inspection Reports for AgeCare London

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.

🔍  November 2023: Proactive Compliance Inspection

The inspection for AgeCare London identified many non-compliance issues, including in the areas of resident care and safety.

• Plan of Care: The licensee failed to ensure adaptive aids were provided for a resident at high nutritional risk during meals, as specified in their care plan. This oversight placed the resident at nutritional risk by not supporting their food and fluid intake adequately.
• Minister’s Directive on IPAC Audits: The licensee did not complete required Infection Prevention and Control (IPAC) self-audits weekly during an outbreak period, potentially missing critical IPAC needs to manage the outbreak effectively.
• Security of Non-Residential Areas: Treatment room doors on two units were found unlocked contrary to the policy requiring these doors to be locked when not supervised by staff, posing a risk to residents accessing these non-residential areas.
• Food Temperature Monitoring: Staff failed to comply with the home’s food temperature policy, not recording food temperatures prior to meal service. This increased the risk of serving food at unsafe temperatures to residents.
• Cleaning and Disinfection of Resident Lifts: Resident lifts were not cleaned and disinfected between uses as required, raising the risk of disease transmission.
• Infection Prevention and Control Program: The home did not follow its written plan for responding to infectious disease outbreaks, specifically failing to complete a polymerase chain reaction (PCR) test for a symptomatic resident, and not recording a resident’s symptoms on every shift as required.
• Medication Cart Security: A medication cart was left unlocked and unattended on multiple occasions, risking unauthorized access by residents.

Inspection Reports for Chartwell London 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.

🔍  August 2023: 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.

🔍  July 2023: Inspection

The inspection for Chartwell London Long Term Care Residence reviewed several areas, including allegations of neglect and compliance with previously issued orders.

• Involvement of Resident’s Substitute Decision-Maker (SDM): The home failed to fully involve a resident’s SDM in the implementation of the resident’s plan of care, particularly in ensuring the resident received medical attention when experiencing a decline in condition.
• Response to Improper Care Incident: Appropriate actions were not taken in response to an incident of improper care that resulted in harm to a resident. Specifically, a Head Injury Routine should have been initiated but was not, and the incident’s investigation results were not reported to the Director.
• Transferring and Positioning Techniques: Safe transferring and positioning techniques were not used during a resident’s transfer, leading to injuries.
• Falls Prevention and Management: The home did not follow its falls prevention and management policy related to head injuries and physician notification, placing residents at risk.
• Skin and Wound Care: Weekly reassessments of a resident exhibiting altered skin integrity were not completed as clinically indicated.
• Infection Prevention and Control (IPAC) Program: Staff did not follow the IPAC program related to contact precautions for a resident, and the resident’s symptoms were not recorded every shift as required.
• Safe Storage of Drugs: The medication cart was not secured and locked, posing a risk of unauthorized access.
• Reporting and Complaints: The response to a resident’s family member’s complaint did not include an explanation of the actions taken to resolve the complaint related to the resident’s infection.

🔍  May 2023: Inspection

The inspection for Chartwell London Long Term Care Residence covered various areas including falls prevention and management, resident care assessments, alleged abuse, and neglect, among others.

The report highlights issues with bed rail assessments, skin and wound care assessments upon a resident’s return to the home, and the monitoring of symptoms indicating the presence of an infection. There were also findings related to the home’s medication management system, specifically the administration and documentation of immunizations, and the handling of medication incidents and adverse drug reactions.

• Plan of Care: Failure to ensure a resident’s Substitute Decision-Maker (SDM) was given an explanation of the resident’s plan of care, particularly concerning vaccine administration without their consent.
• Plan of Care: Failure to base the care set out in the plan of care on resident assessments and preferences, specifically regarding the use and removal of Personal Assistance Services Devices (PASDs).
• Monitoring of PASD Usage: Inadequate documentation of monitoring the use of PASDs.
• Effectiveness of the Plan of Care: Failure to document the effectiveness of the plan of care for a resident, particularly after administration of as-needed medication and subsequent testing.
• Reporting Improper or Incompetent Care: Failure to immediately report to the Director improper or incompetent care of a resident that resulted in harm or risk of harm.
• Use of PASDs: Failure to ensure that the use of a PASD used to assist a resident with a routine activity of living was included in the resident’s plan of care.
• Bed Rails: Failure to assess a resident and their bed system for the use of bed rails according to evidence-based or prevailing practices to minimize risk.
• Skin and Wound Care: Failure to ensure a resident received a skin assessment by registered nursing staff upon return to the home.
• Infection Prevention and Control: Failure to monitor symptoms indicating the presence of infection in a resident on every shift in accordance with the Director’s standards or protocols.
• Medication Management System: Failure to comply with the home’s medication management system policy related to resident immunizations.
• Medication Incidents and Adverse Drug Reactions: Failure to document an adverse drug reaction involving a resident and the immediate actions taken to assess and maintain the resident’s health.
• Reporting and Complaints: Multiple failures related to handling complaints, including keeping documented records of the nature of complaints, actions taken to resolve complaints, and communication with the complainant.
• Required Programs: Non-compliance with the home’s falls prevention and management policy regarding head injuries following falls, including failure to initiate Head Injury Routines (HIRs) as required, notify the resident’s POA or physician promptly after a fall resulting in significant injury, and documenting such notifications and actions taken.

An Administrative Monetary Penalty (AMP) of $5,500 was issued for the licensee’s failure to comply with the requirement resulting in significant risk to residents.

Compliance orders were issued to address specific areas of concern, including the requirement for staff retraining on the home’s bed rail policy and ensuring compliance with the home’s falls prevention and management policy.

🔍  February 2023: Inspection

The inspection for Chartwell London Long Term Care Residence covers a range of issues from non-compliance in areas such as infection prevention and control, medication management, and care plans, to the handling of complaints and incidents involving resident care and safety.

• Infection Prevention and Control: The facility did not properly clean and disinfect residents’ assistive devices, leading to observed soiling and inadequate cleaning frequency.
• Medication Management: The residence failed to follow its own medication reconciliation policy, resulting in medication errors including not discontinuing medications as advised by treating physicians and improperly handling medication orders upon resident admission from hospitals.
• Handling of Complaints and Incidents: Complaints and critical incident reports related to care concerns, medication incidents, staffing, and responsive behaviors were not properly investigated, documented, or resolved.
• Care Planning and Management: Residents’ care plans were not based on thorough assessments, did not reflect changes in care needs, and failed to incorporate necessary interventions for falls prevention, responsive behaviors, and infection control.
• Staff Training and Care Standards: There were gaps in ensuring staff received required training in areas such as infection prevention, medication management, and falls prevention, compromising the quality of care.
• Resident Records and Documentation: The facility did not maintain updated clinical records for residents, including documentation of care plans, medication orders, and incident investigations.
• Falls Prevention and Management: The home did not adequately monitor residents after falls for potential head injuries as per their head injury routine policy, and the Falls Committee did not meet as required to review and analyze falls.
• Nursing and Personal Support Services: The residence did not ensure the organization and scheduling of staff shifts met regulatory requirements, affecting the delivery of nursing and personal care services.

🔍  February 2022: Critical Incident Inspection

The inspection for Chartwell London Long Term Care Residence, conducted by Peter Hannaberg, focused on falls prevention and infection prevention and control (IPAC).

• Plan of Care: The home failed to update a resident’s care plan to include falls prevention interventions after a fall. A Voluntary Plan of Correction (VPC) was requested to ensure all interventions are documented upon assessment or reassessment.
• Hazardous Cleaning Products: Hazardous cleaning products were found accessible to residents on an unattended housekeeping cart. A VPC was requested to ensure hazardous products are kept inaccessible at all times.
• Infection Prevention and Control Program: Resident hand hygiene was not provided before and after meals as required. A VPC was requested to ensure hand hygiene is offered and encouraged before and after meals.
• Critical Incident Report: The home did not update a CIS report with actions taken in response to a resident fall incident, including the outcome or current status of the individual. A VPC was requested to ensure CIS reports are amended to include necessary updates.